CPHQ Principles of Quality PDF

Healthcare Quality Concepts Chapter 1 Sahar Khalil Alhajrassi SB-PROSTH,CPHQ,CPHRM,ISQua Fellowship  Chapter outlines: 1. Definitions of HCQ 2. History of healthcare quality (HCQ). 3. Aspects of HCQ. 4. Concepts and principles...

Healthcare Quality Concepts Chapter 1 Sahar Khalil Alhajrassi SB-PROSTH,CPHQ,CPHRM,ISQua Fellowship  Chapter outlines: 1. Definitions of HCQ 2. History of healthcare quality (HCQ). 3. Aspects of HCQ. 4. Concepts and principles of HCQ 5. Quality dimensions. 6. Total Quality Management (TQM). 7. Concept of value. 8. The quality chasm. 9. To error is human. 10. Role of HQ professional. 11. Quality Trilogy.  Definitions of HCQ Doing the right things right the first time and each time. Compliance to standard. Freedom from defects(avoidable interventions)/ zero defect. meet customer expectations (satisfaction) / adding value to customer. Increase the likelihood of desired outcomes and are consistent with current professional knowledge (IOM, JCI). Agency for healthcare research and quality (AHRQ) define HQ as healthcare is accessible, effective, safe, accountable and fair. High degree of excellent.  Definition of quality in health care JCI defined quality as: The optimal achievement of therapeutic benefit and avoidance of risk and minimization of harm (free from HARM). Another definition: Degree with conformity with accepted principle and practice with appropriate use of resources. History of healthcare quality  Change in Quality emphasis QUALITY CONTROL QUALITY ASSURNCE Implement in short notice Long term process Focus on output Focus on process Emphasis on required standard Emphasis on customer (process (product oriented) oriented) Achieved by sampling and checking Achieved by improve production (inspection) process Make sure that the result of what u Make sure that doing right thing in have done are what u expect right way (((( OLD)))) ((((MODERN))))  Comparison Between Traditional Monitoring and Evaluation utilizing the three aspects of quality (Quality Assurance) and Continuous Quality Improvement (CQI) QA TQM / CQI Objective Outcome. Process and outcome. Entire group. Statistical tail. (Continuous Focus Problem-focused methods (Actions are improvement process) trying to initiated when a problem is identified). improve the process itself. Focus on Clinical and non clinical aspects. Clinical aspects of care only. Comparison Between Traditional Monitoring and Evaluation utilizing the three aspects of quality (Quality Assurance) and Continuous Quality Improvement QA TQM / CQI Cross-departmental acc. to patient flow. Departmental. Frequently separating the dimensions of quality care— review of appropriateness Integrating all efforts to improve both patient separate from effectiveness and/or outcomes and efficiency of care delivery efficiency. (improving value). Errors are due to individual Errors are due to system failure performance. (85%).  Comparison Between Traditional Monitoring and Evaluation utilizing the three aspects of quality (Quality Assurance) and Continuous Quality Improvement QA TQM / CQI Also, focuses to the previous ones: WHAT of care Patient care HOW of care Patient care given. processes. The right service to the right Systems and their key patient at the right time and processes,Policies, Focus place. procedures,andregulatory on WHO of care Patient care compliance,Relationships and giver. communications; Clinical pathways, Competent and qualified staff practice guidelines, and protocols. who is doing the rights things RESULT of care Patient care outcome. right. Quality Bioneers Codman Emphasis on End result ( Outcome )  Philosophy: Deming The problem in a production process are due to defects in the process in the system.  The principles were first developed with products in mind, not services. There is need for further adaptation in healthcare because a patient is a person, not a product. 9 out of 14 ated to behavior, psychology and ethics.  Father of Quality Create concept of vital few and and useful Juran many ((pareto principles 20-80 rules)). Develop juran trilogy ( planning , control , improvement ) Developed Q.council  Juran trilogy Q.Planning Q.Control Q.Improvement Process of Used to constantly understanding what the monitoring performance Problem customer need and Team for compliance with the design all aspects of a RCA original design standard. system to meet those solution ‫لو انحرف الزم‬ needs reliably. take an action  Q.planning Q.control Q.improvement Engage Selecting Identify problems leadership measures Identify team Identify Defining Clarify process customers measures Analyze root Identify customer Collecting data causes needs Analyze data Implement Design processes to meet needs Taking action solutions  Focus on zero defect , Quality is free Crosby , lack of quality is very costly Building quality into process should occur early during the design phase rather than spending time and money on finding and fixing mistakes and errors Berwick Patient center and care coordination  Aspects of healthcare quality Compliance with standard (guidelines, best practice,accreditations, Measurable awards, protocols) measurement tools (KPIs) Appraisal of excellent beyond minimal standards as peer view to judge personal skills, performance & courts of law to determine professional behavior was Appreciative reasonable or negligent. (Judged by expert staff) (Peer review) Degree of excellent that is perceived and judged by recipient or the observer of Perceptive care (respect the opinions affective the care). ‫( اوجهه الجودة تقييم االداء‬ASPECTS OF QUALITY (MAP) Compliance with/ adherence to standards. According to the judgment of peer review bodies. ‫زميللهنفسالتخصصوالخبرة‬ ‫إحساس العميل بالخدمة المقدمة‬As perceived by the recipient of care. A customer is anyone who receives our service Or dependent on me as a supplier.  The concept of customer Customer Person who consider e as a supplier. One who receive goods and services. Customers are our "dependents"; they rely on us for a serv Customer satisfaction is viewed in healthcare as an essential component of success. Cause: they focus on / how service meet their needs and there expected outcome are met. Value of customer include : 1- price of care 2- quality of service  Identifying customers: - "Wheel and spoke" or "sundial“. - Customer lists by type: Internal and external. Identifying customer needs: - Surveys and interviews. - Research. - Brainstorming.  Tools to identify customers: 1. Customer lists by category , e.g., patients/families , practitioners/clinicians. 2. Customer lists by type ; internal and external customers. Any organization has 2 type of customer: 1- internal customer: who is performing work eg. physicians, pharmacists, nurses, finance staff, admitting staff, HR staff 2- external customer: outside the organization eg. patients/families, accrediting bodies, suppliers, community  Tools to identify customers needs: 1. Surveys and questionnaires. 2. Interviews: Assigned interview process; each manager calls 8-10 members/patients/clients per month for feedback on care and service. 1. Focus groups, 6-12 homogenous customer ask for particular process/ function with open-ended questions for qualitative data. 2. Brainstorming 3. Research within the organization / outside the organization  Admitting/reception/front office Patients/families staff Administrative staff Physicians Administrative services staff Purchasers Ancillary staff/technicians Insurance companies and health Care coordination/social plans services staff Communications staff Employers Human resource staff Government agencies Facilities staff Regulators and accrediting Finance staff agencies Medical/clinical record staff Nurses, aides, medical Vendors/suppliers )goods and assistants services) Performance improvement, QM Other providers Pharmacists Educational institutions Physicians, med. directors Healthcare between service or product In healthcare service driven industry In manufacturing product driven industry  Product Service Tangible Intangible ‫غي ملموسة‬ ‫ر‬ Measure Output “objects” Measure Outcome "performances" Homogenous Heterogeneous ‫غي متجانسة‬ ‫ر‬ Can be stored or resold Perishable ‫ضائع‬/ ‫فان‬ ‫ي‬ cannot be stored or resold ‫براءة ر‬ Can be patented ‫اخياع‬ Very difficult to patent  ‫خدمة مناسبة للمريض‬ The degree to which the care and services provided are: 1. Relevant to an individual's clinical needs. 2. Correct: Doing the right things in accordance with the purpose (Medical necessity). 3. Suitable resource utilization as judged by peers.  ‫تقديم الخدمات في وقت مناسب بدون تاخير‬ Timeliness The degree to which care is provided to the individual at the most beneficial or necessary time.  Availability ‫خدمة متاحة‬ The degree to which appropriate care and services are accessible and obtainable to meet an individual's needs.  Competency ‫كفاءة‬ The degree to which the practitioner adheres to professional and/or organizational standards of care and practice.  Continuity ‫استمرارية الخدمة‬ The coordination of needed healthcare services for a patient among all practitioners and across all involved organizations over time. The delivery of needed healthcare as a coherent unbroken succession of services.  Effectiveness 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"  Efficacy 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. Vaccine efficacy and effectiveness Mediecen efficacy and effectiveness  Efficiency The relationship between the outcomes (results of care) and the resources used to deliver care. "The relationship of outputs (services produced) to inputs (resources used to produce the services)"  Prevention/Early Detection The degree to which interventions, including the identification of risk factors, promote health and prevent disease.  