Healthcare Quality Concepts Prepared by: Dr. Alber Paules
Evolution of Quality ManagementWalter Shewhart (1891-1967): o He was an American physicist, engineer, and statistician. o He is called the “Grandfather” of quality movement (the fathers are Deming and Juran, since much of their works was influenced by Shewhart’s ideas). o Also known as the “Father of Statistical Quality Control”; he introduced the concept of Statistical Process Control (SPC) in manufacturing. o Developed the run charts and the control charts (known as “Shewhart Charts”) in order to aid managers in making scientific and economical decisions.
Evolution of Quality ManagementWilliam Edwards Deming (1900-1993): o He was an American engineer and statistician. He is the student of Walter Shewhart. o Post WWII, Deming’s ideas lost popularity in the US, mainly because demand for all products was so great that quality became unimportant; any product was snapped up by the hungry consumers. o He taught statistical process control methods and quality concepts to Japanese business leaders, returning to Japan for many years to consult and to witness economic growth. Deming’s message to the Japanese leaders was “improving quality will reduce expenses while increasing productivity and market share.”
Evolution of Quality ManagementWilliam Edwards Deming (1900-1993): o Deming made a significant contribution to Japans later reputation for high-quality products and its economic power. o Despite being considered something of a hero in Japan, he was only just beginning to win widespread recognition in the U.S. at the time of his death o Deming’s quality ideas went far beyond SPC to include a systematic approach to problem solving and continuous process improvement with the PDCA cycle, which he developed (it is also called the “Deming Cycle”).
Evolution of Quality ManagementWilliam Edwards Deming (1900-1993): o Deming also believed that management is ultimately responsible for quality and must actively support and encourage quality “transformations” within organizations. He then developed his famous 14 key principles to guide the management how to achieve such transformation.
Evolution of Quality ManagementJoseph Juran (1904-2008): o He was born in Romania and later immigrated to the US with his family when he was 8 years old. o He was an engineer. o Working independently of Deming (who focused on the use of statistical quality control), Juran (who focused on managing for quality) went to Japan and started courses (1954) in Quality Management. During his life he made ten visits to Japan, the last in 1990. o Juran’s Quality Handbook was first published in 1951 and remains a standard reference for quality. o Juran was one of the first to define quality from the customer perspective as “fitness for use”.
Evolution of Quality ManagementJoseph Juran (1904-2008): o The training started with top and middle management. The idea that top and middle management need training had found resistance in the United States. o During the 1970s and 1980s, the Japanese automobile industry gained higher popularity in the US and threatened the national automobile industry. The Japanese products were famous for lower prices and higher quality. o In 1941, Juran stumbled across the work of Vilfredo Pareto and began to apply the Pareto principle to quality issues.
Evolution of Quality ManagementJoseph Juran (1904-2008): o Juran is widely credited for adding the human dimension to quality management. He pushed for the education and training of managers. For Juran, resistance to change— or, in his terms, cultural resistance—was the root cause of quality issues. o Jurans vision of quality management extended well outside the walls of the factory to encompass non- manufacturing processes. o He also developed the "Jurans trilogy”. o During his 1966 visit to Japan, Juran learned about the Japanese concept of Quality Circles (Quality Teams) which he enthusiastically spread in the West.
Evolution of Quality ManagementPhilip Crosby (1926-2001): o He was an American businessman. o In 1979, he issued groundbreaking book “Quality Is Free”. In this book, he popularized the idea of the "cost of poor quality", that is, figuring out how much it really costs to do things badly. o He promoted the phrase “right first time”.
Definitions of “Quality”If we look to some famous experts in the subject, wefind that they define “quality” in the following ways:• “Meeting of customers’ needs” (W. Edwards Deming);• “Fitness for use” (J.M. Juran);• “Conformance to requirements” (Philip B. Crosby).
Definitions of “Quality”• Other definitions of quality include: o Doing the right thing right the first time it is done o Conformance to relevant requirements/standards o Satisfying the needs and the expectations of customers o Freedom of deficiencies (less costly because the presence of deficiencies will cause customer dissatisfaction which will need to be reduced or eliminated through correction)
Definitions of “Quality” in Healthcare• Institute of Medicine (IOM) defines “Quality of Care” as: “the degree to which health services for individuals and populations increase their likelihood of desired health outcomes and are consistent with current professional knowledge.”
Definitions of “Quality” in Healthcare• Joint Commission defines “Quality” as “the optimal achievement of therapeutic benefit and avoidance of risk and minimization of harm”.• Another definition: “degree of conformity with accepted principles and practices (standards), the degree of satisfying the patient’s needs, and the degree of attainment of acceptable outcomes, while making appropriate use of resources.”
