Dr. Hala 4 Lectures PDF

Introduction to Health Care Quality Management Quality evolution As early as the 1950s, Japanese companies began to see the benefits of emphasizing quality throughout their organizations and enlisted the help of an American, W. Edwards Deming, who is credited with...

Introduction to Health Care Quality Management Quality evolution As early as the 1950s, Japanese companies began to see the benefits of emphasizing quality throughout their organizations and enlisted the help of an American, W. Edwards Deming, who is credited with giving Japanese companies a massive head start in the quality movement. His methods include statistical process control (SPC) and problem-solving techniques that were very effective in gaining the necessary momentum to change the mentality of organizations needing to produce high quality products and services. Deming developed his 14 points to communicate to managers how to increase quality within an organization. Deming believed that 85 percent of all quality problems were the fault of management. In order to improve, management had to take the lead and put in place the necessary resources and systems. For example, consistent quality in incoming materials could not be expected when buyers were not given the necessary tools to understand quality requirements of those products and services. Buyers needed to fully understand how to assess the quality of all incoming products and services, understand the quality requirements, as well as be able to communicate these requirements to vendors. In a well-managed quality system, buyers should also be allowed to work closely with vendors and help them meet or exceed the required quality requirements. According to Deming, there were two different concepts of process improvement that quality systems needed to address: (1) common (systematic) causes of error, and (2) special causes of error. Systematic causes are shared by numerous personnel, machines, or products and special causes are associated with individual employees or equipment. Systematic causes of error include poor product/service design, materials not suited for their use, and poor physical 1 conditions. Special causes of error include lack of training or skill, a poor lot of incoming materials, or equipment out of order. What is quality ? there is no conclusive definition of quality. For instance, to a manufacturer, a quality product is one that conforms to design specifications, has no defects, and performs to the standards customers expect. To retailers, a quality product is one that has a good combination of price and features and appeals to a majority of customers. WHO (1988) : Has defined as the proper performance according to standards that are known to be safe, affordable to the society, and have the ability to produce an impact on morbidity, mortality, disability and malnutrition. According to Juran Institute "Quality is defined as both freedom from deficiencies and product features (fitness for use) ". Deming: "Quality is defined from the customer’s point of view as anything that enhances their satisfaction" The Institute of Medicine define Quality: involves meeting or exceeding customer expectations. Finally, Quality: Achieved by conforming to established requirements within an organization. What is quality ? Doing the right things… right ….the first time and…. every time 2 Although no universally accepted definition of quality exists, its various definitions share common elements: 3 4  Deming believed that 85 percent of all quality problems were the fault of management. In order to improve, management had to take the lead and put in place the necessary resources and systems. According to Deming, there were two different concepts of process improvement that quality systems 5  Another influential individual in the development of quality control was Joseph M. Juran, who, like Deming, made a name for himself working in Japanese organizations focusing on improving quality. Juran defined quality as “fitness for use,” meaning that the users of products or services should be able to rely on that product or service 100 percent of the time without any worry of defects. If this was true, the product could be classified as fit for use. Quality of design….. involves the design concept and specifications. The quality of a product or service is only as good as its design and intention. Quality of conformance…… is reflected in the ability to replicate each aspect of a product or service with the same quality level as that intended in the design. Availability….. refers to freedom from disruptive problems throughout the process and is measured by the frequency or probability of defects Safety….. is described by Juran as calculating the risk of injury due to product hazards. Field use….. refers to the ability of the product to reach the end user with the desired level of quality. This involves packaging, transportation, storage and field service competence, and promptness. What Is a Quality Management System? A quality management system is a management technique used to communicate to employees what is required to produce the desired quality of products and services and to influence employee actions to complete tasks according to the quality specifications. What is the Purpose of a Quality Management System? ✔ establishes a vision for the employees. 6 ✔ Sets standards for employees. ✔ Builds motivation within the company. ✔ Sets goals for employees. ✔ helps fight the resistance to change within organizations. ✔ helps direct the corporate culture. Elements of a quality system Participative Management: The entire quality process, once started, will be an ongoing dynamic part of the organization, just like any other department such as marketing or accounting. It will also need the continuous focus of management. The implementation and management of a successful quality system involves many different aspects that must be addressed on a continuous basis. Quality system design: is composed of the standards and procedures that are developed to ensure that the level of quality desired is repeated in every unit of a product or service.Before manager start, his organization should establish a core team to carry the performance system process Customers: the inclusion of customers in quality program can take many different methods, including: *The cost of losing a customer *The customers perception of quality and *The satisfaction level of the customers Customers OF Health care: Meeting customers need and expectations is another definition for quality so that customer's satisfaction is a high priority for any organization. 