Respect and Caring The degree to which those providing services do so with sensitivity for the individual's needs, expectations, and individual differences. The degree to which the individual or a designee is involved in his or her own care and service decisions  Safety The degree to which the healthcare intervention minimizes risks of adverse outcome for both patient and provider.  Key dimensions of quality Key Dimensions Explanation Appropriateness the care & services provided are relevant to individual's needs (correct, suitable & judged by peer), doing right thing in accordance to the purpose. Availability The healthcare service can be obtained in the face of financial, organizational, procedural, emotional & cultural to meet individual needs (accessible) Competency The degree to which adheres of professional / organizational standard of care / practice (satisfaction / privilege), practioner’s ability to produce health and satisfaction of customer. Continuity The coordination of needed healthcare services for patient among all healthcare providers across organization/s over time (integration, communication) Effectiveness The degree to which the provided care achieved desired outcomes is reached +ve result of care delivery Efficacy The capability of the care to produce the desired outcomes , the power of procedure and ttt to improve health The relationship between outcomes (results) and resources used (inputs) (cost effective) Efficiency Prevention / Early Identification of risk factors / prevention of diseases (risk assessment) Detection Respect and Caring The degree to which those providing services do with sensitivity for the individual's needs, expectations, differences and involve the individual in decision of care (patient centered) Safety The degree to which the healthcare intervention minimizes risks of adverse outcome for both patient & provider / minimizes risks of organizational environment (risk reduction) ,, environment is free from hazard or danger. The degree to which the healthcare intervention at the most beneficial or necessary time. Timeliness  Basic concepts of quality Quality should be defined by the recipient of care or service. Quality /performance management process: planning ,systemic and organization wide to the monitoring analysis and improvement of organizational performance there by continuously improving the quality of patient care and services provided and likelihood of desired patient outcome. Evaluation of patient outcome and effectiveness of diagnosis and treatment must be placed with in the context of appropriate use of available resources and level of care Always monitoring for adverse outcome Repetition of Observe risk issue as well as the expected positive outcome test procedure Appropriateness of investigation  Business sector Before employers concerned only about increasing cost of care but now they are also requiring proof that the quality of care received is the best possible of dollar spent and that adverse outcome are minimized Value: framework that is utilized for quality management program of facility value depend on the result not input and always should defined by customer Quality of care x outcome value= cost (total cost of full cycle of care)  Value-based healthcare: healthcare delivery model in which providers, including hospitals and physicians, are paid based on patient health outcomes. Under value-based care agreements, providers are rewarded for helping patients improve their health, reduce the effects and incidence of chronic disease, and live healthier lives in an evidence-based way. Value = Quality + Outcome of care / Cost of care The goal from a value-based healthcare system Is transparency enabling consumers to compare the quality and price of healthcare services and make informed choices.  Transparency: Enable customer to compare the quality and the price of healthcare service and make informed choice to provide the value everyone wants , all stakeholder must agree on compatible definitions and measure of value. Frontline staff should be involved in the process ( process owner ) Everyone in organization committed to and actively involved in continuous improvement of the quality of patient care  Four cornerstones for value based healthcare improvement Develop interoperable health information technology (HIT): Sharing electronic health record information requires setting national HIT standards and a certification process. Measure and publish quality information.  