understanding quality of healthcare definitions,concepts and key dimensions

1. Dr. Nilly Shams
Public Health and Clinical Nutrition Specialist
Founder and President of the Egyptian Nutrition and Health Coaching Association, ENHCA
Certified Health Coach, IIN. USA
CPHQ, CBPPS. USA
Quality Applications
in Nutrition Practice

2. Objectives
• What is Quality of Healthcare? how close your Practice is to
its definition?
• What is the effect of applying quality concepts in our
practice as nutritionists?
• What about Measurable and Perceptive considerations in
Nutrition Care?
• Transparency in healthcare?????
• Planning of Nutrition Practice.
• Leadership and Management Basics.
• Nutrition Practice Outcome.

3. Objectives
• How to achieve quality and patients safety in nutritional
care?
• How to improve your performance?
• What are the necessary steps of the Nutrition Care Process
and Diagnosis?
• How to use Information Management to support decision
making?

4. Quality Definitions
• Quality means to do the right things right the
first time and every time.
• Quality is compliance with standards.
• Customers define quality as judging whether
or not the right things are done in ways that
meet their own needs and expectation.

5. Quality Definitions
AHCPR Agency for Health Care Policy & Research:
• Provider deliver the right care to the right patient at
the right time in the right way.
• Patient can access timely care, have accurate and
understandable information about risk and benefits,
protected from unsafe service & product.
• Both patients & clinicians have their rights respected.

6. Quality Definitions
IOM Institute Of Medicine:
Quality of care is the degree to which health
services for individuals and populations increase
the likelihood of desired health outcomes and
are consistent with current professional
knowledge.

7. Quality Definitions
Juran Institute:
1. Freedom from deficiencies (things could be prevented):
excessive wait time, Adverse Drug Reaction.
2. Product features (Meet customer Expectation):
Pleasant waiting area, knowing all treatment options, follow up
care.

8. Aspects of Quality “MAP”
• Measurable Quality: compliance with
standards taken from practice guidelines.
• Appreciative Quality: excellence beyond
minimal standards, peer review.
• Perceptive Quality: degree of excellence
judged by the recipient or observer of care.

9. KEY DIMENSIONS OF QUALITY
CARE/PERFORMANCE
• Appropriateness (relevant, in accordance)
• Availability (accessible, without barriers)
• Competency (ability)
• Continuity (integration, co-ordination)
• Effectiveness (implementation, result, outcome)
• Efficacy (capacity)
• Efficiency (relationship = result of care)
• Prevention/Early detection
• Respect and caring (patient)
• Safety
• Timeliness

10. Appropriateness
"The degree to which the care and services
provided are relevant to an individual's clinical
needs, given the current state of knowledge“

11. Availability (Easy Access)
• The degree to which appropriate care and
services are accessible and obtainable to meet
an individual's needs;

12. Competency (Ability to perform)
• The practitioner's ability to produce both the health
and satisfaction of customers;
• The degree to which the practitioner adheres to
professional and/or organizational standards of care
and practice

13. Continuity (Coordination / Integration)
• The delivery of needed healthcare as a
coherent unbroken succession of services

14. Effectiveness
(Outcome after correct implementation)
• The degree to which care is provided in the correct
manner, given the current state of knowledge, to
achieve the desired or projected outcome(s) for the
individual"

15. Efficacy (capacity)
• The potential, capacity, or capability of the care to
produce the desired effect or outcome, as already
shown, e.g., through scientific research (evidence-
based) findings;
• The power of a procedure or treatment to improve
health status.

16. Efficiency
• The relationship between the outcomes (results of
care) and the resources used to deliver care
• A combination of skill and economy of energy in
producing a desired result.

17. Prevention/Early Detection
• The degree to which interventions, including
the identification of risk factors, promote
health and prevent disease

18. Respect and Caring (Customer)
• The degree to which those providing services do so
with sensitivity for the individual's needs,
expectations, and individual differences.

19. Safety (Base)
• The degree to which the healthcare
intervention minimizes risks of adverse
outcome for both patient and provider

20. Timeliness
• The degree to which care is provided to the
individual at the most beneficial or necessary
time.

22.  Distinguishing one practitioner from another is
based on :
o Meeting patients’ Needs & Expectations
o Achieving patients’ satisfaction
o Gaining higher reputation (Word of the Mouth)

23. 1- Service Features 2- Devoid of deficiency
o Respect & Caring
o Pleasant place
o Reasonable cost
o Participating decisions &
choices
o Patient Education &
counseling
o Data Record (IM)
o Waiting time
o Scheduled Meeting (OPC)
o Regular follow up (inpatient)
o Calibrated devices
o Successful management
o Food access is palatable
o Food served suiting the
condition

24. Apply

25.  Good Nutrition & hydration care is a basic requisite
of high quality care for every patient in every care
 Malnutrition is often unrecognized though it has a
substantial impact on health & disease in all
community care settings & hospitals being both a
cause & consequence of diseases

26. 1) All patients are Screened on admission to identify
the patients who are malnourished or at risk of
becoming malnourished & re-screened weekly
2) All patients have an Individualized Nutrition Care
Plan which identifies their needs & how to be
met.

