Quality Management in Healthcare Services

Colonel Dr Zulfiquer Ahmed Amin
M Phil, MPH, PGD (Health Economics), MBBS
Armed Forces Medical Institute (AFMI)
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A measure of excellence or a state of being free from defects,
deficiencies and significant variations.
Quality is "the totality of features and characteristics of a product or
service that bears its ability to satisfy stated or implied needs.“
Definition of ‘Quality’
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Quality Management
Quality management is the act of management functions to
maintain a desired level of excellence. It is management activities
and functions involved in determination of quality policy and its
implementation.
It has four main components:
- Quality planning,
- Quality assurance,
- Quality control
- and Quality improvement.
Quality management is focused not only on product and service
quality, but also on the means to achieve it.
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- Quality planning:
Quality planning is determining the activities required for
"developing the products, systems, and processes needed to meet or
exceed customer expectations.“
- Quality Assurance:
Quality assurance is means of providing enough confidence that the
goals as outlined in quality planning for a product and/or service will
be fulfilled.
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- Quality Control:
A system of maintaining standards in manufactured products or
services by testing a sample of the output against the specification.
Quality of good or service produced are measured using tools such as
auditing and inspection.
- 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)". This may be done with noticeably significant changes or
incrementally via continual improvement.
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Quality assurance is a way of preventing mistakes and defects in
manufactured products and services to customers; which ‘ISO 9000’
defines as "part of quality management focused on providing
confidence that quality requirements will be fulfilled".
QA= QC + GMP
Good Manufacturing Practices (GMP) are the practices required in
order to conform to the guidelines recommended by agencies that
control the authorization and licensing of production and delivery of
goods and services.
Quality Assurance
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Purpose of QA
• To meet the rising expectations of consumers of quality of
services
• Help patients by improving quality of care.
• Assess competence of medical staff, serve as an impetus to keep
up to date and prevent future mistakes.
• Bring to notice of hospital administration, about the deficiencies
and in correcting the causative factors.
• Help exercise a regulatory function.
• Restricting undesirable procedures.
• Eliminating medical errors, Adverse Drug Events, and HAI.
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Principles of Quality Assurance
• QA is a never ending process of continuous improvement, and
continuous updating with rapid advances in science and
technology and medical knowledge.
• The emphasis is on establishing professional excellence and
patients’ satisfaction at reasonable cost.
• Quality is not proportionate to the use of sophisticated
technology or to be expensive.
• Technical imperative should not insist on prolonging life at any
cost, with no consideration to quality of life.
• Decisions must be based on data.
• Customers define the quality.
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1. Constancy of purpose:
“Create constancy of purpose for continual improvement of products
and service to society.“
Establishment of constancy of purpose means acceptance of
obligations like the following:
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a. Innovate. Allocate resources for long-term planning.
b. Put resources into: Research and Education.
c. Constantly improve design of product and service. This
obligation never ceases

2. Adopt new philosophy- ‘Change’:
People resist change not only because they love the status quo, but
also because they fear the uncertainty of what lies ahead. Yet,
without change we are destined to repeat the past. Once change
itself becomes the status quo then it is less likely to be resisted at
each encounter. Without change, a company can not sustain itself in a
time when innovation occurs every day.
Example: Digitalization in health service, MIS, Health Informatics,
Patient Centered Care etc.
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3. Cease dependence on inspection to achieve quality:
Quality does not come from inspection, but from improvement of
the process. It is better that quality checks take place during the
process so that improvements can be made earlier.
- Inspections are costly and unreliable – and they don't
improve quality, they merely find a lack of quality.
- Build quality into the process from start to finish.
- Don't just find what you did wrong – eliminate the "wrongs"
altogether.
- Use statistical control methods – not physical inspections
alone – to prove that the process is working.
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4. End lowest tender contracts:
Price has no meaning without measure of the quality purchased.
End the practice of awarding business on the basis of price tag
alone. Instead, move toward a single supplier for any one item, on
a long-term relationship of loyalty and trust.
5. Improve every process:
Think continuous, never ending improvement. Continuous process
improvement of production and service results in improved quality
and productivity, which in turn leads to cost reduction.

