CONCEPT OF QUALITY MANAGEMENT IN HEALTHCARE ORGANISATIONS

1. Concept of
Quality Management
In Healthcare Organizations
Dr. Maha Mohamed Khalaf
Senior consultant of clinical pathology and immunology
Hospital management and Quality consultant
LECTURE 2

2. Defining Quality
• IOM – The degree to which health
services for individuals and populations
increase the likelihood of desired health
outcomes and are consistent with
current professional knowledge.
• Donabedian - The systematic
measurement and evaluation of the
predetermined outcomes of a process,
and the subsequent use of information
to improve the process based on
expectations of the customer.

3. What is Quality ???
• Quality is often used to signify ‘excellence’ of a product or service ”.
• Quality is doing the right things right from first time.
• The perception of the degree to which the product or service meets
the customer's expectations.

4. • Is holistic , organizational –
wide approach to improve and
maintain quality.
• All of organization’s activities
and resources are directed
toward achievement of goal
that is , customer satisfaction
with care given.
Total Quality management:

5. We need quality effects
and improvement in the
environment through all
the followings

6. Competition among
Healthcare providers

7. Don’t be like an Ostrich….

9. Quality overview:
Historically, the focus in developing countries was on the
quantity rather than quality of health services .
Now, there are many evidence that show that quality of
care (or the lack of it) , must be at the center of every
discussion about better health.

10. Historical Development of Quality in HCO:
1) Until early in 1950 : quality care review was held by individual
(physicians, pharmacists or nurses) utilizing an unstructured and
subjective process, which relied on practitioner’s knowledge and
experiences.
2) 1950 – 1960 : represented a transition period, where quality care
review expanded beyond physicians to both the hospital and the
board of directors, and medical audits were held as a systematic
procedure based on pre-set criteria.
3) In 1966 : the Joint Commission focused on optimal standers of care.

11. Historical Development of Quality in HCO:
4) In 1975 : JC published the quality professional services standards,
demanding hospitals to present optimal care using valid and reliable
measures, and optimal standards were never defined.This led to the
foundation of performance evaluation program audits.
5) In 1980 :The JC developed the first “quality assurance “(QA)
standards, requiring a problem- focused approach to measuring
quality.

12. Historical Development of Quality in HCO:
6) QA criteria based approach, together with infection control
approach led to the development of “ Quality Improvement “ QI
(10 steps process), requiring hospitals to evaluate improvement
aspects of care and use the result to identify opportunities for
improvement.
7) In 1985: This led to the development of the clinical “ MONITORING
and EVALUATION “ (M & E)

13. History ofTotal Quality Management :
• Ql (1910): Identify sources of non-conformance.
• QC (1924) : Statistically quality control for the cause of variation.
It focus on performance .
• QA (1950) : Is the measurement of actual level of the service provided
plus the efforts to modify when necessary .It focus on process.
• TQM (1980): Is a method for ensuring that all the activities necessary
to design, develop and implement a product or service are effective
and efficient with respect to the system and its performance.

15. Six
Domains of
Healthcare
Quality

16. Six
Domains of
Healthcare
Quality

17. What is quality assurance?
• Process of measuring quality, analysing
the deficiencies discovered and taking
action to improve performance,
followed by measuring quality again to
determine whether improvement has
taken place.
• A systematic process for closing the
gap between actual performance and
desirable outcomes.
17

18. QC & QA focus on meet needs of patients and
performance..
While
TQM focus on all quality approaches.

19. TOTAL QUALITY MANAGEMENT
“TQM” philosophy

20. TQM
• Total - made up of the whole
• Quality - degree of excellence a product or service
provides
• Management - act, art or manner of planning,
controlling, directing,….
Therefore,TQM is the art of managing the whole to
achieve excellence.

21. What doesTQM mean?
•Total Quality Management means that the organization
supports customer satisfaction through an integrated
system of tools, techniques, and training.
•This involves the continuous improvement of
organizational processes, resulting in high quality
products and services.

