This document discusses various approaches to quality improvement in healthcare. It defines quality from several perspectives, including from the viewpoint of customers/patients, providers, and products. Several quality improvement models and strategies are described, such as total quality management (TQM), Six Sigma, Lean, and the 5S methodology. Key dimensions of quality like quality assessment, assurance, control, and improvement are explained. The document also provides definitions of terms used in healthcare quality such as accreditation, certification, clinical governance, benchmarking, and clinical audits.

1. Prof. Dr Swe Win
Honorary Professor
Professor and Head(retired)
Health policy and management Department
UPH
19.3.2016 Hospital Administration Society

2.  To know the various approaches of
quality improvement in health care
services and to select the
appropriate approach applied in
hospital.

3.  A 2013 study on the global burden
of medical error found that unsafe
care causes 43 million injuries a
year and the loss of 23 million
disability adjusted life years
(DALYs), about two-thirds of them
in low- and middle income
countries (Jha et al., 2013).
 The fifth leading cause of DALYs
lost worldwide (i.e underestimate)
Source: Improving Quality of Care in Low- and Middle-Income Countries:
Workshop Summary;NAP

4. provider/manufacturer/supplier
 ongoing process of building and
sustaining relationships by
assessing, anticipating and
fulfilling stated and implied needs
 Error-free
 Reducing the variation around the
target
 doing right things right
Customer/user/consumer/client
 Customers’ perception of the value
of suppliers’ work output
 value-added care and service that
meets and/or exceeds both the
needs legitimate expectations
 properties of products and/services
that are valued by the customer
 The degree to which something
meets or exceeds the expectations
of customers (Degree of excellence
or degree of goodness)
 fulfillment of expectation
 ability of a product or service to
meet a customer’s expectations for
that product or service

5.  FEIGENBAUM (1983): Quality is total composite product (goods and
services) characteristics, through which the product in use will meet
the needs and expectations of the customers. Concept of quality
must start with identification of customer quality requirements and
must end only when the finished product is placed into the hands of
the customer who remains satisfied through various stages of
relationship with the seller
 Institute of Medicine (1990) definition: “Quality is the extent to
which health services for individuals and populations increase the
likelihood of desired health outcomes and are consistent with
current professional knowledge.”
 American Society of Quality Control (ASQC) and American National
Standard Institute (ANSI): totality of features and characteristics of
product (goods and services) that bears on its ability to satisfy given
needs

6. Product
 Perfection
 Consistency
 Eliminating waste
 Compliance with policies and procedures
 Providing a good, usable product
Service delivery
 Speed of delivery
 Doing it right, do right thing
User
 Delighting or pleasing customers
 Total customer service and satisfaction
 Degree of goodness
Quality = Degree of performance
The standard set
empowerment
standards
satisfaction

7. Product/production/provider based
 Features
Augmented product
 Conformance
Degree to which characteristics of
the product meet pre-established
standards
 Performance
Product’s primary operating
characteristics
 Serviceability
Speed, competence & courtesy of
providing services.
Value/ judgmental /user based
 Aesthetics
Look, feel sound, taste, smell
 Perceived Quality
Resulting from advertisement,
image, brand name, earlier use,
hearsay
 Durability
Length of time a product can be
used before it deteriorates or
becomes non functional
 Reliability
Ability of the product to function at
the specified level of performance

8. Mass
Inspection
Quality
Control
(Acceptance
Sampling)
Quality
Assurance
Total Quality
Control
Company
wide Quality
Control

9.  Mass Inspection
 Inspecting
 Salvaging
 Sorting
 Grading
 Rectifying
 Rejecting
 Quality Control
 Quality manuals
 Product testing using SQC
 Basic quality planning
 Quality Assurance
 Emphasis on prevention
 Proactive approach using SPC
 Advance quality planning
 Total Quality Control
 All aspects of quality of inputs
 Testing equipments
 Control on processes

10.  Company wide Quality Control
 Measured in all functions connected with
production such as
 R&D
 Design
 Engineering
 Purchasing,
 Operations etc
 Total Quality Management
 Measured in all aspects of business,
 Top management commitment
 Continuous improvement
 Involvement & participation of employees

11. Dimension of Quality
Quality assessment
Quality assurance
Quality control
Quality improvement

12.  Accreditation: Accreditation is a formal recognition that
an organization is competent to carry out specific
activities
 Audits: The objective of audits is to enhance the
effectiveness and efficiency of programme
Audits should be conducted by:
 People who are technically competent, but
 Do not have any direct responsibility for those
activities

13. Quality Assurance
 planned and systematic actions necessary to provide adequate
confidence that a product or service will satisfy given requirements for
quality.
 Examples of QA:
 type testing, performance testing, and quality audits required by a
regulatory body.
 blind testing and quality audits of the service provider performed by
the user of the service.

