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4- The Total Quality Management (TQM) it focuses on organization, process and product. Total quality managment Quality assurance Quality...

4- The Total Quality Management (TQM) it focuses on organization, process and product. Total quality managment Quality assurance Quality control Inspection Quality Control: verifying the quality of the output Quality control is the most basic level of quality management. It includes all activities of inspecting, testing, or checking a product to ensure it meets the requirements. It is a procedure or set of procedures aimed to ensure that a manufactured product or performed service adheres to a defined set of quality criteria or meets the requirements and expectations of the customer. It is a reactive process aims to identify and correct defects in the finished product. 6  Quality Assurance: managing and planning for quality Quality assurance takes the quality management process a step further. QA is focused on planning, documenting, and agreeing on the steps, rules, and guidelines that are necessary to ensuring quality. The main purpose of QA is to prevent defects from entering into the product in the first place (before work is complete), so it’s a proactive measure to ensure quality. Planning for quality is key to mitigating risks, but also saves you a lot of time and money. Total Quality Management: TQM is the integration of all functions and processes within an organization in order to achieve continuous improvement of the quality of goods and services. It is a broad management philosophy, espousing quality and leadership commitment, which provides the energy and the rationale for implementation of the process of continuous quality improvement Total quality management (TQM) means: Total quality management (TQM) incorporates the concepts of product quality, process control, quality assurance, and quality improvement. Consequently, it is the control of all transformation processes of an organization to better satisfy customer needs in the most economical way. 7  TQM Quality assurance Product Quality control Process Product Organization Product Process It is the comprehensive and structured Product oriented approach to organizational focus on defect Process oriented focus management that seeks to improve the on defect prevention quality of product and service identification through refinements in the response to continuous feedback What is quality? Quality has been defined as excellence in the product or service that fulfills or exceeds the expectations of the customer. Why Quality in healthcare?  Increasing costs of healthcare in presence of rising demands and limited resources.  Variation in quality of medical performance and outcomes in similar health organizations. 8 What is quality in healthcare? Quality in healthcare has been defined in many ways. “Quality” in healthcare is defined as everything the healthcare organization undertakes to fulfill the needs and expectations of its customer as:  Well-designed services create customers satisfaction because they provide the features that customers need.  Customers' satisfaction is a high priority for any organization. “Quality is doing the right things for the right people at the right time, and doing them right first time and every time.” To ensure:  The best possible outcome for patients  Satisfaction for all our many customers  Retentions of talented staff  Sound financial performance “Quality” is the optimal achievement of therapeutic benefit and avoidance of risk and minimization of harm. Who is Involved in healthcare Practice?  Provider: Individuals responsible for providing the healthcare service  Customer: Individuals who directly receive healthcare service  Stakeholder: Individuals that have a vested interest in addressing a given issue and are in position to influence decision-making 9  » Policymakers and institutional players » Funding agencies » Dentists and staff Customers of Healthcare Customers are all those affected by our work  External customers: They are not part of the organization; Patients, third-party payers, insurance companies, employers or government agencies  Internal Customers: They are those within the organization who are affected in some way by the work output of the others Perspectives of Quality The health staff, health manager, clients and communities are all stakeholders in service delivery. Each of these groups may expect different things from health services. One of the reasons why there is low utilization of services is because the users perceive that the service is of poor quality. Quality appreciation is fundamental to clients’ willingness to pay for or take up services.  The Patient/Client The patients/clients want services that : Are delivered on time by friendly and respectful staff. 11  Are safe, produce positive result and that they can afford Provide them with adequate information about their condition and treatment. Provide them with all the medicines they need. Give privacy and confidentiality. Are within their reach (distance) and given in a language they can understand. Are comfortable. Allow continuity of care.  The Health Care Provider The health provider can provide quality care if he/she has: Adequate knowledge and skills. Enough resources, staff, medicines, supplies, equipment, transport, etc. Safe and clean workplace. Regular training. Is well paid and rewarded for good work. Respect / recognition for good work. Encouragement from colleagues and supervisors. Access to information. Guidance from other levels.  The Health Care Manager The health care manager sees quality care as: Managing efficiently the resources of the health facility. Health staff achieving set targets. Health staff being regularly supported and supervised. Having adequate and competent staff to provide care. Staff being disciplined. 