7 Internal customers: have a relationship with, and within, your company, either through employment or as partners who deliver your product or service to the end user( the external customer). External customers: are the people that pay for and use the products or services your company offers. They are not a part of the organization that not provides the service. Patients are the most external customers in healthcare. Purchasing: Purchasing is an area in an organization where substantial gains in quality can be realized through the implementation of just a few policies and procedures designed around quality. Today suppliers need to be partners in the quality effort.Accompany products or services are only as good as the combination off all the inputs. Education and training The education and training of employees for the purpose of reaching higher quality standards has many different sides. The discussion of roles that management must play in a quality system is the most important aspect of their education. Data development and statistics: Statistical analysis is a very important aspect of quality system. It is considered a cornerstone of quality improvement process and is very closely tied to evaluating a quality system. 8 Auditing: Auditing a quality management system is important as any another aspect of the system.The audit process allows everyone involved to see if quality management system is working correctly and if the gools and objectives are being reached Why we need quality in health care 1- Quality in healthcare means providing the care the patient needs when the patient needs it, in an affordable, safe, effective manner. 2- Quality health care also means engaging and involving the patient, so, the patient satisfaction increase. 3-improving the ‘process’, in health care reduces the chances associated with failure. 4- Business success may be due to your organization being able to produce a higher -quality product or service than your competitors are able to do at a competitive price. 5- Better understanding of patients' needs 6- Improved participation of employees 7- Better internal communication 8- Greater consistency in the quality of products and services 9- Reduction of costly errors 10- Improved risk management Key Dimension of Quality Safety—Care intended to help patients should not harm them. Effectiveness—Care should be based on scientific knowledge and provided to patients who could benefit. Effectiveness answers the questions "does the procedures or treatment, when correctly applied lead to the desired results ? "It Concerned with doing things right" 9  Patient centered—Care should be respectful of and responsive to individual patient preferences, needs, and values, and patient values should guide all clinical decisions. Timely—Care should be provided promptly when the patient needs it. Efficient—Waste, including equipment, supplies, ideas, and energy, should be avoided. Efficient—Waste, including equipment, supplies, ideas, and energy, should be avoided (The greatest benefit within the resources available). Equitable—the best possible care should be provided to everyone, regardless of age, sex, race, financial status, or any other demographic variable. Quality principles 1- Customer focus: Meet and exceed customer expectation 2- Leadership: Provide purpose direction and engagement 3- Engagement of people : Recognition, empowerment and improve knowledge and skills 4- Process approach: Understand process to optimize performance 5-Improvement: To maintain current performance and create new apportiunities 10 6-Evidence based decision making: Facts, evidence and data analysis for decision making 7- Relationship management: Manage relationship with the interested parties to enhance performance Factors affecting quality of health care Cost−quality connection **The price of a product is a good indicator of its quality. You always have to pay a bit more for the best. That is the higher the price, the higher the quality. **Cost–Quality Connection: the cost of a product or service is indirectly related to its perceived quality. A quality healthcare experience is one that meets a personal need or provides some benefit (either real or perceived) and is provided at a reasonable cost. **Cost- effectiveness the minimal expenditure of dollars, time, and other elements necessary to achieve a desired healthcare result. How quality measures reduce cost Wasted resources are an example. These include the time nurses spend looking for missing supplies or lab results, the costs of agency nurses because of unfilled 11 positions, and delays in patient discharge due to a lack of coordination or an adverse event (e.g., medication error). Using the Institute for Healthcare Improvement (2009) project, Transforming Care at the Bedside (TCAB), & it was found that found that improving quality reduces costs………. , RN overtime was reduced, RN turnover was lowered, and fewer patients suffered falls. National Initiatives to improve quality (Examples) The National Quality Forum is a nonprofit organization that strives to improve the quality of health care by building consensus on performance goals and standards for measuring and reporting them (National Quality Forum, 2011). The Institute of Healthcare Improvement (IHI) offers programs to assist organizations in improving the quality of care they provide (IHI, 2011). Their goals are No needless deaths No needless pain or suffering No helplessness in those served or serving No unwanted waiting No waste Joint Commission, hospitals’ accrediting body, has adopted mandatory national patient safety goals (Joint Commission, 2011). They charge hospitals to: Identify patients correctly Improve staff communication Use medicines safely Prevent infection Check patient medicines Identify patient safety risks 12 One of the most obvious example of national initiatives to improve quality in health care is Quality and safety education for nurses (QSEN) Quality and Safety Education for Nurses (QSEN) addresses the challenge of preparing nurses with the competencies necessary to continuously improve the quality and safety of the health care systems in which they work. **The creation of QSEN by Linda Cronenwett, and a group of experts in quality and safety. QSEN is a national initiative to identify the competencies and knowledge, skills, and attitudes needed by all nurses (and health professionals in general) to