14.  The operational techniques and activities that are
used to fulfill requirements for quality.
 Examples of QC:
 routine (i.e. daily)
 various statistical analyses used to verify continued
system performance.
Quality Control

15.  Identifies gaps exist between services actually provided and expectation of
services
 lessens these gaps not only to meet customer needs and expectation, but
to exceed them and attain unprecedented level of performance
 QI focus on the Client, Systems and process, teamwork, and the use of data

16.  Total Quality Management (TQM)
is a comprehensive and structured
approach to organizational
management that seeks to
improve the quality of products
and services through ongoing
refinements in response to
continuous feedback

17.  1.It involved in all stages of system
approach ie. input, process and
output stages
 2.Participation of all stakeholders
 3.Linkage with problem solving
approach and accountability
 4.Key process is PDCA /
PDSA(Continuing Improvement)
 5.Standardization
.(Accreditation/certification/Bench
mark)

18.  A management approach for an
organization ,centered on quality,
based on the participation of all its
members and aiming at long-term
success through customer
satisfaction, and benefits to all
members of the organization and
to society. (ISO definition)

19.  2.The 5 key principles of TQM
initiative (a)management
commitment
(b)employee commitment
(c)fact based decision making
(d)continuous improvement
(e)customer focus

20.  1.Ethics
 2.Integrity
 3.Trust
 4.Training
 5.Teamwork
 6.Leadership
 7.Recognition
 8.Communication

22.  Six sigma
 A philosophy and measurement process
developed in the 1980s at Motorola.
 To design, measure, analyze, and control
the input side of a production process to
achieve the goal of no more than 3.4
defects per million parts or procedures.
 A philosophy and measurement process
that attempts to design in quality as a
product is being made.
 one percent of health
care providers in the
United States have
deployed Six Sigma
methods.


23.  Methodological sequences:
DMAIC—define, measure, analyze,
improve, and control; or DMADV—
define, measure, analyze, design,
and verify. DMAIC is generally used
to improve existing systems that
have fallen below Six Sigma levels,
DMADV is used to design and
develop new processes or products
at Six Sigma levels
 Six Sigma projects require to have
expertise in basic statistical tools
such as Pareto Diagrams,
descriptive and higher level
statistics including regression, and
statistical modeling techniques as
well as control processes

24.  The essence of Six Sigma
methodologies is both
improvement of the knowledge
and capability of employees, and
also behavior changes through
training.
 Thus, Six Sigma employs a
classification system that identifies
education and training for
employees, project managers and
executives

25.  The term lean was coined as a
word to describe a system
(Toyota’s)that managed to get by
with half of everything and far
fewer than half of the defects and
safety incidents.
 All we are doing is looking at
timeline from the moment a
customer gives us an order to the
point when we collect the cash.
and we reducing that timeline by
removing the non-value-added
wastes(Toyota’sTaiichi Ohno

26.  Toyota Triangle
Lean is an integrated system of
human development, technical tools,
management approaches ,and
philosophy of that creates a lean
organizational culture.

27.  1.respect for people (eg, patients,
staff members, managers,
physicians),
 2. continuous improvement (eg,
easier, better, faster, cheaper), and
 3.human development.

