Quality Assurance and Total Quality Management CA2 PDF

CA2 WEEK 2 DEAN UAYAN February 21, 2022 QUALITY ASSURANCE AND TOTAL QUALITY - involved with fixing NOW MANAGEMENT - preventing future costly mistakes QUALITY CONTROL...

CA2 WEEK 2 DEAN UAYAN February 21, 2022 QUALITY ASSURANCE AND TOTAL QUALITY - involved with fixing NOW MANAGEMENT - preventing future costly mistakes QUALITY CONTROL (Q.C) CONTINUOUS QUALITY IMPROVEMENT (C.Q.I) - refers to quality related activities associated - ongoing process of monitoring structure, with the creation of project deliverables. process, and outcome indicators in order to - used to verify that deliverables are of identify signal events, significant trends and acceptable quality and that they are complete opportunities for change and correct. - it integrates quality assurance, quality control Examples: and quality improvement ▪ peer review ▪ testing process DIFFERENCE BETWEEN Q.A AND C.Q.I - involves performance management and Quality Assurance – goals only aim at maintaining maintenance care quality at a present level - includes systematic method of ensuring conformance to a desired standard or norm Continuous Quality Improvement – ongoing process through which care standards and practice behaviors QUALITY ASSURANCE (Q.A) are progressively enhanced: - refers to the process used to create the ▪ current research findings deliverables, and can be performed by a ▪ practice manager, client, or even a third-party ▪ patient and public welfare reviewer. Examples: ▪ process checklists ▪ project audits - process of establishing a target degree of excellence - for nursing intervention and taking action to ensure that each client receives the agreed level of care OBJECTIVES OF QUALITY ASSURANCE ▪ Set standard for nursing care delivery ▪ Establish criteria as basis to evaluate this standard COMPONENTS OF QUALITY ASSURANCE PROGRAM ▪ Clear and concise written statement of purpose, philosophy, values and objectives NURSING CARE STANDARDS ▪ Standards or indicators for measuring quality Standard: a desired quantity, quality or level of of care performance that is established as a criterion against ▪ Policies and procedure for using such which worker performance will be measured. standards in data gathering ▪ Analyzing and reporting of the data gathered, Purposes: with isolation of problems and variances ▪ Guide the provision of nursing care ▪ Use of the result to prioritize and correct ▪ Provide the means by which nursing problems and variances personnel are evaluated in the provision of ▪ Monitoring of clinical and managerial care performance and on-going feedback ▪ Provide the means by which to measure the ▪ Evaluation of the Q.A system end results of nursing care through patient outcomes QUALITY IMPROVEMENT - concerned with performance development - ongoing 0 0 Standards of care refers to: ▪ specific incorporation in strategic planning ▪ Nurses conducting themselves professionally according to a generally accepted reasonable PRINCIPLES OF TQM practice of nursing care ▪ Quality can and must be managed ▪ Conduct themselves with a degree of care, ▪ Everyone has a customer to delight skill and knowledge that reasonably ▪ Processes, not the people, are the problem competent nurses would exhibit in any ▪ Every employee is responsible for quality situation ▪ Problems must be prevented, not just fixed ▪ Practice that avoids being found negligent ▪ Quality must be measured so that it can be ▪ Exercise good judgment, education and controlled training to the best of their ability under any ▪ Quality improvements must be continuous circumstances. ▪ Quality goals must be based on customer requirements SOURCES OF STANDARD OF CARE ▪ Nursing law ISSUE AND CONCERNS OF TQM ▪ Professional organizations Management commitment ▪ Code of Ethics for Nurses ▪ Plan (drive, direct) ▪ Joint Commission on Accreditation of ▪ Do (deploy, support, participate) Healthcare Organizations (JCAHO) ▪ Check (review) ▪ Case law and published opinions by judges ▪ Act (recognize, communicate, revise) ▪ State statutes and administrative codes ▪ Hospital policies Employee empowerment ▪ Authoritative nursing journals ▪ Training ▪ Suggestion scheme TOTAL QUALITY MANAGEMENT ▪ Measurement and recognition - is a management philosophy that seeks to ▪ Excellence teams integrate all organizational functions (marketing, finance, design, engineering and Fact based decision making production, customer services, etc.) to focus ▪ SPC (statistical process control) on