22. Definition ofTQM :
• an organization wide philosophy
and top- commitment of
continuous improvement of
people skills and processes.
• Building excellence into every
aspect of the organization.

23. Benefits ofTQM :-
• Increase customer satisfaction.
• Increase productivity.
• Increased profits.
• Increased market share.
• Decreased costs.

24. History ofTQM :
• “Walter Stewart” was the first to call for adopting the concept ofTQM in industry.
• He worked on finding and fixing problems in products not through end- point
inspection, but in the work process.
• Edwards Deming” and “Josef Juran” assisted the Jappanese after WW2 in applying
the concern ofTQM in industry.
• Deming” developed 14 points to help manage quality of services and
products.these points were later revised to be accommodated

25. History ofTQM :

26. 1. Create constancy of purpose towards improvement of product and service.
2. Adopt the new philosophy "doing the right things right the first time through
effective training“
3. Cease dependence on inspection to achieve quality, "move inspection as far to the
beginning of the process as possible".
4. End the practice of awarding business on price tag alone.
5. Improve constantly and forever every process for planning, production, and service.
6. Institute training on the job.
7. Adopt and institute leadership.

27. 8. Drive out fear.
9. Break down barriers between staff areas.
10. Eliminate slogans, exhortations, and targets for the work force.
11. Eliminate numerical quotas for the work force and numerical goals for management
12. Remove barriers that rob people of pride of workmanship.
13. Institute a vigorous program of education and self-improvement for everyone.
14. Put everyone to work to accomplish the transformation.

28. What’s the goal of TQM?
• “Do the right things right the first time, every time.”

29. Key Dimensions of Quality Care/Performance
“Key dimensions of quality care” provide the
framework for quality management activities in
all healthcare settings and a balanced and well-
integrated
quality, cost, and risk perspective.
29

30. Basic of TQM
• 1. The customer makes the ultimate determination of
quality.
• 2. Top management must provide leadership and support
for all quality initiatives.
• 3. Preventing variability is the key to producing high
quality.
• 4. Quality goals are a moving target, thereby requiring a
commitment toward continuous improvement.
• 5. Improving quality requires the establishment of
effective metrics.We must speak with data and facts not
just opinions.

31. The three aspects ofTQM
Counting
Customers
Culture
Tools, techniques, and training in
their use for analyzing,
understanding, and solving quality
problems
the customer is a driving force
and central concern.
Shared values and beliefs,
expressed by leaders, that define
and support quality.

32. Total Quality Management
and Continuous Improvement
• TQM is the management process used to make continuous improvements to all
functions.
• TQM represents an ongoing, continuous commitment to improvement.
• The foundation of total quality is a management philosophy that supports
meeting customer requirements through continuous improvement.

33. Continuous Improvement versus Traditional
Approach
• Market-share focus
• Individuals
• Short-term focus
• Product focus
• Innovation
• Fire fighting
• Customer focus
• Cross-functional teams
• Long-term focus
• Continuous improvement
• Process improvement focus
• Incremental improvements
• Problem solving
Total Quality Management
Traditional Approach Continuous Improvement

34. QualityThroughout
• “A Customer’s impression of quality begins with the
initial contact with the organization and continues
through the life of the product.”
• Customers look to the total package - sales, service
during the sale, packaging, deliver, and service after the
sale.
• Quality extends to how the receptionist answers the
phone, how managers treat subordinates, how sales and
repair people are, and how the product is serviced after
the sale.
• “All departments of the company must strive to
improve the quality of their operations.”
Total Quality Management

35. What about
Quality in
Egypt?

36. • The Quality department was developed in 1997(MOH).
• Started By developing accreditation program for the primary care
• Now, Accredited more than 2000 primary unit and centers

37. International Society for Quality in Health
Care (ISQua), is an international organization
that provides independent assessment of
medical standards against international
principles and Practices (“Accreditor of
Accreditors”)
•Egypt is the first country in the Middle East,
and the 11th worldwide to achieve this
certification….2007.