28.  Specify value – from the
standpoint of the end customer
(the patient)
 • Identify the value stream – all
value-added steps across
departmental boundaries (the
value stream), eliminating steps
that do not create value
 • Make value flow continuously –
eliminate causes of delay, such as
batches and quality problems
 • Let customers pull value – avoid
pushing work onto the next
process or department; let work
and supplies be pulled as needed
 • Pursue perfection – through
continuous process improvement

29. Sort
Clear out rarely used
Items by Red Tagging
Straighten
Organise and Label a
Place for Everything
Shine
Clean ItStandardise
Create Rules to Sustain
the first 3 5’S
Sustain
Use Regular Management
Audits to Stay Disciplined Eliminate
Waste

31.  Seiri – Sorting
 Seiton – Straighten or Set in order
 Seiso – Sweeping, shining or
cleaniness
 Seikestu – Standardising
 Shitsuke – Sustaining the discpline

32. Donabedian concepts
 Efficacy (Power or capacity to
produce a desired effect)
 Efficiency (value for
money)(lowest amount of inputs,
greatest amount of outputs)
 Effectiveness
 Optimality (balancing
improvements with costs)
 Acceptability (to patients and
families)
 Legitimacy (ethical issues-follow
through to treatment)
 Equity (access, fairness,
appropriateness)
The U.S. Institute of Medicine
concepts
 Patient safety to provider safety
to Environmental safety
 Effectiveness (scientifically proven
appropriate care)
 Patient centeredness (respect and
responsiveness)
 Timeliness (minimal delays
barriers to getting access to care)
 Efficiency (minimal waste of
equipment, supplies, ideas, and
energy)
 Equity (care provided consistently
across genders ,ethnic groups,
locations and socioeconomic
classes)

33. WHO

34.  three dimensions of Quality of
Care i.e. professional technical
aspect of care, interpersonal
aspects of quality and social
aspects of quality.
 Professional Technical Aspects
 Accuracy of diagnosis
 Efficacy and efficiency of treatment
 Excellence according to professional
standard
 Necessity of care
 Appropriateness
 Continuity of care
 Consistency (Uniformity, Reliability)

35.  Inter-personal aspects
 Patient Satisfaction
 acceptability
 Time spent with provider
 Attitudes of provider and staff
 Amenities
 Social Aspects
 Efficiency
 Accessibility – including financing

36.  Accreditation is an external quality
evaluation through which an
accrediting organization formally
recognizes that an institution
meets certain standards. “a
voluntary process by which a
government or nongovernment
agency grants recognition to health
care institutions which meet
certain standards that require
continuous improvement in
structures, processes, and
outcomes.” In English, the terms
accreditation,
 certification, and licensure are
often mistakenly used as
synonyms
 Benchmarking.

37.  Accreditation means official
approval given by an organization
stating that somebody/something
has achieved in required standard
 Certification means confirmation
that some fact or statement is true
through the use of documentary
evidence

38.  Popular standards
 ISO 9000 Quality management
 ISO 14000 Environmental
management
 ISO 3166 Country codes
 ISO 26000 Social responsibility
 ISO 50001 Energy management
 ISO 31000 Risk management
 ISO 22000 Food safety
management
 ISO 27001 Information security
management
 ISO 45001 Occupational health and
safety

39.  A measurement of the quality of
an organization's policies,
products, programs, strategies,
etc., and their comparison with
standard measurements, or similar
measurements of its peers.
 The objectives of benchmarking
are (1) to determine what and
where improvements are called
for, (2) to analyze how other
organizations achieve their high
performance levels, and (3)to use
this information to improve
performance.

40.  Clinical in-service training is a
broad category of quality
improvement strategies, including
all training for health professionals
who have
already completed their formal
credentialing process.
In-service training is meant to
either reinforce important concepts
and practices or to introduce new
knowledge about how a health
professional should work.

41.  designed for quality improvement
in family planning and is now also
used in maternal, child, and
reproductive health.
 uses group problem solving and
self-assessment to identify
problems and set priorities for
quality improvement starts with an
orientation for managers at the
worksite, followed by a self-
assessment where participants
identify and rank their main
problems.
 COPE® is meant to be
implemented with other tools for
continuous quality improvement,
such as supervision and training

42.  use a continuous quality
improvement process
 iterative problem solving,
encourages prompt process
improvements
 Collaboratives usually last about 9–
24 months, during which time the
participating teams analyze a
problem and its causes; plan
changes
 Collaboratives can be used to
improve processes for patients and
providers ,teams, organizations, or
systems.