meeting customer needs and ▪ DOE (design of experiment), FMEA (failure organizational objectives. modes and effect analysis) - views an organization as a collection of ▪ The 7 statistical tools (SPSS, R, MatLab, MS processes Excel, SAS, GraphPad Prism, Minitab) - maintains that organizations must strive to ▪ TOPS (FORD 8D – Team Oriented Problem continuously improve these processes Solving) - by incorporating the knowledge ad experiences of workers Continuous improvement - infinitely variable and adaptable ▪ Systematic measurement and focus of COQ - generic management tool (cause on quality) ▪ Excellence teams OBJECTIVES OF TQM ▪ Cross-functional process management “Do the right things right, the first time every time” ▪ Attain, maintain, improve standards TQM ACTIVITIES INCLUDE Customer focus ▪ commitment by senior management and all ▪ Supplier partnership employees ▪ Service relationship with internal customers ▪ meeting customer requirements ▪ Never compromise quality ▪ reducing development cycle times ▪ Customer driven standards ▪ just in time/ demand flow manufacturing ▪ improvement teams ▪ reducing product and service costs THE CONCEPT OF CONTINUOUS IMPROVEMENT ▪ systems to facilitate improvement BY TQM ▪ line management ownership - TQM is mainly concerned with continuous ▪ employee involvement and empowerment improvement in all work, from high level ▪ recognition and celebration strategic planning and decision-making to ▪ challenging quantifies goals and detailed execution of work elements on the benchmarking shop floor ▪ focus on processes/ improvement plans 0 0  - It stems from the belief that mistakes can be Beckhard and Pritchard (1992) have outlined the basic avoided and defects can be prevented steps in managing a transition to a new system, such - It leads to continuous improving results, in all as TQM: aspects of work, as a result od continuously - identifying tasks to be done improving capabilities, people, processes, - creating necessary management structures technology and machine capabilities - developing strategies for building - Continuous improvement must deal not only commitment with improving results, but more importantly - designing mechanisms to communicate the with improving capabilities to produce better change results in the future. - assigning resources - A central principle of TQM is that mistakes may be made by people, but most of them are caused, or at least permitted, by faulty systems and processes. - This means that the root cause of such mistakes can be identified and eliminated, and repetition can be prevented by changing the process THE 5 MAJOR AREAS TO FOCUS FOR CAPABILITY IMPROVEMENT ▪ demand generation ▪ supply generation ▪ technology ▪ operations ▪ people capability 3 MAJOR MECHANISMS OF PREVENTION ▪ Preventing mistakes (defects) from occurring (Mistakes – proofing or Poka-Yoke) ▪ Where mistakes can’t be absolutely prevented, detecting them early to prevent them being passed down the value-added chain (Inspection at source or by the next operation) ▪ Where mistakes recur, stopping production until the process can be corrected, to prevent the production of more defects (Stop in time) IMPLEMENTATION PRINCIPLES AND PROCESSES - A preliminary step in TQM implementation is to assess the organization’s current reality - If the current reality does not include important preconditions, TQM implementation should be delayed until the organization is in a state in which TQM is likely to succeed. - If an organization has a track record of effective responsiveness to the environment, and if it has been able to successfully change the way it operates when needed - People need to feel a need for change, Kanter (1983) addresses this phenomenon be describing building blocks which are present in effective organizational change. STEPS IN MANAGING THE TRANSITION 0 0  TQM AND CQI PROCESSES TOTAL QUALITY MANAGEMENT (TQM) - is continuously improving quality (CQI) by focusing on customers’ requirements, improving the processes which relate to these expectations and involving everyone in the process of improvement THE CONTINUOUS QUALITY IMPROVEMENT CYCLE ▪ PLAN - Plan for CQI and build teams to do the following - Set standards - Monitor current quality level and PRINCIPLES FOR INVOLVING PEOPLE IN CQI identify problems ▪ Involve those who do the work as a leader in developing better and better ways to do the - Analyze root causes of problems job - Generate solutions ▪ Make sure they understand customer needs ▪ DO - Implement choses solutions ▪ Partner with specialists or other ▪ CHECK knowledgeable people who understand how the process does or should work – people - Monitor success of solution who can teach you and other employees ▪ ACT about the underlying theory or principles that - Adjust solutions to ensure success guide the work - Standardize effective solutions ▪ Designate an “owner,” a person responsible QUALITY PROBLEM SOLVING TOOLS for keeping visible the documentation, for updating the standard and documentation as ▪ generating ideas → brainstorming improvements are identified, and for assuring ▪ generating consensus on ideas → nominal that newcomers and others are trained group technique ▪ clarifying processes → flowcharting ▪ analyzing cause and effect → cause-effect diagram ▪ organizing data → check sheets ▪ prioritizing → Pareto chart ▪ Showing patterns in data → histogram ▪ showing changes → 0 0 0 0  QUALITY ASSURANCE CARE AND NURSING the practice, as well as the population of patients as a QUALITY CIRCLES/ TEAMS whole. - quality circle = quality teams - circle is a small group of employees who Useful information includes recommended services voluntarily meet at regular times to identify, (e.g., am Asthma Action Plan), key outcome measures (e.g., symptoms-free days, ER visits), patient contact analyze and solve quality and other problems information, and patient encounter history (e.g., how in their working environment often patient accesses care; last time seen). This IHI - recommend and implement improvement strategies and be a useful reservoir for the sponsored webpage provides a number of ideas for generation of new ideas change and allows visitors to upload their own ideas and comments. - members face and share similar problems in their daily work lives CLINICAL PRACTICE GUIDELINES - create a program to tap human creative Clinical Pathways energy that is capable of generating - are standardized, evidence-based handsome rewards. multidisciplinary management plans, which identify an appropriate sequence of clinical ACTIVITIES IN QUALITY CIRCLES/ TEAMS interventions, time frames, milestones and 1. List the project name, goal, reasons for the expected outcomes for a homogenous patient project group (Queensland Health Clinical Pathways 2. Create an activity schedule. The entire team Board definition 2002) will compose an action plan, deem how to implement it, and then evaluate the results, Nursing audit (Joint Audit) Title the sections as research, compilation, - a review of the patient record designed to analysis, investigation, action plan, identify, examine, or verify the performance of implementation and evaluation, with relevant a certain specified aspects of nursing care by volunteer names and notes written under each using established criteria section. Types: 3. The quality circle team works with ▪ Concurrent audit- performed during ongoing management to decide specific goals against nursing care which to measure the data, then analyze the ▪ Retrospective audit- performed after results again against project goals so that the discharge from a care facility, using the company can prevent future excess scrap and patient’s record. Often a nursing audit and a its consequence monetary loss. medical audit are performed collaboratively, 4. Develop a quality circle action plan based on resulting in a joint audit. the team’s analysis and work with management to implement it. PURPOSE OF NURSING AUDIT 5. Work with management to evaluate the ▪ Evaluate nursing care given quality circle activity. ▪ Achieves deserved and feasible quality of QI TEAM PROCESS USING DEMING CYCLE nursing care (FOCUS-PDCA) ▪ Stimulant to better records ▪ F-ind a process to improve ▪ Focuses on care provided and not on care provider ▪ O-rganize a team that knows the process ▪ C-larify current knowledge of the process ▪ U-nderstand causes of process variation UTILIZATION REVIEW ▪ S-elect the process improvement - is a health insurance company’s opportunity to ▪ P-lan the improvement review a request for medical treatment ▪ D-o data collection, data analysis and - The purpose of the review is to: ▪ confirms that the plan provides improvemnt ▪ C-heck data from process improvement and coverage for your medical services customer outcome ▪ minimizes cost and determine if the ▪ A-ct to maintain and continue improvement recommended treatment is appropriate SAMPLE OF QUALITY IMPRVEMENT ACTIVITIES ▪ gives opportunity to confirm that your Ideas for Change: Clinical