continuously improve the quality safety of health care **Patient safety and quality of care are the backbone of nursing practice. ** The six QSEN competencies developed for nursing programs: (Patient-centered care/Teamwork and collaboration/ Evidence-based practice / Quality improvement /Safety/ Informatics (Hunt, 2012) Nurses can positively impact patient outcomes by utilizing the QSEN competencies!! Patient centered care In order to deliver patient centered care, the nurse should view the patient as an individual and tailor the care and interventions needed to promote a better prognosis for the patient. “Recognize the patient or designee as the source of control and full partner in providing coordinated care based on respect for patient’s preferences, values, and needs.” Teamwork and collaboration Patient care is dependent upon effective communication and teamwork between healthcare professionals. Teamwork can be denoted as working collaboratively with other healthcare professionals to achieve a common goal, such as providing 13 efficient and safe patient care.“Function effectively within nursing and inter- professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care. Evidence-based practice Evidence based practice is the process of analyzing, collecting, and interpreting valid information that has been proven effective from research derived evidence. “Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.” (AACN, 2012) Examples in practice: A nurse who regularly reads medical journals to keep up-to-date with current knowledge and practice, performing a procedure with a sterile field because evidence shows it reduces chance for infection. Quality improvement Nurses also are pivotal in hospital efforts to improve quality! "Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems. Safety Nurses implement safety precautions to avoid the occurrence of errors related to patient care. Minimizes the risk of harm to patients and providers through both system effectiveness and individual performance. Informatics Computer technology has been integrated into hospitals through means of using computers and computerized physician order entry. Use information and technology to communicate, manage knowledge, mitigate error, and support decision making. Examples in practice computerized charting, bar-code scanning of meds, graphing of lab value trends to determine course of treatment. 14  Health care quality management activities What is Quality Management?? For quality to be achieved, a systematic evaluation & improvement process must be implemented. Quality management is a way of doing business that continuously improves products and services to achieve better performance……….. to achieve maximum customer satisfaction at the lowest overall cost to the organization while continuing to improve the process. Quality management moved health care from a mode of identifying failed standards, problems, and problem people to a proactive organization in which problems are prevented and ways to improve care and quality of care are sought. Institute of Medicine (IOM) report recommended eliminating overuse, underuse, and misuse of services 15 Measurement Healthcare organizations track performance through various measurement activities to gather information about the quality of patient care and support functions. Results are evaluated in the assessment step by comparing measurement data to performance expectations. If expectations are met, organizations continue to measure and assess performance. If expectations are not met, they proceed to the improvement phase to investigate reasons for the performance gap & implement changes based on their findings. Assessment 16 Results are evaluated in the assessment step by comparing measurement data to performance expectations. If expectations are met, organizations continue to measure and assess performance. If expectations are not met, they proceed to the improvement phase to investigate reasons for the performance gap and implement changes based on their findings. Improvement The quality management cycle doesn’t end at this point, however. Performance continues to be evaluated through measurement activities. 17 Measurement in Quality Management Measurement is the starting point of all quality management activities. The organization uses measurement information to determine how it is performing. In the next step, assessment, the organization judges whether its performance is acceptable. If its performance is acceptable, the organization continues to measure it to ensure it does not deteriorate. If its not acceptable, the organization advances to the improvement step. 18 Tips for quality management QM is based on data; anything measured and recorded can be improved. Concentrate QI energies on factors that are most important to patient quality and safety. Working together to prevent problems is more effective than fixing problems after they Occur. External forces affecting on healthcare quality management 1- Regulations are issued by governments at the local, state, and national levels to protect the health and safety of the public. Regulation is often enforced through licensing. For instance, to maintain its license, a restaurant must comply with state health department rules and periodically undergo inspection. 2- Accreditation is a voluntary process by which the performance of an organization is measured against nationally accepted standards of performance. Accreditation standards are based on government regulations and input from 19 individuals and groups in the healthcare industry. Healthcare organizations seek accreditation because it ◆ enhances public confidence, ◆ is an objective evaluation of the organization’s performance, and ◆ stimulates the organization’s quality improvement efforts. 3- Large Purchasers The largest purchaser of healthcare services is the government. Quality management requirement Requirements of a QM helps to achieve the overall goals of meeting the customers’ and organization’s requirements: ✓ The organization’s quality policy and quality objectives ✓ Procedures, instructions, and records ✓ Data management ✓ Internal processes ✓ Customer satisfaction from product quality ✓ Improvement opportunities ✓ Quality analysis Measurement Characteristics in quality management Measurement is a tool usually in the form of a number or statistic used to monitor the quality of some aspect of healthcare services. 