This document discusses quality improvement in healthcare. It defines quality improvement and outlines its core principles, including that quality improvement is a cyclical process of planning, doing, studying, and acting. It also discusses strategies for testing and implementing changes. Additionally, it outlines Ethiopia's quality structures, provides guidelines for clinical audits, and discusses defining and measuring quality standards. The overall purpose is to encourage a culture of continuous quality improvement in healthcare facilities and ensure national policies around quality are reliably implemented.

1. QUALITY IMPROVEMENT IN
HEALTH CARE
RAS DESTA DAMTEW MEMORIAL HOSPITAL QI & CG UNIT
August 2011 E.C.
BY YITBAREK ZELEKE(M.D)

2. Buzz…..The Bees are
working.
 At present, the evidence is clear that
healthcare is not always safe and can
lead to poor patient experience and
outcomes.

3.  Why should you bother with making changes?
 Why not simply deal with problems as they
arise and try to maintain the status quo?

4. Outline
 Change
 Definition
 Strategy
 Principles of Quality Improvement(QI)
 QI as a cyclic process
 Ethiopian Quality Structures
 Clinical Audit Guidelines
 Quality Standards

5. Change Concepts
 The rate and extent of improvement is
directly related to the nature of the
changes that are developed and
implemented.
 Art of improvement is combined with the
science of improvement.

6. Developing a Change
 More of the same is very limited as a
long term strategy for improvement.
 The search for the perfect change.
◦ Continued analysis and debate
◦ Because unanticipated side effects, the
search for perfection can continue endlessly.
 Develop changes that fundamentally
alter the system.

7. Testing Changes
 Find a way to test a change on a small
scale to minimize risks,
 Observe how the system reacts to it
over time.

8. Implementing and Spreading a
Change
 Change must be fully integrated into
the system.
◦ Planning, and additional learning.
 To Spread
◦ A strategic effort
◦ A spread plan
◦ Building Knowledge

9. Defining Quality
 “The degree to which health services for individuals
and populations increase the likelihood of desired
health outcomes and are consistent with current
professional knowledge.” +6 dimensions (Safe, Effective,
Patient centered, Timely, Efficient, Equitable) IOM
 Ethiopian Context
◦ “Comprehensive care that is measurably safe,
effective, patient centered, and uniformly delivered in
a timely way that is affordable to the Ethiopian
population and appropriately utilizes resources and
services efficiently.”

10. Pioneers and our Strategy
 The roots of many quality improvement approaches traced back
to the thinking about production quality control that emerged in the
early 1920s.
 Pioneered by W Edwards Deming, Joseph Juran and Armand
Feigenbaum and Japanese expert Kaoru Ishikawa. Don Berwick
(Institute for Healthcare Improvement)
 Quality improvement in health institutions has been exercised
since 2009.
 Began to be run by FMoH since 2011 with Quality planning and
auditing of EHRIG.
 Focus areas in NQS
◦ Maternal, neonatal and child health
◦ Communicable diseases
◦ Non communicable
◦ Clinical and surgical services
 100% in evidence based practice guidelines.
 Purpose of quality guidelines

11. Rationale
 Encouraging HWs to institutionalize
and develop a culture of quality.
 To enable all HFs to have a credible
quality improvement program.

12. Why Quality now?
 To ensure that national policies, guidelines,
and protocols around quality are reliably
implemented.
 To close remaining gaps in health outcomes
and ensure equity.

13. Core elements of quality
Quality
plannin
g
Quality
Improvement
QUALITY
Quality
Control

14.  Quality Planning
◦ Establishes goals, policies and strategy to close gaps.
◦ Designates a structure that delivers the right care
 Quality Improvement
◦ “…the combined and unceasing efforts of Everyone to make the
changes that will lead to better patient outcomes (health), better
system performance (care), and better professional
development(Learning).
 Quality Control
◦ Quality assurance (maintenance , improvement, error
reduction/elimination
◦ Evaluate heath care quality, identify problem areas, create a
method to overcome issues, and monitor the method taken to
improve quality through internal and external quality assurance

15.  Quality improvement (QI)-
◦ Ability to provide care addressing the clients’ needs in an
effective, responsive and respectful manner continuously.
QUALITY IMPROVEMENT CONCEPTS AND DEFINITIONS