11 Dimensions of Quality:  Appropriateness: Care/intervention is relevant to the patient’s needs. (Doing the right things)  Availability –Access to service: Everyone should have access to quality health care. Access refers to the ability of the individual to obtain health services. Some of the factors that can affect access are: a) Distance: e.g. where health facility is sited far away or it is difficult to get transport to the facility access to quality health care becomes a problem. b) Financial: e.g. where people cannot pay for the services provided. c) Culture, beliefs and values: The services provided may not be in line with the culture, beliefs and values of some people.  Timeliness: Needed care is provided at the most beneficial or necessary time.  Efficacy: The power of procedure/ treatment to improve health, as already shown through scientific research findings. (Evidence based).  Effectiveness: Effectiveness is the degree to which desired results (outcomes) of care are achieved. It is the extent to which a specific intervention, procedure, regimen or service, when deployed in the field in routine circumstances, does what it is intended to do for a specified population. (Doing things right) 12  Examples of effectiveness  Giving a child with diarrhea Oral Rehydration Salt (ORS)  An.effective tuberculosis (TB) control program is where the percentage of patients diagnosed with TB who complete the full treatment course is high.  Giving suitable antibiotics to a patient with tooth abscess.  Efficiency: Efficiency refers to using the minimum amount of effort or resources needed to achieve an intended result. This involves making the best use of the resources available or producing the maximum output for a given input. Efficiency minimizes wasted time, drugs, supplies and travel. Example: We waste resources by:  prescribing unnecessary drugs  stocking more drugs than is required and making them expire  buying supplies and equipment we do not use What happens when we stock more drugs than is required?  Equity: Quality services should be provided to all people who need them, be they poor, children, adults, old people, pregnant women, disabled etc. Quality services should be available in all parts of the country, in villages, towns and cities.  Competency: Adherence to professional standards of care and practice. (Skills, capability, actual performance). Technical competence as an indicator of quality assurance implies 13  that we should have adequate knowledge and skills to carry out our functions in order to provide quality service. Example: one must go to a Dentistry faculty and pass the examinations before he can work as a Dentist. Even though we are no longer in school, we have to continue to update our knowledge by reading health books and attending in-service training workshops etc. As health professionals, we should also know our limits, that is, know what we can do and what we cannot do. With respect to what we cannot do, we are expected to refer them to other centers or personnel who are more competent to handle them. Our practice should also be guided by laid down standards and guidelines e.g. Standard Treatment Guideline.  Continuity: Coordination of needed healthcare services for patient across all involved organizations over time Continuity means that the client gets the full range of health services he/she needs, and that when the case is beyond us, we refer him/her to the right level for further care. Continuity may be achieved by the patient seeing the same primary health care worker or by keeping accurate health records so that another staff can have adequate information to follow up the patient.  Respect and Caring: Patients are involved in the decision & the provider’s reaction to the patient needs. 14  Interpersonal Relations: It refers to the relationship between us and our clients and communities, between health mangers and their staff. We should: » Show respect to our clients; » Feel for our patients; » Not be rude or shout at them; » Not disclose information we get from patients to other people. » These will bring about good relations and trust between the clients/communities and us. Clients consider good interpersonal relationship as an important component of quality of care.  Safety: Patient safety is the absence of preventable harm to a patient during the process of health care. The discipline of patient safety is the coordinated efforts to prevent harm to patients, caused by the process of health care itself. It is generally agreed upon that the meaning of patient safety is…“Please do no harm”. There are multiple examples which may put the safety of the public at risk: 1- Faulty blood transfusion services can transmit HIV, hepatitis B, syphilis and malaria. 2- Incorrect diagnosis and treatment puts the safety of patients at risk. 3- Poor infection control may allow disease spread through procedures. 4- Hospital acquired infections is the most adverse event in health care in many communities. 15 Principles for good quality management in healthcare Principle 1 Patients focus: Our healthcare organization depends on the patients and therefore should understand current and future patients’ needs, should meet patients’ requirements and strive to exceed their expectations. Principle 2 Leadership: Leaders establish unity of purpose and direction of the organization. They should create and maintain the internal environment in which people can become fully involved in achieving the organization’s objectives. Principle 3 Involvement of people (employees): People at all levels are the essence of an organization and their full involvement enables their abilities to be used for the organization’s benefit. Principle 4 Process approach: A desired result is achieved more efficiently when activities and related resources are managed as a process. Principle 5 System approach to management: Identifying, understanding, and managing interrelated processes as a system contributes to the organization’s effectiveness and efficiency in achieving its objectives. Principle 6 Continual improvement: 16 Continual improvement of the organization’s overall performance should be a permanent objective of the organization. Understanding Work as Processes and Systems: An organization's effectiveness and efficiency in achieving its quality objectives are contributed by identifying, understanding and managing all interrelated processes as a system. A process is defined as،، a sequence of steps through which inputs from suppliers are converted into outputs for customers ”.In routine healthcare delivery, many processes occur at the same time and involve many professional functions in the organization. All processes are directed at achieving one goal or output from the system. There are different types of processes in healthcare, these include:  Clinical algorithms: The processes by which clinical decisions are made  Information flow processes: The processes by which information is shared across the different persons involved in the care  Material flow processes: The processes by which materials (e.g., drugs, supplies, food) are passed through the system  Patient flow processes: The processes by which patients move through the medical facility as they seek and receive care  Multiple flow processes: Most processes are actually multiple flow processes. 