Four cornerstones for value based healthcare improvement Measure and publish price information. Promote quality and efficiency of care: offering pay-for-performance incentives to all providers.  Cost of poor quality ▪Any cost that would not have been expended if quality were perfect” Cost of scrap, rework, reordering replacement parts for defective items, missing items is cost of poor quality. ▪The total cost of quality is the cost of the effort to eliminate errors and defects, plus the cost of defects that remain. That is, when we spend money to prevent or remove a defect, we save money at the other end, when the customer gets a working product. Cost of quality  Integrated healthcare: Refer to: interprofessional healthcare is an approach characterized by high degree of collaboration and communication among healthcare professional ( physician , nurses , insurers , nonclinical servers ) in this environment they are tracking data and monitoring and analyzing it for any opportunities of improvement. all care giver will follow guideline and pathway.  Healthcare quality frame work based upon TQM philosophy and continuous improvement. TQM Is a broad management philosophy, espousing quality and leadership commitment that provides the energy and the rationale for implementation of the process of Continuous Quality Improvement (CQI) within the organization wide Quality Strategy (add value to all customers). It is the involvement of the entire organization in a process of quality improvement to provide value. All functions and all employees have to participate. Focusing on meeting customer needs and organizational objectives. Continuous improvement in all work, from high level strategic planning and decision-making, to detailed execution of work elements on the shop floor.  Key concepts of TQM ▪Continuous Quality Improvement ( aim of TQM) reflecting in: 1. Increase Customer Satisfaction. 2. Increase Productivity. 3. Increase Profits. 4. Increase Market share. 5. Decrease Costs.  key concepts of TQM Top management leadership. Creating corporate framework for quality Transformation of corporate culture. Customer focus. Process focus. Collaborative approach to process improvement. Employee education and training. Learning by practice and teaching. Benchmarking. Quality measurement and statistics. Recognition and reward. Management integration. The key principles are: - Management Commitment. - Employee Empowerment. - Fact Based Decision Making. - Continuous Improvement. - Customer Focus. - Organizational Culture. - Continuous learning. The ISO 9000:2005 Quality Management Principles  International standards for organization(ISO) Principle Description ▪ Customer focus ▪ Understand current and future customer needs & expectations ▪ Leadership ▪ Commitment and establish environment that help employees to become involved in achieving org. objectives ▪ Involvement of people at all levels of the organization are fully involved and empowered ▪ Process approach ▪ Processes must be managed by the leaders, and related resources provided ▪ System approach to management ▪ Systems management and systems thinking ▪ Continuous improvement ▪ A continuous focus on performance improvement ▪ Factual approach to decision making ▪ Analysis of data and information will lead to effective decision-making ▪ Mutually beneficial supplier relationships ▪ The organization and its suppliers are interdependent and a good relationship between them creates value for all  QUALITY MANAGEMENT PRINCIPLES 1. Productive work is accomplished through processes." Each person in the organization is a part of one or more processes. 2. Soundcustomer-supplier relationships are absolutely necessary for sound quality management.“ 3. "The main source of quality defects is problems in the process."  QUALITY MANAGEMENT PRINCIPLES 4. Poor quality is costly. 5. Understanding the variability of processes is a key to improving quality. 6. Quality control should focus on the most vital processes. 7. The modern approach to quality is thoroughly grounded in scientific and statistical thinking.  QUALITY MANAGEMENT PRINCIPLES 8. Total employee involvement is critical. 9. New organizational structures can help achieve quality improvement. 10. Quality management employs basic, closely interrelated activities: Quality planning, quality control [quality measurement], and quality improvement.  