Benefits of Providing Quality Services• Increasing customer satisfaction and/or decreasing customer dissatisfaction; with subsequent increase in market share and revenues/profits.• Reducing the cost of poor quality.• Increasing staff productivity; due to increased morale and the standardization of the work processes.
The 3 Aspects of Quality Care1. Measurable Quality: • is the aspect of care which can be judged by the provider through comparative measures between the actual performance versus the standard one.2. Appreciative Quality: • is the aspect of care which can be judged by the experienced practitioners who rely not only on standards but on their personal judgments and experiences as well. Peer review is an example.3. Perceptive Quality: • isthe aspect of care which is perceived/judged by the recipient of care.
The 3 Aspects of Quality CarePerceptive Quality: Quality perceived by the patient is generally based on the degree of care expressed by health care providers rather than on the physical environment and technical competence. The latter two are essential to prevent dissatisfaction but do not necessarily lead to patient satisfaction.
Key Dimensions of Quality of Care1. Appropriateness: • The degree to which the care and services provided are relevant to the individuals clinical needs, given the current state of knowledge.2. Availability: • The degree to which the care and services are accessible and obtainable to meet the individuals clinical needs.3. Competency: • The practitioner’s ability to achieve both desired clinical outcomes and patient’s satisfaction.
Key Dimensions of Quality of Care4. Continuity: • The provision of a seamless care through the coordination among all practitioners and across all the involved settings over time.5. Effectiveness: • The degree to which care achieves the desired outcomes.6. Efficacy: • The potential capacity or the capability of care to produce the desired outcomes.
Key Dimensions of Quality of Care7. Efficiency: • The optimum utilization of resources to produce the desired outcomes.8. Prevention: • The degree to which care promote health and prevent disease.9. Respect and Caring: • The degree to which those providing care and services do so with sensitivity for the individuals’ needs, expectations, and differences. • This may also include the provision of equitable care to all patients.
Key Dimensions of Quality of Care10. Safety: • The degree to which the risk of an intervention and risk in the care environment are minimized for patients, visitors, and staff.11. Timeliness: • The degree to which care is provided to the individual at the most beneficial or necessary time.
The Concept of “Value”• Nowadays, consumers and insurers are demanding proof that the quality of the purchased care is worth the dollars paid. Value = Quality of care (service usefulness perceived by the patient) CostAssume that a patient can have a surgery (X) at either hospital A orhospital B. The level of care provided is the same and the samesurgery team will perform the surgery in either of the two hospitals.If there is charges vary significantly between the two hospitals;then the patient will feel that he has received greater value for theprice paid if he has the surgery done at the lower price hospital.
A Value-based Health Care System• Value-based purchasing is increasing, whereby consumers and insurers utilize those healthcare facilities that embrace quality improvement efforts and hence have better outcomes.• Transparency allows consumers to compare the quality of health care services and make informed choices.
Quality Management• Definition: “A planned, systematic, and organization-wide approach to monitor, analyze, and improve the organizational performance; thereby continually improving the quality of care and services provided” Quality Management (QM) includes efforts to develop and maintain programs to keep it at an acceptable level (quality planning and control) and to institute improvements when the opportunity arises or the care does not meet standards (quality improvement).
Total Quality Management• Total Quality Management (TQM): It is an organization-wide management strategy / philosophy / program aiming at embedding awareness of quality among all staff and at involving every process of the organization in a cycle of continuous improvement with the aim of satisfying the customers’ needs and expectations.
Continuous Quality Improvement• Quality Improvement (QI): the sum of all activities which create desired change in the quality. An effective QI system results in a stepwise increase in quality of care. QI approach emphasizes reducing the variability in the entire process and shifting the process in the desired direction; rather than just taking actions whenever thresholds are exceeded. Continuous Quality Improvement (CQI): implies the continuity of the improvement efforts (i.e.) whenever an improvement is achieved, we might seek another opportunity to achieve further improvement.
TQM/CQI• A hospital with TQM/CQI philosophy will, for example, set specific quality goals, choose a number of high priority QI projects, make quality improvement part of job descriptions throughout the organization, provide necessary resources (dedicated time, financial resources, etc…) for QI efforts, and provide essential training for staff involved in QI efforts.
QA vs. QI• Quality Assurance (QA) is a conformance quality (i.e.) ensures that the performance meets standards/requirements, rather than continually improving performance beyond standards/requirements (e.g.) reducing infection rate at the neonatal ICU to a specific level is a QA project. The new QI approach involves not being satisfied with meeting a specific goal but rather having the organization making continual progress toward 100% compliance (e.g.) reducing infection rate at the neonatal ICU with a systematic continuous effort till reach 0% is a QI project.