17  Tools such as the flowchart help people understand the steps in a process. Through the understanding of the processes of systems of care, QI teams can identify weaknesses and change processes in ways that make them produce better results A system is defined as “the sum total of all the elements (including processes) that interact together to produce a common goal or product.” A system is also defined as an interdependent group of people, items, and processes with common purpose while a process is a set of causes and conditions that repeatedly come together in a series of steps to transfer inputs into outcomes. The World Health Organization (WHO) Health System Framework describes health systems in terms of six core building blocks: 1- finances, 2- health workforce, 3- information, 4- governance, 5-medical products and technologies, 6- service delivery. Systems thinking looks at the whole, the parts, and the connections between the parts, and studying the whole in order to understand the parts. To execute any activity it is important 18 to understand what needs to be done, the individual steps that have to be taken, and in what order. Traditional Problem Solving: When facing quality challenges, practitioners often think that the cause is obvious. The tendency is to want to jump in and make improvements, without exploring the situation. This increases the risk of a mismatch between the intervention and the true cause of the quality problem. We need to understand the problem before defining the solution!  Example of solving the wrong problem - Quality challenge- Very long wait times for HIV test results - Proposed intervention - Increase number of technicians in lab - Assumption - The problem is lab-staffing - Actual problem - Stock out of gloves in the lab. System analysis focuses on inputs, processes, outputs, outcomes and impact of health services provided. Structure Process Outcomes Donabedian model (causal relationship) 19   Structure/Inputs: Inputs (resources) - materials, money, human resources, equipment, policies and other resources that are required for an activity  For example, in the hypertension treatment system, inputs include anti-hypertensive drugs and skilled health workers. Example: 1- Staff no 2- Adequate nursing :patient ratio 3- Trained nursing staff 4- Staff qualifications 5- Resources (equipment, budget, beds…….) 6- Computer system 7- Updated treatment guidelines 8- Geographical location  Process: It is the activities and tasks that turn the inputs into products and services.  Example For hypertension treatment, this process would include the tasks of taking a history and conducting a physical examination of patients complaining of headache, making a diagnosis, providing treatment, and counseling the patient. Example 1- Services (registration, lab, pharmacy …….) 2- Clinical processes (treatment, assessment, medication...) 3- Administration and management  Output: 21  The immediate results of completion of an activity. It is a direct result of interaction between inputs and a process.  Example: The outputs of hypertension treatment system are patients receiving therapy and counseling.  Outcome: Outcomes are the end result of care and a change in the patient’s current and future health status due to antecedent health care interventions. It is the relation of the output to the objective of the activity.  Example: The outcome of the hypertension treatment is improved patients. If the treatment is proper and clients satisfied, that is a good outcome, and if it is not proper, the clients are disappointed, and the outcome is poor. Example: 1. Clinical (complication rate, mortality rate…..) 2. Functional (long term health status…). 3. Perceived (patient satisfaction, peer acceptability).  Impact : The long term effect of the outcomes on users and the community at large. These are the consequences: social, economic, environmental, etc.  Example :For hypertension treatment, the impacts would be improved health status in the community and reduced morbidity and mortality rates. 21  Quality Management Process: It is to help every person in the service to take responsibility for controlling quality and enable them to use quality methods to improve the process for delivering the service. Building a quality management program: Policies on quality, procedures, and processes are implemented simultaneously, starting at the top and moving down the organization. It typically begins with a review of standards and specific actions. This is followed by an assessment of healthcare and support services. Priority areas for quality improvement can be identified based on the results of comprehensive monitoring or systems analysis. This approach has three dimensions: Quality design, quality control, quality improvement which form the three sides of the “quality triangle” also called “Quality management Triad.  Juran Trilogy Quality Quality Improvement planning 1- Quality Planning (design) 2- Quality Control/Measurement 3- Quality Improvement Quality control The three components work together to provide QM Process that function like a loop. There is no starting point or end point, put all components work together in a continuous way. 22 1- Quality planning /design: Includes  Establish the project setting vision and objectives, allocating resources, and establishing standards and guidelines to ensure effectiveness and safety, training, team building.  