Basic principle of total quality management Sound of customer necessary for sound Productive work is accomplished through of quality Process Source of quality defects in system not Poor quality is costly individual performance Understanding the variability of the Focus on the most vital process process Employee involvement (Quality is Ground on scientific and statistical responsibility to all) thinking New org. structure can help achieve Q. Q. Q. Management Managementactivities activities : :Planning Planning&& Improvement Improvement & Improvement & Control Control  TQM philosophy promotes ▪emphasis on quality, leadership being responsive rather than directive. ▪Decrease emphasis on inspection, focus on systems rather than individual. ▪ investment in learning & education. ▪long term vision. ▪Cautions use minimal standards. ▪Ongoing quality improvement. ▪Effort should be directed not to finding and fixing the problem in product through end point of production but at finding and fixing problem in work process ( strip down the process to find and eliminate the problem)  TQM fosters a belief in the value Customer Needs , Expectations Staff Involvement Managemen t Commitment , Empower staff Team work Ownership , Mult experts  National quality strategy The National Quality Strategy (NQS) was established in 2011 by the Agency for Healthcare Research & Quality (AHRQ), guided by the Triple Aim of the Institute for Healthcare Improvement (IHI). IHI's Triple Aim: 1. Better care 2. Healthy people and communities 3. Affordable care To achieve these aims there are 6 priorities which address the range of healthcare quality concerns.  6 priorities which address the range of healthcare quality concerns:  To achieve the value 1. Offer better value customer experience with more choice of product. ( transparency ) 2. Offer website displaying healthcare information that is easy to read and understood. 3. Looking to the future especially interaction technology. Responsibility of healthcare quality professional ▪understand, teach, and guide the development and implementation of the Strategy and processes, with the effective use of data and information, to make wise improvements and effect positive change. ▪understand the principles of both Total Quality Management and Continuous Quality Improvement. ▪They must articulate to all administrative and governing body leaders how TQM philosophy, with the processes of performance measurement, analysis, and improvement; and the development of an effective Healthcare Quality Strategy, are necessary and compatible with the organization's financial health, and, making the Strategic Plan achievable. ▪demonstrating the value of quality that is linked to reduced risk, reduced costs, and better patient outcomes  DONABEDIAN PARADIGM ▪It is causal relationship between structure, process and outcome. Structure is the arrangement of parts or elements of the Care system that facilitate care. It is the evidence of organization’s capacity to provide care to patients. e.g. resources, staff number, staff qualifications, Ps & Ps, medical record information, settings of care, organizational chart, and accreditation status process refer to the procedure , methods , means , or sequences of steps of providing or delivering care and producing outcomes. refer to activities that act on an “input” from “suppliers” to produce an output for a customer e.g clinical process care delivery process administrative and management process  “Process variation” any change or deviation in form, condition, appearance, extent, etc., from the usual state or assumed standard either in the whole process or in a step of the process. Special Common (assignable & extrinsic) cause variation (random & intrinsic) cause variation ▪ Extrinsic of the usual process. ▪ Intrinsic to the process itself. ▪ Related to Identifiable factors can be tracked to root ▪ Related to situations within process, chronic, noise & cause. inliers. ▪ Refer to sentinel event, unique, one time occurrences, ▪ More time consuming, more difficult. out of the ordinary circumstances, outliers & tails. ▪ Response: no focus, monitoring, process redesign & ▪ More easy to identified & resolved. improvement (aim to reduce variation). ▪ may be positive or negative. ▪ Response: root cause analysis (RCA).  Process reliability ▪DEF: probability that each step of the process will occur when, where, and how it needs to occur. ▪failure-free operation over time. ▪Reliability Rate (PR): the probability of success in HC (delivering desired outcome) by measuring compliance with performance measures (KPIs). Example: medication administration process consisted from 4 steps ((( Step1 (99%) step 2 (95%) step 3 (90%) & step 4 (95%) )))) PR= 0.99*0.95*0.90*0.95= 80% (20% probability of failure)  How to improve process reliability? 1) Reduce the number of steps (lean): Medication administration process in 3 steps PR= 0.99*0.95*0.95= 90% (10% probability of failure) 2) Improve the reliability of individual steps (redesign process): Compliance of staff in Medication administration process increase PR= 0.99*0.95*0.95*0.95= 85% (15% probability of failure) ▪Process Breakthrough improvement: is any sudden or significant solution to problems that leads to further advances, significant improvement or removal of barriers to progress.  