Information Systems health plan provides adequate Example 1: To provide good care for people with coverage for your particular condition chronic illness, clinicians need access to timely, clinically relevant information about each patient in 0 0 COMPLAINT ANALYSIS Preparation ▪ comments, feedbacks coming from ▪ Identify clinicians who will form the core dissatisfied customer group for the department meetings, taking ▪ a customer complaint is a blessing in disguise into account the benefits of a multidisciplinary ▪ prompt resolution of a complaint often approach involving the working group generates more customer loyalty than trouble- ▪ Provide potential to broaden the group for free service specific cases, where significant input to care occurred from the other clinical areas FACTS ABOUT COMPLAINTS ▪ Appoint a senior consultant to be the Chair ▪ While the average customer doesn’t complain and to have responsibility for meeting to the company, he will tell ten people or arrangements more about the problem, and these people ▪ Appoint a registrar or fellow with a will tell others responsibility for case coordination and ▪ A complaint identifies an area of your business minute taking, outlining expectations that might need improvement ▪ Book regular meeting on time. It is a ▪ If you suddenly see several customers with the requirement that meetings are held monthly. same complaint, then you have a functional problem that needs analysis, discussion, and Purposes correction ▪ discussing management decisions ▪ Complaints are a great tool to fine-tune your ▪ providing a learning opportunity focused on customer service, to ger better at what you do system thinking ▪ identifying opportunities to improve safety HOW TO ANALYZE CUSTOMER COMPLAINTS and quality of care There are three primary tools for analyzing complaints: SENTINEL EVENTS MONITORING 1. Customer survey Sentinel events 2. Policy technicians who always tell - are defined as serious adverse events that management about complaints cause death or severe injury to the patients 3. Customer complaint form – the form and result in loss of trust in the healthcare documents the complaint, and forces system by client/patients corrective action - the surveillance of sentinel events, is an important role of public health. It is an Use the files for training: How could we have indispensable tool for the prevention of such prevented this service? How would you have handled events and for the promotion of patient safety. it differently? Could we have responded better to the customer? Complaints should be considered not as a SENTINEL EVENT LIST inconvenience, but as a tool to be used to improve ▪ Procedures performed to wrong patient service. ▪ Surgery performed to wrong part of body (site, organ, part) EFFECTIVE QUSTIONS TO ANALYZE COMPLAINTS ▪ Erroneous procedure to correct patient ▪ How could we have prevented this service ▪ Instruments or other material retained in problem? surgical site which requires successive ▪ How would you have handled it differently? interventions or ulterior surgery ▪ Could we have responded better to the ▪ Transfusion reaction consequent to ABO customer? incompatibility Note: Complaints should be considered not as an ▪ Death, coma, or severe harm originating form inconvenience, but as a tool to be used to improve error in pharmacologic therapy services. ▪ Maternal death or severe illness correlated to labor and/or childbirth MORBIDITY AND MORTALITY REVIEW MEETINGS - are requirements of all medical departments CREDENTIALING within the hospital. These guidelines have - is a process obtaining, verifying, and been prepared to assist departments conduct assessing the qualifications of a healthcare effective meetings and set the minimum practitioner to provide patient care services in standard expected. or for a healthcare entity - Re-credentialing is the process of obtaining and evaluating data to support the continued competence of the healthcare practitioner to 0 0  provide patient care services in or for a FLOWCHARTS healthcare organization ▪ Remember systems theory: - Input CLINICAL PRIVILEGING - Output - is the process used to identify, document, and - Customer supplier approve the specific procedures and - Interactions treatments that may be performed in a ▪ Divide complex processes into simple sub- specific setting. processes - Privileges are granted based on the findings ▪ A qualitative tool of the credentialing function and should only be granted for services that are