38. What does health care quality mean
?
Quality means different things to
different people
To the PATIENT:
Get well – feel better – recover
Skilled and helpful staff
Effective health outcomes
Welcoming atmosphere

39. What is health care quality mean?(Cont.)
• To the STAFF:
Standards of care
Up to date and working equipment
Continuing education and training
Effective team work

40. What is health care quality ?(Cont.)
• To the HOSPITAL MANAGEMENT
Positive health outcomes for patients
Continuous quality development at all levels of
the organization
Providing education and training for staff
Stable and trained work force.

41. What is health care quality ?(Cont.)
To the GOVERNMENT & POLICY MAKERS:
Effective health care system
Improved quality of life for people
Research-based continuous quality development
Monitoring of results/achievements and taking
actions to improve outcomes

42. Quality Improvement in Health Care
• Major elements of quality:
• Structure
• Process
• Outcomes
• Major aims for improvement in healthcare:
• Safe, effective, patient-centered, timely, efficient, and equitable
• (STEEEP)

43. Dimensions of quality
High- quality care is efficacious,
appropriate, effective, safe, efficient, and
coordinated over time and across practitioners and
settings. It is also available when needed, delivered in
a timely fashion, and perceived by the patient to be
provided in a manner that is respectful
and caring.

44. Dimensions of quality
 Accessibility.
 Appropriateness.
 Continuity.
 Effectiveness.
 Efficacy.
 Efficiency.
 Patient respect and care.
 Safety.
 Timeliness.
JCAHOs, 1990

45. Accessibility
"The ease with which users can obtain
the care that they need when they need
it"

46. Appropriateness of Care
"The degree to which the correct care (the care that is relevant to
the patient’s/users medical needs) is provided, given the current
state of knowledge".
Continuity of care
"The degree to which the care needed by
patients/users is coordinated among
practitioners, organizations and over
time".

47. Effectiveness of Care
"The degree to which the care given to
patients/users is provided correctly
(i.e. without error), given the current
state of knowledge".
 Doing the right thing.

48. Efficacy of Care
"The degree to which a service/care has
the potential to meet the need for which it
is planned under ideal circumstances."
BACK

49. Patient Perspective Issues
"The degree to which patients/users and
their families are satisfied with their care
and involved in the decision-making
processes of their care and to which those
providing the care do so with sensitivity
and respect for the patient’s needs,
expectations and individual difference."
BACK

50. Safety of the Care Environment
"The degree to which the environment is
free from risk (hazard or danger) for both
users and providers."
BACK

51. Timeliness of Care
"The degree to which care is provided to
patients/users when it is needed i.e., at
the most beneficial or necessary time."

52. Acceptability:
Conformity to the wishes, desires, and
expectations of patients and responsible
members of their families.

53. Equity:
Conformity to a principle that determines
what is just or fair in the distribution of
health care and its benefits among the
members of a population.

54. Efficiency of Care
"The relationship between the outcomes
(results of care) and the resources used
to deliver the care".
 "The degree to which the care received
has the desired effect with a minimum
of effort, expense or waste.“
BACK

55. Quality is free..
If you do a quality job it will not
cost you, what costs you is non
quality.

56. Key Dimensions of Quality Care/Performance
1. Appropriate
• “The degree to which the care and services provided
are relevant to the patient’s clinical needs, given the
current state of knowledge
2. Available
• The degree to which appropriate care and services
are accessible and obtainable to meet the patient’s
needs
56

57. Key Dimensions of Quality Care/Performance
3. Competent
◦ The practionationer’s ability to produce both the health and satisfaction of
customers
4. Continuit
◦ The coordination of needed healthcare services for a patient or specified
population among all practitioners and across all involved organizations
over time;
◦ The delivery of needed healthcare as a coherent unbroken succession of
services (truly “managed” care)
57