outcome the results of care whether adverse or beneficial, or it is the product of the process. Type of outcome: Clinical outcome Functional outcome Perceived outcome ▪ short term results of process ▪ long-term health status ▪ Patient/family satisfaction and ▪ Mortality& morbidity rates, infection ▪ Activities of the daily living knowledge rate status( ADL) ▪ Peer accountability ▪ The patient progress to meet objectives Control blood sugar level ▪ Patient back to normal activity, ▪ Patient satisfied with new life diet, sport & medications & style follow up ▪Factors affect the degree to which healthcare services achieve desired outcome: 1. Disease process & severity. 2. Care process. 3. Patient compliance. 4. Random & unidentified variables.  Important Roles and Quality Functions Quality Role Important Functions of Role Quality Management (QM) ▪ Organizational systems assessment ▪ Clinical performance monitoring (compliance to standards) ▪ Patient outcomes and care delivery process measurement, analysis, interpretation, and reporting ▪ Patient safety planning, program implementation, Measurement ▪ Organization performance improvement process Patient Safety Management (PS) ▪ Patient safety planning, program implementation. ▪ process measurement, analysis, interpretation, and reporting. Utilization Management ▪ Review medical necessity and appropriateness (UM) ▪ Resource allocation: timeliness, appropriateness, efficiency, and cost ▪ Role of Case Management/Discharge Planning in some organizations Risk Management (RM) ▪ Clinical occurrences, Environmental and claims ▪ Mitigation of the effects of negative outcomes on both the organization and the patient  Quality Role Important Functions of Role Infection Control (IC) ▪ Surveillance & prevention Practitioner credentialing, ▪ Medical Staff at time of appointment and reappointment privileging & competency appraisal ▪ All independent practitioners, specific requirements & depending on the setting Continuing medical/clinical ▪ Orientation of quality management program, performance education standards, policies, procedures, and documentation standards Professionals performing any of the ▪ Data collection, summarization, and aggregation first four components (QM, UM, RM, ▪ Information analysis, display, and presentation ▪ Information interpretation, sharing, and use and IC) ▪ Ongoing communications within the organization ▪ Effectiveness oversight Wise improvement…  System thinking System: whole elements continually affect each other over time (hang together) and operate toward a common purpose. Process: flow or sequence of activities (steps) operate toward a common purpose. Change in step in a process does not necessarily change other steps. system Function Function proce proce proce proce ss ss ss ss step step step step  System thinking Approach of system analysis help a person to view system from abroad perspective that include seeing overall structure ,pattern and cycles in system rather than seeing only specific event in the system The ability or skills to perform problem solving in complex system Way to optimize every things u do ▪System structure: the pattern of interrelationships among all key components of the system, e.g.: Process flows, attitudes, decisions & hierarchy.  Levels of system ▪4 level in systems: 1. Events (occurrences). 2. Pattern or behavior (trend). 3. Systematic structure (interrelationship) 4. Mental models (beliefs & assumptions, mind set about the ways of work gets done). The goal of the system: is maximize the output of the system not output of each of its components, So we must optimize rather than maximize performance of each components to maximize the output of the system.  How to use system thinking Define the problem accurately without jumping to conclusions Look for causes (5 whys) Apply pattern Lookof forperformance to fill the gap causes (5 whys) Apply pattern of performance to fill the gap Determine the strategies for solutions Redesign the system  How to use syste m thinki ng  IOM Reports 1999: To Err is Human At least 44,000 and perhaps as many as 98,000 Americans die in hospitals each year as a result of medical errors  One death in every 343 to 764 admissions. In comparison, aviation averages one death for every 8 million flights.  2001: Crossing the Quality Chasm -The report described America's health system as "a tangled, highly fragmented web that often wastes resources by duplicating efforts.“ - Should create new methods to monitor and track quality in six key areas (IOM aims or attributes of care).  Six key areas (IOM aims or attributes of care) STEEEP 1. Safe care. 2. Timely care. 3. Effective care. 4. Efficient care. 5. Equitable care. 6. Patient-centered care. Thanks a lot