6. Institute training on the job:
Training must be done on the job, learning by doing; going into the
work and experimenting with work methods and new ideas, and
striving for perfection.
7. Institute leadership of people:
Don't simply supervise – provide support and resources so that each
staff member can do his or her best. Be a coach instead of a
policeman. Emphasize the importance of participative management
and find ways to reach full potential of under command.
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8. Drive out fear:
Fear is paralyzing. Therefore, fear must be eliminated on the work
floor. To achieve better quality, people need to feel secure.
- Allow people to perform at their best by ensuring that they're not
afraid to express ideas or concerns.
- Make workers feel valued, and encourage them to look for better
ways to do things.
- Ensure that your leaders are approachable.
- Use open and honest communication to remove fear from the
organization.

9. Break down barriers:
Break down barriers between departments.
- Recognize that each department serves other departments that
use their output.
- Build a shared vision.
- Use cross-functional teamwork to build understanding.
- Focus on collaboration and consensus.
10. Eliminate exhortations:
Posters ask people to do what they can not do. Eliminate slogans,
warnings and targets for the work force asking for zero defects. Such
urging only creates hostile relationships. Recognize that majority of
low quality and low productivity is basically caused by faulty system.
- Let people know exactly what you want – don't make them guess.
- "Excellence in service" is short and memorable, but what does it
mean? How is it achieved? 18

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11. Eliminate arbitrary numerical targets:
No more focus on achieving certain margins; that impedes
professionals from performing their work well and taking the
necessary time for it. Rushing through the work can cause production
errors. Managers should therefore focus on quality rather than
quantity.
12. Permit pride of workmanship:
We need people to have pride in their work. Barriers to pride (a basic
human need) among other things, results in low morale and
absenteeism.

13. Encourage education:
Integrate and promote training, self-development and improvement
for each employee.
- Improve the current skills of workers.
- Encourage people to learn new skills to prepare for future
changes and challenges.
- Build skills to make your workforce more adaptable to
change.
14. Make "transformation" everyone's job.
Improve your overall organization by having each person take a step
toward quality.
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Components of Quality Assurance
1. Strategic or organizational level (Dealing with the quality policy,
objectives and management and usually produced as the Quality
Manual);
2. Tactical or functional level (Dealing with general practices such as
training, facilities, equipment etc); and
3. Operational level (Dealing with the Standard Operating Procedures
(SOPs) and day to day operations).
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Donabedian's model to analyse quality includes three factors: structure,
process, and outcome. Structure refers to prerequisites, such as hospital
buildings, staff and equipment. Process describes how structure is put into
practice, such as specific therapies. Outcome refers to results of processes, for
instance, results of therapy.
23

PDCA (Plan–Do–Check–Act or Plan–Do–Check–Adjust) is an iterative
four-step management method for the control and continual
improvement of processes and products.
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Approaches of Quality Assurance Program
1. General Approach:
It involves a large governing or official bodies’ evaluation of a
person or agency to meet established criteria or standards at a
given time.
- Credentialing
- Licensure
- Accreditation
- Certification
2. Specific Approach.
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Credentialing:
Credentialing is the process of obtaining, verifying, and assessing the
qualifications of a practitioner to provide care or services in or for a
health care organization. Credentials are documented evidence of
licensure, education, training, experience, or other qualifications.
Examples of credentials include academic diplomas, academic
degrees, certifications, security clearance etc.
Licensure:
Licensing is an obligatory process by which an agency of government
regulates a profession. A process by which a governmental agency
grants time-limited permission to an individual to engage in a given
occupation after verifying that he or she has met predetermined and
standardized criteria (Usually education, experience, and
examination). Example: BMDC issues license for practice of doctors.
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Accreditation:
Accreditation is the process of formally obtaining credibility from an
authorized body, such as the International Organization for
Standardization (ISO), Joint Commission International (USA),
Accreditation Canada International etc.
Certification:
Formal procedure by which an accredited or authorized person or
agency assesses and verifies the attributes, characteristics, quality,
qualification, or status of individuals or organizations, in accordance
with established requirements or standards and attests in writing by
issuing a certificate. eg, certificate of quality issued by BSTI
(Bangladesh Standards and Testing Institution).
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Types of QA
External QA:
QA can be evaluated by independent assessors from outside the
hospitals.
Internal QA:
QA can be evaluated by local assessors (Usually by senior persons)
from the same hospitals.
Benchmark is - something that serves as a standard by which others may be measured or judged.
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QA Committee
- Medical Administrator
- Two Senior Clinicians
- Pathologist
- Radiologist
- Matron (Senior Nurse)
- Medical Record Officer (Secretary)
- Additional Personnel: eg Super-Specialists, consultants
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Factors Affecting QA in Healthcare
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Absence of mechanism
of reporting Medical ErrorsAbsence of system
of accountability