Identify customers  Discover customer’s needs  Develop service features,  Develop detailed process  Designing various forms of regulation, including accreditation, licensure, or certification standards  Designing systems for quality output 2- Quality control/measurement: Quality control process helps health teams to understand and control their everyday work processes, and establish a basis for improvement of these processes. Consists of supervising and continuous monitoring activities and staff performance to assure that routine activities and responsibilities are performed correctly and consistently. It consists of the following steps: Step 1: Measure actual performance Step 2: Compare the results with established standards (quality expected) Step 3: Act on the difference Measurement is a tool usually a number or a statistic used to monitor the quality of some aspect of healthcare services. 23 Number/Statistic Measure Example Absolute number Number of patients served in the health clinic Number of patients who fall while in the hospital Number of billing errors Percentage Percentage of nursing home residents who develop an infection Percentage of newly hired staff who receive job training Percentage of prescriptions filled accurately by pharmacists Average Average patient length of stay in the hospital Average patient wait time in the emergency department Average charges for laboratory tests ratio Nurse-to-patient ratio Cost-to-charge ratio Technician-to-pharmacist ratio Healthcare Quality Measurement: It is the process where the healthcare providers/clinicians review their own performance and make adjustments, and probe for causes of deficiency to improve patient health outcomes Importance of Measurements 1. They provide an objective view of the existing level of quality and of the progress made as a result of the actions for improvement that have been conducted 2. prove that progress has indeed been made 3. They also give value to the work accomplished and confidence to the participants in their capacity to continuously improve the quality of the services they provide and their work organization 24  This is in order: » To improve the proposal for change » To further analyze problems in changing care » To alter strategies and measures for change » To alter the implementation plan. Measurement Tools.  Indicators  Surveys  Data collection Sheets  Expert Opinion (qualitative) Indicators Are reliable and valid measures used to screen/assess organizational and practitioner performance issues, but not direct measures of quality Types of Indicators  Outcome Indicator measures what happens or does not happen as the result of a process or processes;  Process Indicator measures a discrete activity that is carried out to provide care or service  Structure indicator measures the inputs to the process and resources allocated to provide care 25  3- Quality improvement: QI is the continuous, day to day process of identifying opportunities for improvement and implementing solutions to them. QI is a systems approach that applies the scientific method to the analysis of performance and systematic efforts to improve it. The QI Methodology and Steps QI methods are applied to improve the safety and quality of patient care and provide health care workers with the tools to 1- Identify the problem 2- Measure current performance 3- Perform a cause analysis 4- Develop and implement an improvement strategy 5- Measure the effect of the intervention 6- Modify, maintain, or spread the intervention Quality improvement differs from quality assurance (which is retrospective in nature) in that it attempts to use a quality assessment cycle and focuses on the organization or system of production as a whole. 26 One of the QI methods that can be used is a Plan–Do–Study– Act (PDSA) cycle. (Or Plan–Do–Check–Act (PDCA) cycle) Once we know what changes we want to make, we can test these using the PDCA cycle. “Plan-Do-Check-Act” or “PDCA Cycle”: It is a popular methodology to fix a problem or improve a process that emphasizes four phases of activity 1- In the planning phase:  Make a plan for the change (What, Who, How, When, Where)  Collect baseline data  Communicate the test of the change 2- In the doing phase:  Test the change  Document the results of the change  Continue to monitor the data 3- In the checking phase:  Verify the effects of the change  Check results for Achievement/Success, Constraints: Unforeseen problems / resistance to change  Collect data on the new process and compare to the baseline. 4- In the acting phase:  If the result is successful, standardize the changes and then work on further improvements or the next prioritized problem.  If the outcome is not yet successful, look for other ways to change the process or identify different causes for the problem. 27 Continuous quality improvement (CQI): The adjective “continuous” is used to indicate that the quality approach aims to gradually and permanently reduce dysfunctional processes, patient complaints or risk. Whereas quality assurance is intended to give confidence that it will inevitably achieve a specified level of quality, continuous quality improvement instead focuses always ahead in the direction of betterment Time Depiction of the PDCA cycle (or Deming Cycle). Continuous quality improvement is achieved by iterating through the cycle and consolidating achieved progress through standardization. 28 Three methodological principles characterize the continuous process of quality improvement:  Any activity may be described as a process. Quality improvement always results from the step-by-step improvement of processes and can be aimed for whatever the initial status.  Processes are always analyzed in their initial functioning. This helps to identify real-life dysfunctions and to define actions for improvement with the persons concerned.  The effectiveness of any improvement should be measured objectively. Quality Improvement Tools Definition: Methods used by individuals, teams, organizations or health systems in TQM or continuous quality improvement to improve work progress. 29