58. Key Dimensions of Quality Care/Performance
5. Effective
• “ The degree to which the care and services are provided in the correct
manner, given the current state of knoweldge (evidence-based) to achieve the
desired outcome and positive results for the patient”
6. Timeliness
• “The degree to which needed care and services are provided to the patient at
the most beneficial or necessary time”
• The degree to which services are provided to customers in accordance with
their needs
58

59. Key Dimensions of Quality Care/Performance
7. Respect and Caring
• “ The degree to which those providing services do so with sensitivity and respect
for the patient’s needs, expectations, and individual differences”
8 Safety
• The degree to which the healthcare intervention minimizes risks of adverse
outcome for both patient and provider;
• The degree to which the organizational environment is free from hazard or
danger;
• “The degree to which the risk of an intervention and risk of the care environment
are reduced for the patient and others, including the health care provider”
59

60. Key Dimensions of Quality Care/Performance
9. Respect and Caring
• “ The degree to which those providing care and services do so with sensitivity
and respect for the patient’s needs, expectations, and individual differences”
(and) “involved in his or her own decisions”
10. Safety
• The degree to which the intervention minimizes risks of adverse outcome for
both patient and provider;
• The degree to which the organizational environment is free from hazard or
danger;
60

61. Continuous Quality Improvement
(CQI)
• CQI is a cyclical process.
• It involves identifying an area where there is an opportunity for
improvement then outline the sequence of activities that should
occur in order to solve that problem, and implementing them.
• Once the cycle is completed it has to be determined whether the
problem has been solved.
• If the problem continues, the cycle should be repeated.

62. Continuous Quality Improvement (CQI)(Cont.)
Basic Principles:
• Teamwork
• Includes customer perspective
• Continuously improve Q even in absence of
problems
• Measurement of work process
• Willingness, even eagerness to change

63. CQI ask "WHY" not "WHO"
 "why" the problem happens ? not
"who" did it ?,
 What was wrong with the system ?
 What can I do to improve the system ?

64. To improve a system…
• You need a good understanding of the system
• You need to understand where it is failing - Identify what is wrong .
• Make sure it is the step that needs fixing.
• Then you can implement a change to the “system”

65. What is a system?
• System = any assembly of procedures, resources and routines to carry out a
specific activity

66. System
• To understand a system and identify what is wrong with it Map it out!

67. How do you map out a system?
• Use a flow chart/diagram
• Use different perspectives (a doctor’s perspective is different to a nurse’s or a
porter’s to a patient’s perspective)

68. • Change is difficult and can be
threatening
• Change can be time-consuming
• Change involves understanding
people, systems and processes
• Healthcare systems are often complex
and fragmented
Changing systems

69. Why change?
Why change?
Because:
‘If you always do what you have always done, you will always get
what you have always got!’

71. Benefits of Quality Management/improvement
Quality Improvement
Improved Productivity
Improved outputs (product/service)
Better resource use (Efficiency)
Decreased Production Costs
Lower Prices
Increased Customer Satisfaction
Increased Market Share/Enhanced competitive position
Increased Profit

72. What is the best way to approach change that results in
improvement?
Trial & Error? Detailed prior study
Too much action,
not enough thinking
‘Something must be done,
this is something,
therefore we must do it…’
Too much thinking,
not enough action
‘We can’t do anything
until we know exactly
what to do…’
‘Trial and Learning’Approach
How it has been done so far…

73. • Setting challenging aims
- is it worth doing? Not ‘change for change sake’
• Identifying principles/change ideas
- what has worked for someone? What might work for us?
• Measuring progress
- knowing what’s happening
• Testing changes
- starting small; reducing risk
• Implementing and sustaining change
- change in systems and routines; developing skills and abilities
‘Trial and Learning’

74. • Trial and learning :
• Setting challenging aims
- is it worth doing? Not ‘change for change sake’
• Identifying principles/change ideas
- what has worked for someone? What might work for us?
• Measuring progress
- knowing what’s happening
• Testing changes
- starting small; reducing risk
• Implementing and sustaining change
- change in systems and routines; developing skills and abilities
and and Learning’

75. ThThe fundamental improvement questionse
fundamental improvement questions
• What are we trying to achieve?
• Know exactly what you are trying to do – have clear aims and objectives
• How will we know that change is an improvement?
• Measuring processes and outcomes
• What changes can we make that will result in an
improvement?
• What have others done?What can we learn as we go along?