Quality Control
Quality Control is a system of maintaining standards in manufactured
products or services by testing a sample of the output against the
specification.
33

Although QA and QC are closely related concepts, and are both
aspects of quality management, they are fundamentally different in
their focus:
- QC is used to verify the quality of the output;
- QA is the process of managing for quality. 34

The Kano Model of Customer satisfaction conceptualizes that
satisfaction of clients depend on functionality of three attributes of
products or services:
- Threshold,
- Performance,
- and excitement.
These classifications are useful for guiding design decisions in that
they indicate when good is good enough, and when more is better.
KANO MODEL OF SERVICE SATISFACTION
(1984 by Professor Noriaka Kano)
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The Kano Model addresses three types of requirements:
- Satisfying basic needs (Threshold attributes): Allows a company to
get into the market.
- Satisfying performance needs (Performance attributes): Allows a
company to remain in the market.
- Satisfying excitement needs (Excitement/delight attributes): Allows a
company to excel, to be world class.
40

Threshold attributes (Dis-satisfiers or Basic Needs):
Threshold (or basic) attributes are the expected attributes or “musts”
of a product, and do not provide an opportunity for product
differentiation. These features alone will not increase customer
satisfaction, since they are taken for granted when fulfilled but result
in dissatisfaction when not fulfilled.
Example: Cleanliness of a hotel. This includes a clean bathroom, clean
linens and a pleasant, fresh aroma in the air. When a person books a
reservation at a hotel, they do not request a clean room. They expect
it. If this basic need is not met, they will be extremely dissatisfied.
Improving the performance of these attributes do not guarantee
increased customer satisfaction and may only add to the cost of
product.
42

Performance Attributes (Satisfiers or Performance Needs):
These are the features customers are more interested in, and the
price customers are willing to pay depends on these attributes. These
attributes result in satisfaction when fulfilled and dissatisfaction when
not fulfilled. These are attributes that are spoken and the ones in
which companies compete. If they are excelled customer satisfaction
increases accordingly.
Using the hotel example again, “spoken” needs could be Internet
access, a room away from the elevators, a non-smoking room, the
corporate rate, waiting time at a hospital etc.
The better fulfillment leads to linear increment of customer
satisfaction and absence or poor performance of these attributes will
diminish the customer satisfaction. The price for which customer is
willing to pay for a product is closely tied to performance attributes.
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Delighters or Excitement Needs:
These attributes provide satisfaction when achieved but do not cause
dissatisfaction when not fulfilled. They are not normally expected and
thus often unspoken.
Example: Those who stay in a hotel, are delighted by a free wi-fi,
internet access in TV, HD TV etc; which are not expected normally.
The presence of these attributes delights the customer and results in
high satisfaction. The absence of these attributes however does not
cause dissatisfaction.
The marketers can build on these attributes to delight the customers
and gain competitive advantage. A point to be noted here is that
today’s excitement attribute would evolve into performance attribute
in near future and finally could end up as a threshold attribute. An
example could be power steering in a car.
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Kano Requirements Type Definitions: A Summary
Requirements Type Definition
Must Be (Expected Quality)
Requirement that can dissatisfy
(expected, but cannot increase
satisfaction)
One-Dimensional (Desired Quality)
The more of these requirements that
are met, the more a client is satisfied
Delighters (Excited Quality)
If the requirement is absent, it does
not cause dissatisfaction, but it will
delight clients if present
Indifferent
Client is indifferent to whether the
feature is present or not
Reverse Feature actually causes dissatisfaction
A competitive product meets basic attributes, maximizes
performances attributes, and includes as many “excitement”
attributes as possible at a cost the market can bear. 49

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Quality Management in Healthcare Services

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