1- Accuracy Performance measures must be accurate. Accuracy relates to the correctness of the numbers. For example, in the case study, the time the patient entered the clinic must be precisely recorded on the registration sign-in sheet. 2- Usefulness Performance measures must be useful. Measurement information must tell people something they want to know. Computers have made data collection easier. For instance, the computerized billing system of a health clinic contains patient 20 demographic information (e.g., age, address, next of kin, insurance coverage). The clinic manager could use this information to report several performance measures. 3-Easy of Interpretation Performance measures must be easy to interpret. The purpose of performance measurement is to provide information, not to make people sort through lots of data to find what they want to know 4-Consistent reporting Performance measures must be uniformly reported to make meaningful comparisons between the results from one period and the results from another period. For example, suppose the clinic manager starts calculating patient wait time information differently. Measurement categories in quality management Quality measures are necessary for determining the overall quality of care. 1-Structure Measures of structure are the foundation of quality measurement. These measures evaluate different attributes such as medical staff and policies in different health care settings—such as clinics and hospitals. Regulators and health insurance companies use them to gauge a provider’s level of quality care. 2-Process If measures of structure are the foundation of quality measurement, then process measures are the blocks. Process measures use evidence-based guidelines to assess the extent and quality of services provided to patients, and incorporate evidence- based best practices into improvement efforts. 3- Outcome Process measures relate to the evidence-based care administered to a patient; outcome measures evaluate the effect of that care on the patient’s health. Process and outcome measures go hand in hand because process measures are closely associated with outcome. Improving a process can result in an improved outcome. 21 4- Patient Experience Patient experience measures encompass process and outcome measures. They provide insight into the quality of care patients receive for example, how quickly do patients get an appointment for urgent care? How well do doctors communicate with their patients? Performance Improvement Steps Performance improvement steps includes six steps that should be implemented in a participatory process involving utility managers, utility staff, and stakeholders: Step 1: set organization goal and objective The process begins with a presentation of the mentee utility vision, mission and goals. The following example is provided for illustration. Vision: A mental picture of what you want to accomplish or achieve Mission: General statement of how the vision will be achieved Step 2: participatory assessment On a 1-to-5 scale, assess current conditions by rating the mentee utility’s practices and approaches and current level of achievement Step 3: ranking importance of themes On a 1-to-10 scale rank the importance of each theme based on the following key points: Consider the utility’s vision, mission, goals, and specific needs. Reflect the interests and considerations of all stakeholders (managers, staff, customers, and community,) Consider long-term needs of organization and all stakeholders Step 4: plotting the themes importance against the level of achievement: Insert each theme in table based on the rating and ranking Step 5: select themes for short and medium term, and identify long-term themes 22 It should be emphasized that performance improvement in all the themes, it is important for the overall performance improvement of the utility, and the sustainability of its services. Step 6: development and implement short-term performance improvement This exercise will focus on the development of the short-term performance improvement based on the selection of the themes for short-term, the short-term performance improvement would include the following items: Utility SWOT analysis for selected each theme to identify strengths, weaknesses, opportunities, and threats for performance improvement. Performance improvement action plan for each theme that includes underlying root causes or issues of under-performance, actions to address these issues, and cost of the action. Monitoring and evaluation plan to assess and monitor the accomplishments of these actions. Performance Improvement tools ✓ Brainstorming is a technique used to quickly generate lots of ideas about a problem or topic. It encourages creative thinking and incites enthusiasm. ✓ Affinity diagrams are used to organize large amounts of language data (ideas, issues, opinions) generated by brainstorming into groupings on the basis of the relationships between data items. This process helps improvement teams sift through large volumes of information and encourages new patterns of thinking. ✓ Definition a cause-and-effect (root cause analysis) diagram The cause and effect diagram is sometimes called an Ishikawa diagram after its inventor. It is also known as a fish bone diagram because of its shape. A cause and effect diagram describes a relationship between variables. ✓ Decision Matrix 23  Decision Matrix or decision grid or problem matrix, It evaluates and prioritizes a list of options according to specific criteria. ✓ Five why: The" five why" is a systematic technique of asking five questions successively to determine the root of causes and also help you to determine the relationship between different root causes of a problem. It is easy to apply and to complete without statistical analysis. ✓ Flowcharts, sometimes referred to as process maps, are used to document the flow or sequence of events in a process or to develop an optimal new process during the solution stage of improvement. ✓ A workflow diagram is a visual representation of the movement of people, materials, paperwork, or information during a process. The diagram can also illustrate general relationships or patterns of activity among interrelated processes ✓ A planning matrix is a diagram that shows the tasks needed to complete an activity, the people or groups responsible for completing the tasks, and an activity schedule with deadlines for task completion. 