16. Cont’d…
 Quality has two components:
◦ Technical Quality, concern of service providers
and has a bearing on outcome or end-result of
services delivered.
◦ Service Quality, a facility based care and
service; a concern for patients, and effect on
patient satisfaction

17. PRINCIPLES OF HEALTH SERVICES QUALITY
IMPROVEMENT
1. Client focus
◦ Meet needs and expectations of the clients
both internal(health workers) and external(the
population)
2. Provider focus
◦ Support from administrators.
◦ Getting clear job description, Feedback,
Equipment and supplies, Good work
environment, Recognition, Motivation,
+Reward etc

18. 3. Systems and processes focus
4. Team work
◦ Collaboration and assisting each other
◦ Information
5. Effective communication
◦ Information, ideas, emotions, knowledge
and skills between people
6. Use of data

19. QUALITY IMPROVEMENT AS A CYCLICAL
PROCESS
 Planning should be done by QI team and staff.
 It is the task of All staffs to carefully plan
activities.
 A budgeting with the plans.
 Four major steps in QI
◦ Plan, Do, Study, Act

20. Sort
Set in
Order
Shine
Standardize
Sustain
Kaizen

21. 5S IN MIND
 Sort ; to concentrate on your work
 Set ; to organize your work
 Shine and Standardize ; To enjoy your work and maintain your
way of working
 Sustain;to carry out your work actively and maintain your work
quality.
5S IN BRAIN
 Sort ;to clarify your work on what / for whom / what purpose /
how / by who and by when
 Set; to prioritize your work
 Shine; to manage your work step by step
 Standardize; to remove barriers of managing your work
 Sustain; to solve problems and execute your work continuously

23. Five fundamental principles of
improvement
1. Knowing why we need to improve
2. Having a feedback mechanism to tell us if the
improvement is happening
3. Developing an effective change that will result
in improvement
4. Testing a change before attempting to
implement
5. Knowing when and how to make the change
permanent (implement the change)

24. ETHIOPIAN QUALITY STRUCTURES
 FMoH: Health Service Quality Directorate (HSQD)
 Regional: Quality Unit (QU)
 Zonal: Quality focal person
 Woreda: Quality focal person
 Hospitals: Quality Unit (QU)
 Health centers: Quality Committee
 Community level: Health Development Army
(HAD)/QIT

26. QUALITY UNIT (QU) IN HOSPITALS
 The Quality Unit will be assisted by a Quality
committee
 Quality Committee represented by heads of all
clinical departments and selected experts.

27. CONT’D…
oGenerally, the Quality Unit will function to
oCoordinating and providing guidance and
information to heads of department and SMT
oCoordinate all QI projects
oCoordinate the implementation of guidelines,
protocols and Quality standards
oEnsure adherence to quality standards
oMonitoring the implementation of quality
activities
oConducting patient satisfaction surveys

28. oCoordinate the use of data to QI
oIdentify quality problems and drawing up action
plans
oDisseminating information
oQuality scoring
oEnsure Coordination
oPromoting QI awareness
oCoordinate clinical audit programs
CONT’D…

29. Role of SMT
 Be committed to QI and control programs in
the health facility.
 Provide all the support and resources to QI
activities

30. Role of Staff
 Be aware of the need to improve quality.
 Bring quality issues to attention
 Carry out specific quality improvement tasks
◦ See tasks as routine responsibilities rather than extra
duties.

31. CLINICAL AUDIT GUIDELINES
 Definition
◦ “The systematic critical analysis of the quality of
clinical care, including the procedures used for
diagnosis and treatment, the use of resources
and the resulting outcome and quality of life for
the patient.” US department of health

32.  “A quality improvement process that
seeks to improve patient care and
outcomes through systematic review of
care against explicit standards and the
implementation of change.” the National institute
for Clinical Excellence NICE

33. A core principle of quality improvement is that what is
not measured cannot be improved.
Measuring everything is not important but may be
interesting.