43.  SBM-R is a management method
developed by Jhpiego that aims to
improve quality of care by
improving health worker
performance.
 It adapts the four main elements
of the continuous quality
improvement cycle (plan, do,
study, act) to standardize, do,
study, and reward
 1.Assessment-standardsAction-
self assessment ,internal
assessment and External
assessments.
 recognized for their efforts;
rewards, such as feedback, praise,
and social recognition,

44.  Supportive supervision refers to a
process of working with staff to set
goals, identify and correct
problems, and monitor staff
performance.
 It generally takes one of three
forms: managerial, clinical, or
educational.

45.  TQM / SQI = Professionalism x Motivation x Leadership x Management x
Partnership
a. Practice professionalism by all categories of health
professionals
b. Fulfill basic and social needs to motivate professionals
c. Develop leadership quality
d. Better management and use management tools
Establish strong partnership both internal and external users
45
Prof.Dr Mya Oo

46. The governance
means the process of
decision making and
the process by which
decisions are
implemented

47. Clinical
Governance
Risk
Management
Guidelines
Cl. Standards
Ethical Stand
Audit &
Cl. Meeting
CPC
Information
Management
Patient
Safety
Openness /
Truthfulness
Education
and
Training
Research
Clinical
effectiveness &
Efficiency
Responsibility
&
Accountability
Enabling
Environment
Patient
Satisfactions

48. 1. Clinical Effectiveness
2. Research & Development
3. Openness
4. Risk Management
5. Education & Training
6. Clinical Audit
In 1990s, the UK introduced clinical (including doctors, nurses and therapists)
audit programs to assess the performance of clinical process and to educate the
health workforce concerned. This form of self regulation activities should be
welcome. We should avoid blame culture and develop our learning from those
experiences.
This form of clinical audit should be introduced and promoted in central
tertiary care hospitals.

49.  Clinical audit is a process that has
been defined as "a quality
improvement process that seeks to
improve patient care and
outcomes through systematic
review of care against explicit
criteria and the implementation of
change“
 The key component of clinical audit
is that performance is reviewed (or
audited) to ensure that what
should be done is being done, and
if not it provides a framework to
enable improvements to be made
Definition was announced
by the NHS executive:“
Clinical audit is the
systematic analysis of the
quality of healthcare,
including the procedures
used for diagnosis,
treatment and care, the
use of resources and the
resulting outcome and
quality of life for the
patient."

50.  WHO HPH movement focuses on
four areas: promoting the health of
patients, promoting the health of
staff, changing the organization to
a health promoting setting, and
promoting the health of the
community in the catchment area
of the hospital. These four areas
are reflected in the definition of a
health promoting hospital:

51.  A health promoting hospital does
not only provide high quality
comprehensive medical and
nursing services, but also develops
a corporate identity that embraces
the aims of health promotion,
 develops a health promoting
organizational structure and
culture, including active,
participatory roles for patients and
all members of staff, develops itself
into a health promoting physical
environment, and actively
cooperates with its community”

52. Increasing complexity
Individual
problem
solving
Rapid team
problem
solving
Systematic
team
problem
solving
Process
improvement

53.  Step1. Identify -Determine what
to improve
 Step 2.Analyse -understand the
Problem
 Step3.Develop -Hypothesize
about what changes will improve
problem
 Step4. Test/Implement- Test the
hypothesized solution to see if it
yeilds improvement; based on the
results, decide whether to
abandon, modify, or implement
solution.

54. Individual
Problem solving
approach
Rapid Team
Problem solving
approach
When to use the
approach
When you know
the problem is
dependent on only
one person
When the team
needs quick
results and has a
lot of intuitive
ideas
Teams Unnecessary Ad hoc
Data Almost none Can succeed with
little data
Time Little Little

55. Systematic Team
problem solving
approach
Process
improvement
approach
When to use the
approach
When the problem
is complex or
recurring,
requiring analysis
When a key
process or system
requires ongoing
monitoring or
continuous
improvement
Teams Ad hoc Permanent
Data Need data to
understand the
causes of problem
Data from
continuous
monitoring, may
need to collect
more
Time Limited to the time
necessary
continuous

57.  1. cost-effectiveness,
 2.The method’s affordability
 3.The feasibility of the method—
 4.it is realistic to implement
 5.the replicability of results in new
settings and
 6.the scalability, or ease of
expansion,
 7.Lastly, the sustainability of the
method, or the extent to which a
program can be integrated into
existing system,.

58. THANK YOU FOR YOUR ATTENTION
dr.swewin1969@gmail.com