76. Quality Improvement Models
PDSA

77. WHAT is the PDSA Cycle?
• A simple tool for staff to use test out ideas that will improve
healthcare systems and processes
• A structured approach for making small incremental changes to
systems
• A full cycle for planning, implementing, testing and identifying
further changes

78. Plan, Do, Study, Act
Act Plan
Study Do
What changes
are we going to
make based on
our findings?
When and how
did we do it?
What exactly are
we going to do?
What were the
results?

79. Why use PDSAs?Why use PDSAs?
• The PDSA Cycle was developed for use in healthcare systems by
the Institute for Healthcare Improvement in the USA.
• Small rapid cycles lead to improvement
• It is highly effective, changes are quick and immediately evident
• It is a powerful tool for learning. As much is learned from ideas
that don't work as from those that do

80. • Identify the changes
• Set objectives
• Make predictions
• Plan how to measure outcomes
• Define roles and responsibilities
Plan

81. Do Do
• This is the stage where the plan is put into action.
• Remember to keep it small and manageable, i.e. one patient, one doctor, one nurse,
one day.(PILOT STUDY)

82. Study Ststudy
• Review the cycle
• Reflect with all relevant stakeholders
• Analyse data collected
• Generate ideas for improvements prior to re-testing

83. Act
• The cycle should be tested again unchanged under different conditions
• Alternatively, you may decide to amend your plan to reflect learning from first
cycle and re-test

84. Repeated use of the PDSA cycle
Testing and
refining ideas
Implementing new
procedures & systems
- sustaining change
Bright
idea!

85. Your turn!
Develop your own PDSA cycle in relation to a small part of your working life you would
like to change

86. “When you have two
data points, it is very
likely that one will be
different from the other.”
W. Edwards Deming

87. WhatAre Performance Measures?
PERFORMANCE MEASURES ARE USED ATTHE
TREATMENT PROGRAM LEVEL FOR QUALITY
IMPROVEMENT

88. Attributes of Performance Measures
• Well defined
• Objective
• Measurable (reliable and valid)
• Comparative and
• Graphically displayed
88

89. Keep it simple
Performance Measures must be
• • simple to operate
• • simple to understand
• • simple to action

90. MeasurementTools
• Indicators
• Surveys
• Data collection Sheets
• Expert Opinion (qualitative)
90

91. What is an Indicator?
91

92. Indicators are reliable and valid
measures used to screen/assess
organizational and practitioner
performance issues, but not
direct measures of quality
92

93. Types Of Indicators
•Outcome Indicator measures what happens or does not happen as the
result of a process or processes;
•Process Indicator measures a discrete activity that is carried out to
provide care or service
•Structure indicator measures the inputs to the process and resources
allocated to provide care
93

94. -Quality means doing the right things right the first
time.
-TQM is the integration of all functions and processes
within an organization in order to achieve continuous
improvement of the quality of services.The goal is
customer satisfaction.
-Approaches of quality include QC,QA,TQM and CQI.
-Dimension of quality (safety, continuity, timeliness
,effectiveness of care ,efficiency and efficacy of care……).
Conclusion

95. Conclusion
• CQI is a cyclical process.
• It involves identifying an area where there is an opportunity for
improvement then outline the sequence of activities that should
occur in order to solve that problem, and implementing them.
• PDSAs are one of models of quality improvement.
• PDSAs offer confidence to those who are afraid of change