34. CLINICAL AUDIT
 Purpose:
◦ To what degree standards are met
◦ Reasons why if they are not met
◦ Identify and implement changes to meet standards.
 All clinicians need to ensure delivery of best
care
 All clinicians should audit
 Use findings of audit

35. Clinical
Audit
Cycle
Planning
Standard
Selection
Measuring
Performance
Making
Improvements
Sustaining
Improvements
THE FIVE STAGE APPROACH IN CLINICAL AUDIT

36. Stage 1 Planning for audit
1. Involve all relevant stakeholders
◦ all employees
◦ Management
◦ 10% service user involvement
2. Determining topic
3. Planning the delivery of audit
◦ The audit team must understand the overall purpose
◦ Audit team needs to involve the right people
◦ All audit team members should be trained and briefed

37. Stage 2 Standard selection
 A standard describes and defines the quality of
care to be achieved
 For each standard a quality statement and
quality measures will be defined.
 A quality measure should be consistent with
SMART guidance:
◦ Specific
◦ Measurable
◦ Achievable
◦ Relevant
◦ Theoretically sound or timely

38. Stage 3 – Measuring performance
1. Data collection
2. Data analysis
◦ to compare actual performance against the
standards
◦ Requires working out the percentage of cases that
have met each audit criterion
3. Drawing conclusions
4. Presentation of results

39. Stage 4 – Making improvements
 Priorities for action should be identified
 QI plan to achieve the required improvements
Stage 5 – Sustaining improvements

40. QUALITY STANDARDS
 A Standard is a statement of expected level of
quality
◦ Inputs-required to deliver a service
◦ Process- how things should be done and
◦ What the output or outcome should be

41.  Input Standards
◦ Resources
 e.g., physical structure, people, equipment and materials
 Process Standards
◦ Tasks or steps
 effectiveness, safety, patient centeredness, efficiency,
equity, timeliness of care
 Output/ Outcome Standards
◦ Results
 denote to what extent goals of the care have
been achieved.

42. Maternal health care Standard
3: Every woman and newborn
receives evidence-based
routine care and management
of complications during labor,
childbirth and the early
postnatal period according to
National guidelines.
MH3.1 All Women
coming for ANC
follow up are
routinely assessed
and are provided
with timely and
appropriate care
according to
National guidelines
All problems identified in classifying form
AND senior health professional consulted
when necessary
10 CHART
REVIEW
BP measured at each visit, interpreted
correctly and appropriate management given
10 CHART
REVIEW
all essential lab tests (hemoglobin, VDRL,
blood group typing, urine analysis, HIV and
HBsAg) were done, result interpreted
correctly and managed accordingly
10 CHART
REVIEW
All lab tests were done in the same facility 10 CHART
REVIEW
partners are counseled and tested for HIV 10 CHART
REVIEW
Iron folate supplementation is given as per the
hemoglobin result and national
recommendation
10 CHART
REVIEW
Quality Standard
Quality Statement
Quality Measures
Quality Measures
Quality Statement Quality Measures

44. Measuring Improvement
Indicator Framework and how it maps to the Balanced Scorecard Framework

48. Improvement/Learning
Collaborative

49. Prioritization criteria for quality
indicators
1. Health Priority: does it measure a specific health priority/quality more
broadly?
2. Scope of Impact: (e.g., population-size clinical outcomes)
3. Feasibility: How easy will this be to implement?
4. Measurability:
5. Accuracy: is the data collected through this indicator accurate?
6. Actionable: are clear actions and change in behavior likely to happen?
7. Comparability: can we compare this indicator against a standard? How
easy is it to establish consensus for standards?
8. Defensible: is this indicator defensible from a scientific point of view and
from the perspective of what key decision-makers view as important?
9. Credible: is the indicator credible for those who need to take action and
those whose performance is being measured and compared?

50. References
 NATIONAL QUALITY STRATEGY,FMOH,2016-2020
 HEALTH SECTOR TRANSFORMATION IN
QUALITY,FMOH,2016
 THE IMPROVEMENT GUIDE-, A PRACTICAL APPROACH TO
ENHANCING ORGANIZATIONAL PERFORMANCE SECOND EDITION,
2009
 HOW TO GUIDE FOR QUALITY IMPROVEMENT, Aurum Institute,

51. Thank You!