QA vs. QI• QA has traditionally been performed by the QA staff who collaborate with the involved department, but the QI paradigm moves the responsibility to all stakeholder departments (through the multi-disciplinary QI team) who get support from the QM staff.
Basic Principles of Quality Management1. The active participation and the commitment of Top Management is crucial.2. Establishment of new organizational structures, which are responsible for all quality-related issues, can help achieve quality improvement (e.g., the quality council).3. Work is accomplished through processes; the main source of quality defects is problems in the process.4. Understanding the variability in the process is crucial.5. Poor quality is costly.
Basic Principles of Quality Management6. Scientific statistical methods and proper quality tools/techniques should be used to improve care.7. Total employee involvement is critical. Employees should be provided with appropriate education and training. Quality is everyone’s responsibility.8. Recognition and reward systems.9. Customer focus.10. Corporate culture should be transformed to that of quality.
Deming’s 14 points for Management1. “Create constancy of purpose for continual improvement of products and services, with the aim to become competitive and to stay in business”: this is achieved through proper strategic planning, investment in education/training, listening to all customers, and responding to their needs.2. “Adopt the new philosophy that quality must become the new trend”: providers have to realize that the era of cost- based retrospective reimbursement, when they were paid whatever they charged, is over. During that era, efforts to improve efficiency and effectiveness of care were minimal. The introduction of new prospective payment methods, with their financial constraints, has forced the providers to adopt the quality principles in order to provide a “value” care, which is both effective and efficient.
Deming’s 14 points for Management3. “Eliminate the need for mass inspection”: a better approach is that inspection should be used to see how we are doing, and not be left to the final product, when it is difficult to determine where in the process a defect took place. When this principle is applied to the healthcare services, it can be achieved through considering process review/re-design when the outcome(s) is/are not favorable.4. “End the practice of awarding business solely on the basis of price tag”: vendors of pharmaceuticals, medical equipment, supplies, software…..etc must be chosen based on quality and reliability of the products they provide, in addition to the timeliness. Mechanisms should be in place to ensure that products selected to be utilized inside the organization undergo a sort of scrutinizing before being chosen.
Deming’s 14 points for Management5. “Improve constantly and forever the system of production and service”: improvement is not a one-time effort — management is obligated to improve quality continuously.6. “Institute modern methods of training on the job for all, including management”: healthcare practitioners must be provided with continuing education and training especially with the emerging demands that care provided be based on current, scientific, and valid evidence. Web-based education, specially the one depending on multimedia tools, is a good practical solution (e.g., www.cmeweb.com). Providing the practitioners with access to professional sites is another solution (e.g., www.cochrane.org).
Deming’s 14 points for Management7. “Adopt and institute leadership aimed at helping people to do a better job”: top management should optimize output from people (i.e.) increase productivity, while maintaining or increasing quality of the care provided. One way to achieve this is through establishing reward and recognition systems.8. “Encourage effective two-way communication and other means to drive out fear throughout the organization”: in some organizations, suggesting new ideas is too risky; people are afraid of losing their raises, promotions, or jobs. Fear robs people of their pride in their jobs and of the chance to contribute to the organization (i.e.) decreases productivity. Empowering staff and seeking their contributions through the QI teams are approaches that improve fear in the organization and improve productivity.
Deming’s 14 points for Management9. “Break down barriers between departments”: there are numerous problems when departments have different goals and do not work collaboratively to solve problems. Alignments of the goals and functions of different departments through essential to achieve the ultimate organizational goals.10. “Eliminate the use of slogans, posters, and exhortations for the workforce that do not provide methods”: Slogans never helped anybody do a good job. Setting goals (through slogans) without describing how they are going to be accomplished is pointless. Rather than generate slogans, the organization should change the work environment and develop policies and procedures through which goals will be achieved and productivity will be increased.
An Example to Explain “Principle 10”− The administration at XYZ hospital was becoming progressively more concerned about dropping patient satisfaction scores in the ED. Qualitative surveys were conducted to identify the reasons of dissatisfaction and the results were depicted on a Pareto chart.− The figure demonstrates that long waiting times and staff discourtesy were among the most prevalent reasons for patient dissatisfaction.− The administration placed a number of signs around the ED staff rooms, with slogans such as “The Patient Is Our First Priority” and “Rapid Care Is Excellent Care”.− Over the next few months, administrators noted that satisfaction survey scores actually dropped slightly, rather than rising in response to the slogans campaign.