27. 3) Patients are involved in the planning &
monitoring arrangements for food service
provision.
4) The ward implements Protected Mealtimes to
provide an environment conducive to patients
enjoying & being able to eat their food.

28. 5) All Staff have the appropriate Skills &
Competencies needed to ensure that patient’s
nutritional needs are met. (regular training on
nutritional care & management).
6) Hospital facilities are designed to be Flexible &
Patient centered with the aim of providing &
delivering an excellent experience of food
service and nutritional care 24 /7

29. 7) The hospital has a Policy for food service &
nutritional care which is patient centered &
performance managed in line with home
country governance frameworks.
8) Food service and nutritional care is delivered
to the patient Safely.
9) The hospital supports a Multi-disciplinary
approach to nutritional care & values the
contribution of all staff groups working in
partnership with patients and users.

30. “Transparency”
implies openness, communication, and accountability.

31. • Patient Education on the current medical condition
• Counseling on hazards & benefits of every intervention
• Applying of the effective & efficient maneuver that suit
every patient
• Food ingredients (required food processors to label
products with amounts of key nutrients as a public health
measure)
Transparency Matters:

32. Do You Consider Transparency in your
practice?
• Drugs?
• FAD Diets?
• Considering the patients needs?
• Considering the Patients comorbidities?
And…………
Or you use your desperate patient to gain more
money?

33. Leadership and Management Basics
• Leading by Example

34. Six leadership actions to inspire
motivation

36. Setting The Climate
• Examine your own strengths and weaknesses
• Listen actively
• Discover others' strengths
• Remove barriers (dissatisfiers)
• Obtain involvement
• Lead by example
• Provide positive reinforcement
• Ensure rewards
• Provide stretch
• Expect excellence

37. People Reactions to Change

38. The final success of any change depends
on????
the perceptions of and acceptance by the people
involved in the change.
Process Owners
So we must be attuned to the
personal side of change
In order to manage the change process successfully

39. Communication
Modes:
1. Symbolic
2. Verbal
3. Non-verbal
4. Written
5. Combination
Effective Communication:
1. Two way
2. Active listening
3. Effective feedback

43. Listening is the most powerful
form of acknowledgment
…a way of saying, “You are
important.”

44. Listening promotes being heard
…”Seek first to understand, then
be understood.”
- Stephen Covey

45. Bad Listening Habits
• Criticizing the subject or the speaker
• Getting over-stimulated
• Listening only for facts
• Not taking notes or outlining
everything
• Tolerating or creating distraction
• Letting emotional words block
message
• Wasting time difference between
speed of speech and speed of
thought

46. Negotiation
is the art of conferring, discussing, or bargaining to reach agreement.

47. preparation is the key

48. Force Field analysis
• is The tool that can be used to analyze a situation or process
to be changed, based on Lewin,

52. Examples of Nutrition Goals
 Maintain a Healthy Weight.( suiting height , gender,
physical activity , status) (adopt healthy life style)
 Eat a Variety of Nutrient Rich Foods ( not Calorie
dense)
 Enjoy Plenty of Whole Grains, Fruits, and
Vegetables ( suitable servings)
 Watch portion sizes (avoid oversize meals)

53. Examples of SMART healthy eating Goals
 Trying to stop skipping breakfast
 Every day this week, I will eat breakfast that has all 4
food groups (e.g. a whole grain bagel, peanut butter
and banana slices with a glass of milk)
 Want to get more active?
 Go for a walk for 30 minutes every other day this
week.

55. o Target to be :
 Role Model for application of quality of health care
in the nutrition field
 Target the best practice & keep on continuous
improvement
 Leader to your internal & external customers

56. To your internal customers
 To your supervisors & Top Management:
o Highlight & professionally express the importance of
quality based nutrition care
o Innovate the best applicable methods to implement the
quality based nutrition care ( nutrition champion)
o Introduce your professional evidence based strategy of
work

57.  To your colleagues & subordinates:
o Be Model for evidence based focus & standards guided
o Lead an interdisciplinary team to establish nutrition
algorithms for use in various scenarios when positive
screens or diagnostic assessments are obtained
o Introduce the hierarchy ( chain of commands)
o Announce job description ( duties & responsibility
clarification )
o Communication skills , Integrate care & encourage CME

58.  To your patients:
o Should have good communication skills
o Talented with health coaching & education
o Experienced with counseling
o Professional management
o Model of practicing healthy life style

59. • refers to the results of care (end), adverse or beneficial, as
well as gradients between; the products of one or more
processes:
• Clinical:
Short-term results of specific treatments and procedures
 Complication rates
 Adverse events
 Mortality rates
Outcome