24  Quality Improvement Introduction Quality improvement is a central tenet of healthcare. It is a part of the daily routine of all those involved in delivering healthcare, and it became a statutory obligation in many countries. Also, it is very important in healthcare organizations because it improve quality of healthcare services, enhance the accountability of health practitioners, managers, maintain resource efficiency, identify and minimize medical errors while maximize the use of effective care, improve outcomes, and aligning care to what clients/patients want in addition to what they need. To build a healthcare system which provides efficient, effective, and consistent care, it is important that healthcare organizations apply the principles of quality improvement in all aspects of clinical care strive to improve the value of care delivery, and prevent costly negative patient outcomes through quality improvement initiatives that promote patient's care efficiency, patient-centered care, provider coordination, and clinical best practices. But we can not discuss quality improvement before introduce some focus on performance improvement because of the interchangeable relationship between them. Performance improvement Is a form of organizational development focused on increasing outputs and improving efficiency for a particular process or procedure. Performance 25 improvement can occur at different levels including the employee level, team level, the division or unit level and the organization as a whole. Steps of performance improvement 1. Identify any underlying issues. Before you start to put the plan together, make sure you are fully aware of any issues which may be behind poor performance. 2. Involve the employee. 3. Set clear objectives. 4. Agree training and support. 5. Review progress regularly. Quality Indicators (QIs) Are standardized, evidence-based measures of health care quality that can be used with readily available hospital inpatient administrative data to measure and track clinical performance and outcomes. Benefits of quality indicators: The constant use of indicators helps to Improve the quality of care. Support the confidence of users. Meet the requirements of the organizations. Reduce costs, and stimulate the participation of professionals. Definition Quality Improvement Quality improvement (QI) is the framework we use to systematically improve the ways care is delivered to patients. Processes have characteristics that can be measured, analyzed, improved, and controlled. 26  It is consisting of systematic and continuous actions that lead to measurable improvement in health care services and the health status of selected patient groups. key principles of quality improvement QI work as systems and processes. Focus on patients. Focus on being part of the team. Focus on use of the data. 1) QI Work as Systems and Processes To make improvements, an organization needs to understand its own delivery system and key processes. Both resources (inputs) and activities carried out (processes) are addressed together to ensure or improve quality of care (outputs/outcomes). 2) Focus on Patients An important measure of quality is the extent to which patients’ needs and expectations are met. Services that are designed to meet the needs and expectations of patients and their community include: Systems that affect patient entry Care provision that is evidence-based Patient safety Support for patient engagement Coordination of care with other parts of the larger health care system Cultural efficiency, including assessing health literacy of patients, patient- centered communication, and linguistically appropriate care 3) Focus on Being Part of the Team At its core, QI is a team process. Under the right circumstances, a team use the knowledge, skills, experience, and perspectives of different individuals within the team to make lasting improvements. A team approach is most effective when: 27  The process or system is complex No one person in an organization knows all the dimensions of an issue The process involves more than one discipline or work area Solutions require creativity Staff commitment and buy-in are needed 4) Focus on use of the data Data is the cornerstone of QI. It is used to describe how well current systems are working; what happens when changes are applied, and to document successful performance. Using data: Separates what is thought to be happening from what is really happening Establishes a baseline (Starting with a low score is acceptable) Reduces of ineffective solutions Allows monitoring of procedural changes to ensure that improvements are sustained Indicates whether changes lead to improvements Allows comparisons of performance across sites Comparison of Quality Assurance and Quality Improvement Quality Assurance Quality Improvement Quality Assurance is the collection of systematic approach that uses specific activities directed towards assuring the top techniques to improve quality management and customers that all quality requirements related to the product/process/service are being fulfilled Individual focused Systems focused Top to down Down to top Solo practitioners Teamwork Peer review ignored Peer review valued Errors punished Errors seen as opportunities for learning Reactive Proactive (future plan) 28 Focus on solving problems Focus on improving process Limited staff involvement Full staff involvement Monitor process/systems of delivery systems Monitor and correct performance. Quality improvement models Quality improvement models present a systematic, formal framework for establishing QI processes in your practice. Examples of common QI models include the following: Six Sigma Model lean methodology The PDCA cycle Donabedian's model 1 -Six Sigma Model: Six Sigma is a measurement-based strategy for improve the quality of process outs by identifying and removing the causes of defects and problem reduction. It is completed through the application of the QI project and accomplished with the use of two Six Sigma models: A) DMAIC (define, measure, analyze, improve, control), which is designed to examine existing processes 1-Define the process improvement goals that are consistent with customer demands and enterprise strategy. 2-Measure the current process and collect relevant data for future comparison. 3-Analyze to verify relationship and causality of factors. Determine what the relationship is, and attempt to ensure that all factors have been considered. 4-Improve or optimize the process based upon the data analysis using techniques like design of experiments. or mistake proofing, and standard work to create a new future state process. 