currently offered by the hospital CREDENTIALING and PRIVILEGING are required for increased patient safety, reduction of medical errors and the provision of high-quality health care services. VARIANCE REPORT AND ANALYSIS - is usually associated with a manufacturer’s product costs - In the healthcare setting, variance analysis attempts or identifies the causes of the differences between the services provided: 1. standard costs of the inputs that Types of Flowcharts should have occurred for the actual 1. Layout flowchart – example: staff movement products it manufactured 2. Data flow diagrams – leave approval process 2. Price variance identifies whether the company paid too much for each unit ISHIKAWA DIAGRAMS of the input – or they have paid more - also known as Fishbone or Cause-and-Effect per actual input than it had planned. diagrams 3. Quantity variance identifies whether - non-qualitative tools (qualitative) the health institutions used too much - sometimes called 5M Diagram of the input – perhaps it used too ▪ Men many materials for the number of ▪ Machine services it renders to client. ▪ Materials - Variance analysis for manufacturing overhead ▪ Measurements costs is more complicated than the variance ▪ Methods analysis for materials. However, the variance analysis for manufacturing overhead costs is very important as manufacturing overhead costs have become a very large percentage of a product’s costs. TOOLS FOR TQM ▪ data-driven methodology ▪ data generated by processes THE ‘SEVEN SIMPLE TOOLS’ ▪ Flowcharts ▪ Cause and effect (Ishikawa/ fishbone) diagrams ▪ Check sheets ▪ Pareto Charts CHECKSHEETS ▪ Histograms ▪ central tool for Quality Assurance programs ▪ Run charts and Control charts ▪ especially useful for operational procedures ▪ Scatter plots and Correlation analysis ▪ could be derived from the flowchart and fishbone diagrams 0 0  ▪ Construct and label bars for each category ▪ Calculate the percentage for each category ▪ Calculate and draw cumulative sums PROCESS DECISION PROGRAM CHART (PDPC) - is a very simple tool with an unnecessarily impressive sounding name, possibly derived from the Japanese name, from where it came as one of the ‘Second Seven Tools’ (also known as the ‘Seven tools for management and planning’) PARETO CHART - is a bar graph. The lengths of the bars represent frequency or cost (time or money), and are arranged with longest bars on the left and the shortest to the right. In this way the chart visually depicts which situations are more significant. WHEN TO USE A PARETO CHART ▪ When analyzing data about the frequency of problems or causes in a process ▪ When there are many problems or causes and you want to focus on the most significant ▪ When analyzing broad causes by looking at their specific components How do you do it? 1. Break down the task into a Tree Diagram. The bottom ‘leaves’ on the tree will now indicate the actual tasks to be carried out. 2. For each bottom-level task ‘leaf’, brainstorm or otherwise identify a list of possible problems that could occur 3. Select one or a few of the risks identifies in step 2 to put on the diagram, based on a combination of probability of the risk occurring and the potential impact, should the risk materialize. 4. For each risk selected in step, brainstorm or otherwise identify possible countermeasures that you could take to minimize the effect of the risk. 5. Select a practical subset of countermeasures Pareto chart procedure identified in Step 4 to put on the cart ▪ Decide what categories you will use to group 6. Continue building the chart as above, finding items risks and countermeasure for each task. If ▪ Decide what measurement is appropriate. there are a large number of tasks, you can Common measurements are frequency, simplify the task by only doing this for tasks quantity, cost and time. that are considered to be at risk or where the ▪ Decide what period of time the Pareto chart impact of their failure would be felt. will cover: One work cycle? One full day? A week? ▪ Collect the data, recording the category each time. (Or assemble data that already exist) ▪ Subtotal the measurements for each category ▪ Determine the appropriate scale for the measurements you have collected 0 0  ▪ Check – measure the change ▪ Act – modify as needed as long as significant improvements are obtained JURAN - focused on quality control with the “trilogy” ▪ quality planning ▪ quality control ▪ quality improvement - An SPC representation of the trilogy is used in the figure at the right. A spec is developed usually with a ± tolerance. A control chart is used to get the process under control. As special causes are removed to improve the process, variation is reduced. These are the 10 STEPS OF QUALITY IMPROVEMENT basic steps in Six Sigma process 1. Commitment development. 