60. Outcome
• Functional:
Longer-term health status
 Activities of daily living (ADL) status
 Patient progress toward meeting stated outcome objectives, e.g.,
behavioral
• Perceived:
 Patient/family satisfaction
 Patient/family level of understanding and knowledge
 Peer acceptability

61. How to achieve quality and patients
safety in nutritional care?

62. Risk in healthcare
• The probability that something undesirable
will happen. it implies the need for avoidance.
• Error: An act of commission doing something
wrong or omission failing to do the right think that
leads to an undesirable outcome or significant
potential for such an outcome

63. Why Do Errors Happen?
IOM definitions:
• Error: failure of a planned action to be completed as
intended (error of execution) or the use
of a wrong plan to achieve an aim (error of planning)
• Medical error: refer to unintentional, preventable
mistakes in the provision of care that have
actual or potential adverse impact on the patient.
• Adverse event: an injury resulting from a medical
intervention.

64. • Serious error: an error causing permanent injury or
transient but potentially life threatening
hard.
• Minor error: an error causing harm that is neither
permanent nor potentially life threatening.
• Near Miss : An error that could have caused harm,
but did not, either by chance or because of
timely intervention

65. Types of medical error:
• Medication mistakes.
• Missed and delayed diagnoses.
• Miscommunications during transfers /
transitions in care.

66. Patients are harmed
from :
o Avoidable malnutrition
(omission )
o Unsafe practices relating to
parenteral nutrition
(commission )
o Unsafe practices relating to
enteral tube feeding
(commission )
o Under or over hydration
(commission )
It is required to :
o Describe what good nutrition
& hydration care looks like &
outline the services
organizations should be
providing
o Deliver nutrition and
hydration intervention care
 Success is dependent upon
the right policy for the
prevention, detection &
treatment of malnutrition &
dehydration

67. Food Safety
o know the food they use (read labels on food package,
make an informed choice, become familiar with
common food hazards)
o handle and prepare food safely ( cooking & catering)
o IC standards , policies& procedures
See : WHO fact sheet ( Nov. 2014)
USDA tips

68. Food Safety Advice
USDA
o Clean: Wash Hands and Surfaces Often
o Separate: Don't Cross Contaminate
o Cook: Cook to Proper Temperatures
o Chill: Refrigerate Promptly

69. Tools of a Performance-Based QM System
Standards and Guidelines:
describe appropriate and expected
courses of action
• A standard is a statement of expectation
defining the capacity of a governance,
managerial, clinical, or support system to
deliver value-to perform as expected.
• A guideline generally refers to a set of
specifications for care and process that
pertain to the functions of healthcare
practitioners.

70. Performance Measures / indicators
• points of reference for evaluating the organization's actual
performance and comparing with a targeted objective or a
standard.
• Well defined and constructed performance measures are
predictors of the organization's ability to achieve strategic
goals and vision.
• They are measurement tools to assess the degree to which
the appropriate and expected course of action is being
followed (process), and the degree to which the expected
outcome is being met.

72. Always seek Reliable sources:
o Go for Educational ,Trusted
scientific links
o Seek the Evidence based
o Check the references & in
charge owners
o Go for accredited certified
associations & experts
o frequent revising & updating
info
o Avoid commercial links
o mostly go for ( .gov, .org,
.edu)
o Alert for the ( .com)

73. WHO guidelines in nutrition
http://www.who.int/publications/guidelines/nutri
tion
ESPEN nutrition guidelines
http://www.espen.org/
ASPEN guidelines
https://www.nutritioncare.org/guidelines_and_cli
nical_resources/

74. USDA
http://www.choosemyplate.gov/
NICE guidelines
http://www.nice.org.uk/Guidance
NHMRC ( Australian Government)
https://www.nhmrc.gov.au/
 Academy of Nutrition & Dietetics
http://www.eatright.org/

75. Cod
e
Quality of
Evidence
Definition
A High
Further research is very unlikely to change our confidence in
the estimate of effect.
•Several high-quality studies with consistent results
•In special cases: one large, high-quality multi-center trial
B Moderate
Further research is likely to have an important impact on our
confidence in the estimate of effect and may change the
estimate.
•One high-quality study
•Several studies with some limitations
C Low
Further research is very likely to have an important impact on
our confidence in the estimate of effect and is likely to change
the estimate.
•One or more studies with severe limitations
D Very Low
Any estimate of effect is very uncertain.
•Expert opinion
•No direct research evidence
•One or more studies with very severe limitations

76. "In God we trust. All others must use data."

77. • Data: Uninterpreted observations or facts
• Information is data transformed through
analysis and interpretation into a form useful
for decision making

78.  The key is :
 Systematic identification of patients who are
malnourished or at risk of malnourishment
 Promptly implement a suitable management plan.
 Regular Follow up (rescreening & continuous
monitoring)
 Individualization & quality targeting is essential

79. Thank You