29 5-Control to ensure that any variances are corrected before they result in defects. To establish continuously measure the process and institute control mechanisms. B) DMADV (define, measure, analyze, design, verify) which is used to develop new Basic methodology consists of the following five steps: 1. Define the goals of the design activity that are consistent with customer demands and enterprise strategy. 2. Measure and identify CTQs (critical to qualities), product capabilities, production process capability, and risk assessments. 3. Analyze to develop and design alternatives, create high-level design and evaluate design capability to select the best design. 4. Design details, optimize the design and plan for design verification. This phase may require simulations. 5. Verify the design, set up pilot runs, implement production process, and handover to process owners. Benefits of Six Sigma in the healthcare industry ✓ Creates methods/trains members within organization how to effectively decrease costs per procedures, save hospitals, and health industry ✓ Reduced medication and laboratory errors. So, thereby improving patient safety ✓ Efficient, organized, and reliable internal operations. ✓ Helps shorten reduce admission time and length of patient stay in hospital ✓ Minimize the use of materials and devices ✓ Optimize use of available capacities 30 ✓ Improved productivity, customer satisfaction, enhanced quality of services, reduced cost of operations ✓ Cost effectiveness and higher processes quality; Six Sigma yields long term benefits as an indicator of future performance and growth 2- Lean methodology Lean management seeks to implement work processes that achieve high quality, safety and worker morale, whilst reducing cost and shortening lead times. What sets lean management apart, and makes it particularly effective, is that it has at its core a laser-sharp focus on the elimination of all waste from all processes. Lean Objectives There are three main objectives in lean philosophy: 1. Improving the flow of the organization 2. Applying only value-adding time and steps into the organization 3. Eliminating all or wastes. 3-The PDSA cycle Is a strategy to systematically and effectively manage change, which stemmed from the work of William Edwards Deming, also known as the founder of continuous QI. PDSA phase 1-PLAN: State the objectives of the improvement project. ◆ Determine needed improvements. ◆ Design process changes to achieve the improvement objectives. ◆ Develop a plan to carry out the changes (define who, what, when, and where). 31  ◆ Identify data that need to be collected to determine whether changes produced desired results 2-DO : ◆ Implement the changes on a small scale. ◆Document problems and unexpected events. ◆ Gather data to assess the changes’ impact on the process. 3-Study Analyze data to determine whether the changes were effective. ◆ Compare results with expectations. ◆ Summarize lessons learned during and after implementation of the changes 4-ACT: If changes were not successful, repeat the PDSA cycle. ◆ If changes were successful, or partially successful implement them on a wider scale or modify them as necessary. 4-Donabedian’s model this model is a conceptual model that provides a framework for examining health services and evaluating quality of health care. According to this model, information about quality of care can be drawn from three categories: structure, process, and outcomes. Structure includes all the factors that affect the context in which care is delivered. This includes the physical facility, equipment, and human resources, as well as organizational characteristics such as staff training and payment methods. Process is the sum of all actions that make up healthcare. These commonly include diagnosis, treatment, preventive care, and patient education but may be expanded to include actions taken by the patients or their families. Processes can be further classified as technical processes, how care is delivered, or interpersonal processes, which all encompass the manner in which care is delivered. 32  Outcome contains all the effects of healthcare on patients or populations include changes to health status, behavior, or knowledge as well as patient satisfaction, and health-related quality of life. Outcomes are sometimes seen as the most important indicators of quality because improving patient health status is the primary goal of healthcare Quality improvement Tools 1-Brainstorming Is a technique used to quickly generate lots of ideas about a problem or topic. It encourages creative thinking and incites enthusiasm. 2-Nominal group technique Is it the approach of decision making that involves idea generation by group members, group interaction only to clarify ideas, member rankings of ideas presented, and alternative selection by summing up the rankings. 3-Multi-voting Multi-voting is a structured series of votes by a team, in order to narrow down a broad set of options to a few. 4-Affinity diagram Are used to organize large amounts of language data (ideas, issues, opinions) generated by brainstorming into groupings on the basis of the relationships between data items. This process helps improvement teams sift through large volumes of information and encourages new patterns of thinking. 5-Definition a cause-and-effect (root cause analysis) diagram The cause and effect diagram is sometimes called an Ishikawa diagram after its inventor. It is also known as a fish bone diagram because of its shape. A cause and effect diagram describes a relationship between variables. 6-Decision Matrix 33  Decision Matrix or decision grid or problem matrix, It evaluates and prioritizes a list of options according to specific criteria. 7-Five why: The" five why" is a systematic technique of asking five questions successively to determine the root of causes and also help you to determine the relationship between different root causes of a problem. It is easy to apply and to complete without statistical analysis. Quantitative tools 1- Bar chart is a type of graph that are used to display and compare the number, frequency or other measure (e.g. mean) for different discrete categories of data. 2-Histogram A histogram is a type of bar chart that displays a set of continuous data that you can use to evaluate the distribution or variation of data over a range, for example, weight, length of time, size and age. 4- Pareto chart A Pareto diagram puts data in a hierarchical order, which allows the most significant problems to be corrected first. 