2. Improvement teams 3. Education VALUE ANALYSIS TEAMS 4. Measures, display and review - In Value Analysis, developed by Larry Miles at 5. Cost of quality GE during WWII, multi-functional teams 6. Communication (design, production engineering, purchasing, 7. Corrective/ preventive actions quality) use a formalized process to identify 8. Recognition alternative materials, manufacturing 9. Event processes, and designs to improve function 10. Goal setting and continuous improvement while reducing costs. - The “Job Plan” for a value analysis of a specific “QUALITY IS NEVER HAVING TO SAY YOU’RE SORRY” product or process has the following format: ▪ Pre-study - collect customer data QUALITY-BASED PROBLEM-SOLVING/ PROCESS - collect product and process IMPROVEMENT data Quality improvement tools: - build product and process ▪ Control charts models - Statistical Quality Control (SQC) or - form the multi-functional team Statistical Process Control (SPC) for ▪ Study repetitive, high-volume production began - Information phase – analyze in the 1930’s when Shewhart developed data control charts. Small production samples - Function Analysis phase – were measured periodically to monitor identify and cost functions quality. Sample mean (Xbar) and range ( - Creative phase – brainstorm R ) charts were used to detect when a ideas process was going out of “economic - Evaluation phase – rank then control” develop ideas ▪ Lot sampling - Development phase – quantify ▪ Process capability benefits and plan actions ▪ Value analysis - Presentation – make oral report and prepare written DEMING PDCA reports The Deming / Shewhart cycle was especially useful in ▪ Post-study solving these quality problems. The PDCA circle - complete changes denotes continuous improvement by repeating the - implement changes basic cycle of - monitor changes ▪ Plan - Get the data TEAMS - Analyze the problem - Japanese Quality Circles demonstrated the - Plan the solution effectiveness of worker teams in identifying ▪ Do 0 0  and solving process problems in their work area. - However, most serious quality problems in non-manufacturing (as well as manufacturing) organizations arise in activities that involve more than one department/ function. - Quality circles has evolved into Kaizen which utilizes multi-functional worker and production engineering teams to improve quality and productivity in a given process. - The teams use TQM techniques in implementing “lean” manufacturing methods TOTAL QUALITY MANAGEMENT (TQM) CREDENTIALING emphasized: - credentials = certification ▪ using multi-functional teams (professional - process by which an agent qualified to do so staff workers from all departments involved) grants formal recognition to and records such ▪ to solve problems status of entities (individuals, organizations, ▪ the teams were trained to use basic statistical processes, services, or products) meeting pre- tools to collect and analyze data determined and standardized criteria. ✓ check sheets PORTFOLIO ✓ pareto diagrams - is a collection of investments ✓ histograms - evidentiary documents ✓ run charts - information intended to expand and provide ✓ flow charts evidence of accomplishments ✓ cause and effect diagrams - it includes skills and experiences, in the ✓ force field analysis academe, workplace, and community service ✓ scatter diagrams ISO/ QS9000 ▪ ISO9000 was developed as a standard for business quality systems ▪ To be certifies, businesses needed to document their quality system and ensure adherence to it with reviews and audit ▪ A key element was the identification of non- conformances and a Corrective action system to prevent re-occurrences ▪ Specific quality improvement methodologies were not prescribed ▪ The automotive industry adopted the QS9000 standard for their suppliers to require the use of specific practices in quality planning and in production operations ▪ advanced product quality plans ▪ design/ process failure mode and effects analysis (FMEA) BRECKER PROCESS IMPROVEMENT Brecker Associates integrated the: ▪ Team-based process improvement of TQM ▪ Data gathering and brainstorming of VA ▪ Quality methodologies of QS9000 ▪ Statistical process control of Juran 0 0