Pareto Analysis50%45%40%35%30%25%20%15%10% 5% 0% Waiting Staff Facilities Amount of Availability Others Time Courtesy Bill of Foods and Drinks 38
An Example to Explain “Principle 10”− At this point, the administrators decided to poll the staff at the ED, who noted that the scheduling pattern left the department understaffed during the early evening hours.− Administrators delegated scheduling to the department manager, and over the next several months, patient satisfaction survey scores improved by 30%, and the ranking of waiting time and staff courtesy complaints, in the Pareto analysis, changed.− Therefore, we can see how the ED staff identified and corrected scheduling problems with better distribution of the workload. This caused staff satisfaction improvement leading to better scores on staff courtesy. Additionally, diminished waiting time was associated with improved satisfaction scores.
Deming’s 14 points for Management11. “Eliminate work standards that prescribe quotas for the workforce and numerical goals for people in management”: Quotas or other work standards, such as measured day work or rates, impede quality.12. “Remove the barriers that rob people of their right to pride of workmanship”: Delegate responsibility to the staff to seek out quality and do whatever it takes to accomplish it (empowerment). Receptionists, housekeeping workers, nurses’ aides, and transport staff all spend copious time with patients and their attitudes and behavior can have significant influence on patient perceptions of a provider.
Deming’s 14 points for Management13. “Institute a vigorous program of education and encourage self improvement for everyone”: change requires education. Education not only facilitates change, it also promotes personal growth and development because workers who learn more about their professions tend to be more satisfied, productive, and empowered.14. “Take Action to Accomplish the Transformation”: Top management should ensure that quality is embedded as a cultural value within the organization. Senior managers must make sure that the organizational structure, the organizations policies and procedures, and the incentives system altogether support everybody’s commitment to quality.
Juran Model of QM (Juran Trilogy)1. Quality Planning: concerned with the development of services/products to meet customer needs, through the following steps: • Definition of the project. • Identification of the customers. • Discovery of customer needs. • Development of the product and processes to meet the customer’s needs.
Juran Model of QM (Juran Trilogy)2. Quality Control: involves the developing and maintaining of operational methods in order to ensure that the processes work as they are designed to work and that the target levels of performance are being achieved, through the following steps: • Set performance goals. • Develop performance measures. • Measure and analyze. • Compare actual performance to target performance. • Take action in case of difference.
Juran Model of QM (Juran Trilogy)3. Quality Improvement: an approach that improves the level of performance of the process. After ensuring that the new levels of performance are achieved, quality control mechanisms are in place to sustain that effectively. This is achieved through: • Collaboratively studying the process. • Analyzing causes of process failure, dysfunction, and inefficiency. • Systematically developing optimal solutions to the chronic problems in the process.
“Avedis Donabedian” Paradigm Structure, Process, and OutcomeBiography of Prof. Avedis Donabedian:• He was born in Beirut, Lebanon in 1919• He studied at the faculty of Medicine, AUB.• He then migrated to the US, where he joined the public health school.• Donabedian authored 16 books and more than 100 articles that focused on quality assessment and improvement in the HC sector.• He published his famous article about the classification of methods for quality assessment: structure-process-outcome in 1966.
“Avedis Donabedian” Paradigm Structure, Process, and Outcome• Donabedian was one of the first to view healthcare as a system composed of structure, process, and outcome.• He believed that quality of care is not only related to each of these elements individually, but also to the relationships among them.
Structure• Structure component of Donabedian’s Paradigm designates the conditions under which health care is delivered. The conditions included may be material/physical resources, such as facilities and equipment; human resources and intellectual capital, such as the number, variety, and qualifications of professional and support personnel; and organizational characteristics such as the organizational structure and the hierarchy.
Process• Process component of Donabedian’s Paradigm refers to the procedures, methods, means or sequence of steps that are followed in order to provide care and produce outcomes.• The “process” is a series of activities that transform inputs (resources from suppliers) into outputs (services/products to customers). Those who perform those activities are called “processors” or “process owners”.• Viewing healthcare services as processes is the first step in applying techniques/methods for improving care.• In health care settings, processes have the following 3 types: 1. Patient flow processes 2. Information flow processes 3. Material flow processes
Outcomes• According to Donabedian, structures combine with processes to produce outcomes (i.e., S + P = O)• Outcomes refer to the results of care, whether adverse or beneficial.• Classification of Outcomes: 1. Clinical: (e.g.) mortality, complications, and adverse events. 2. Functional: (e.g.) ability to perform Activities of Daily Living 3. Perceived: (e.g.) patient satisfaction 4. Financial: (e.g.) cost savings 5. Utilization: (e.g.) productivity, LOS