5-Flow diagram: Flow diagram (also called flow chart) describe a process in as much detail as possible by graphically displaying the steps in proper sequence. Steps of Quality improvement Step One: Identify The goal of the first step, identify, is to determine what to improve. This may involve a problem that needs a solution, an opportunity for improvement that requires definition or a process or system that needs to be improved. 34 Step Two: Analyze Once we have identified areas for quality improvement, the second step is to analyze what we need to know or understand about this opportunity for improvement before considering changes. The objectives of the analysis stage can be any combination of the following:  Clarify why the process or system produces the effect that we aim to change.  Measuring the performance of the process or system that produces the effect.  Formulating research questions, such as the following: 1. Who is involved or affected? 2. Where does the problem occur? 3. When does the problem occur? 4. What happens when the problem occurs? 5. Why does the problem occur?  Learning about internal and external clients through the tools available to reach these objectives. Step Three: Develop The third step, develop uses the information accumulated from the previous steps to explore what changes would yield improvement. Hypotheses, tentative assumptions used to test consequences are formulated about which changes, interventions, or solutions would reduce the problem and thus improve the quality of care. Hypotheses are based on people's knowledge and belief about the likely causes and solutions of the problem. It is crucial to remember that at this point the hypothesis remains a theory, as it has not yet been tested. Step Four: Test and Implement This step, test/implement builds on the first three. A hypothesis is tested to see if the proposed intervention or solution yields the expected improvement. 35 Because interventions that prove to be effective may not yield immediate results, allowing time for change to occur is important in the testing process. The results of this test determine the next step. Definition of Continuous Quality Improvement Continuous Quality Improvement (CQI): Is the process of monitoring structure, process and outcome indicators in order to identify signal events that will guide health care professionals in preventing patient care problems and improving already satisfactory patient services. Key points about continuous quality improvement (CQI) are: It involves collecting information, assessing the information, planning, taking action, and reviewing the action. There is engagement of all health staff involved. It involves raising general standards of care. The process is dynamic and ongoing – building on successes. There is promotion of efficiency within existing resources. It promotes organized, integrated and fully developed systems of care. 36  Key Performance Indicators (KPI’s) as a Qualiy Measurment Introduction One of most important reasons is that they have no Performance Management System that Collect, Analyze and Report Information regarding the performance of the organization. The purpose of developing a system for effective measuring of performances is to understand, adjust and improve business in all department of the organization. Performance Measurements and Key Performance Indicators are the means to monitor the execution of the Strategy of the Organization. It is, therefore, vital that organizations should have proper strategies and proper means of executing the strategies. Performance measurement enable effective organizations to express their success by numbers. Beside control function indicators of performances also have two other functions: 1. Developing and Guiding Function - they present a base for formulating and implementation of the strategy of the organization 2. Motivation Function - they induce management to fulfill goals and motivate all stakeholders to realize those goals and on even higher level A successful organization has the culture of setting clear expectations for organizational performance, as well as structured reviews and monitoring to ensure that they are met. A performance management process sets the platform for rewarding excellence by aligning both functional/departmental teams and 37  individual employee accomplishments with the organization’s mission and vision. What is a Key Performance Indicator (KPI)? Key Performance Indicators (KPIs) are the critical (key) indicators of progress toward an intended result. KPIs provides a focus for strategic and operational improvement, create an analytical basis for decision making and help focus attention on what matters most. KPIs specifically help determine a company's strategic, financial, and operational achievements, especially compared to those of other businesses within the same sector. A Key Performance Indicator (KPI) is a type of measure that is used to evaluate the performance of an organization against its strategic objectives. KPIs help to cut the complexity associated with performance tracking by reducing a large number of measures into a practical number of 'key' indicators. Key Performance Indicators ( KPIs ) or Key Success Indicators ( KSIs ) help the organization identify and measure its progress towards its objectives. When the organization identifies and analyzes its objectives, it needs a way to measure its progress towards these goals. Key performance indicators (KPI’s) apply both at the organizational and individual levels. At an organizational level, a Key Performance Indicator (KPI) is a quantifiable metric that reflects how well an organization is achieving its stated goals and objectives 38  At employee level, appraisals of KPI’s is a proactive approach to manage employee performance towards desired performance and results Why Are KPIs Important? KPIs are an important way to ensure your teams are supporting the overall goals of the organization. Here are some of the biggest reasons why you need key performance indicators. Keep your teams aligned: Whether measuring project success or employee performance, KPIs keep teams moving in the same direction. Provide a health check: Key performance indicators give you a realistic look at the health of your organization, from risk factors to financial indicators. Make adjustments: KPIs help you clearly see your successes and failures so you can do more of what’s working, and less of what’s not. Hold your teams accountable: Make sure everyone provides value with key performance indicators that help employees track their progress and help managers move things along. Reasons of applying KPIs When is the technique applicable They can be defined for a number of reasons: ▪ To assess performance of current state ▪ To determine whether future state has been achieved or whether further action required ▪ To identify whether business objectives have been achieved ▪ To judge the quality of the requirements gathered ▪ To measure the quality of each of the solutions being considered when evaluating options ▪ To enable the solution being deployed to be monitored 39 SMART Most organizations will use the well-known SMART model when creating their Key Performance Indicators. SMART stands for: Specific: So that the KPI is clear and objective. Measurable: So that its progress can be measured and tracked to assess attainment of the goal or objective. Attainable: With the right level of stretch to encourage high-performance, but achievable so that the organization's employees remain motivated and empowered to deliver. Relevant: To the goals and objectives of the business strategy. Time-Bound: Define a start and end-point. What’s the difference between a KPI, a target, and a goal? Occasionally you will see people use the term ‘KPI’ interchangeably with ‘goal’ or ‘target’. 40 It’s better to treat them as three distinct things. ▪ A goal is the thing you are aiming to achieve ▪ A KPI is a measure of performance, you have decided is important ▪ A target is a set number you are aiming to hit Example………………. If your goal is to increase sales revenue by 20% – then perfect – your goal happens to include a KPI (sales revenue) and a target (increase by 20%). Types of KPIs Strategic: These big-picture key performance indicators monitor organizational goals. Executives typically look to one or two strategic KPIs to find out how the organization is doing at any given time. Examples include return on investment, revenue, and market share. 41  Operational: These KPIs typically measure performance in a shorter time frame and are focused on organizational processes and efficiencies. Some examples include sales by region, average monthly transportation costs and cost per acquisition (CPA). Functional Unit: Many key performance indicators are tied to specific functions, such finance or IT. While IT might track time to resolution or average uptime, finance KPIs track gross profit margin or return on assets. These functional KPIs can also be classified as strategic or operational. Leading vs Lagging: Regardless of the type of key performance indicator you define, you should know the difference between leading indicators and lagging indicators. While leading KPIs can help predict outcomes, lagging KPIs track what has already happened. Organizations use a mix of both to ensure they’re tracking what’s most important KPIs are measures used to evaluate the success of an organization. KPIs can be quantitative or qualitative in nature. Quantitative KPIs include metrics such as sales revenue per employee, number of customers served by each call center agent, or revenue. Qualitative KPIs, on the other hand, may include customer satisfaction scores, quality ratings, or product reliability rates. Managing with the use of KPIs includes setting targets (the desired level of performance) and tracking progress against that target. Managing with KPIs often means working to improve leading indicators that will later drive lagging benefits and are precursors of future success; while lagging indicators show how successful the organization was at achieving results in the past. How to measure KPI? 42  How to Develop KPIs With so much data, it can be tempting to measure everything—or at least things that are easiest to measure. However, you need to be sure you’re measuring only the key performance indicators that will help you reach your business goals. The strategic focus is one of the most important aspects of the KPI definition. Here are some best practices for developing the right KPIs Step 1 –Create Objectives ✓ The Golden Rule: KPIs are based on objectives. A KPI should not exist unless it contributes to an objective ✓ Work on objectives first, these provide the reason to measure. A KPI should not exist without an objective. 43  ✓ Write down an objective or two that you believe will result in a business improvement in your organization. Here are some examples that you may have considered: Increase company profit Increase revenue by 10% next year Reduce sales costs Step 2 –Describe Results Objectives, like KPIs, are concerned with results. It is essential to create a result for each objective using a results-oriented language. Step 3 –Identify KPIs activities The KPI needs to be calculated and ownership assigned. The KPI needs to be rated in terms of importance The KPI needs to be clearly described (and based on an objective). For now, let’s concentrate on the description, the key things to remember are; - Write the description in the form of a sentence. - Include the tangible words, the things that can be counted. - Think in terms of a calculation that will be performed. Step 4 –Define Thresholds A Key Performance Indicator has limited value unless it can be compared to something. There may be some value as a record of change over time; however, unless it is known what sort of change is required, even this has little value. Step 5 –Measure 44 It is at this stage that objectives and KPIs can be loaded into a dedicated performance management system. It is possible to keep track of your KPIs using a spreadsheet, however, spreadsheets are notoriously difficult to manage and maintain. Step 6 –Interpret Results Once you have a set of historical actual data you can start interpreting the results. There are two phases to this activity, first to create a set of dashboards and reports from the data and second to interpret the results. The purpose of reporting is to provide enough detail to enable an organization to be managed effectively and make decisions. Step 7 –Take Action Taking action comes in two major forms. The first is to put in place a remedial activity when a problem occurs; the second is to create strategic initiatives to promote change. Remedial Activity is putting in place a remedial activity or assigning an action is a relatively simple process and something that organizations do almost every day. The key here is to ensure that the activity or action is well thought through and not the result of a knee-jerk reaction due to an anomaly. Remember that,,,,,,,,,,,,,, 45 46 47