how to improve quality of healthcare

1. How to improve
Quality of Health
care
Prof. Dr Swe Win
Honorary Professor
Professor and Head(retired)
Health policy and management Department
UPH
26.5.2016 UPH

2. HEALTH CARE PROBLEM
• A 2013 study on the global burden of medical error found that
unsafe care causes 43 million injuries a year and the loss of 23
million disability adjusted life years (DALYs), about two-thirds
of them in low- and middle income
countries (Jha et al., 2013).
• The fifth leading cause of DALYs lost worldwide (i.e
underestimate)
Source: Improving Quality of Care in Low- and Middle-Income Countries:
Workshop Summary;NAP

3. Quality
(fundamentally relational)
provider/manufacturer/supplier
• ongoing process of building and
sustaining relationships by
assessing, anticipating and
fulfilling stated and implied
needs
• Error-free
• Reducing the variation around
the target
• doing right things right
Customer/user/consumer/client
• Customers’ perception of the value
of suppliers’ work output
• value-added care and service that
meets and/or exceeds both the
needs legitimate expectations
• properties of products
and/services that are valued by the
customer
• The degree to which something
meets or exceeds the expectations
of customers (Degree of excellence
or degree of goodness)
• fulfillment of expectation
• ability of a product or service to
meet a customer’s expectations for
that product or service

4. Quality
• FEIGENBAUM (1983): Quality is total composite product (goods and
services) characteristics, through which the product in use will meet
the needs and expectations of the customers. Concept of quality
must start with identification of customer quality requirements
and must end only when the finished product is placed into the
hands of the customer who remains satisfied through various
stages of relationship with the seller
• Institute of Medicine (1990) definition: “Quality is the extent to
which health services for individuals and populations increase the
likelihood of desired health outcomes and are consistent with
current professional knowledge.”
• American Society of Quality Control (ASQC) and American
National Standard Institute (ANSI): totality of features and
characteristics of product (goods and services) that bears on its
ability to satisfy given needs

5. Quality
Product
• Perfection
• Consistency
• Eliminating waste
• Compliance with policies and procedures
• Providing a good, usable product
Service delivery
• Speed of delivery
• Doing it right, do right thing
User
• Delighting or pleasing customers
• Total customer service and satisfaction
• Degree of goodness
Quality = Degree of performance
The standard set
empowerment
standards
satisfaction

6. Attributes of Quality
Product/production/provider based
• Features
Augmented product
• Conformance
Degree to which characteristics of
the product meet pre-established
standards
• Performance
Product’s primary operating
characteristics
• Serviceability
Speed, competence & courtesy of
providing services.
Value/ judgmental /user based
• Aesthetics
Look, feel sound, taste, smell
• Perceived Quality
Resulting from advertisement,
image, brand name, earlier use,
hearsay
• Durability
Length of time a product can be
used before it deteriorates or
becomes non functional
• Reliability
Ability of the product to function at
the specified level of performance

7. Evolution of Quality Management
Mass
Inspection
Quality
Control
(Acceptance
Sampling)
Quality
Assurance
Total Quality
Control
Company
wide Quality
Control

8. Evolution of Quality
Management
• Mass Inspection
• Inspecting
• Salvaging
• Sorting
• Grading
• Rectifying
• Rejecting
• Quality Control
• Quality manuals
• Product testing using
SQC
• Basic quality planning
• Quality Assurance
• Emphasis on prevention
• Proactive approach
using SPC
• Advance quality
planning
• Total Quality Control
• All aspects of quality of
inputs
• Testing equipments
• Control on processes

9. Evolution of Quality
Management
• Company wide Quality Control
• Measured in all functions connected with production such as
• R&D
• Design
• Engineering
• Purchasing,
• Operations etc
• Total Quality Management
• Measured in all aspects of business,
• Top management commitment
• Continuous improvement
• Involvement & participation of employees

10. QUALITY OF ORGANIZATION
Dimension of Quality
• Quality assessment
• Quality assurance
• Quality control
• Quality improvement

11. Quality Assessment
 Accreditation: Accreditation is a formal recognition that
an organization is competent to carry out specific
activities
 Audits: The objective of audits is to enhance the
effectiveness and efficiency of programme
Audits should be conducted by:
 People who are technically competent, but
 Do not have any direct responsibility for those
activities

12. Quality Assurance
 planned and systematic actions necessary to provide adequate
confidence that a product or service will satisfy given requirements for
quality.
 Examples of QA:
 type testing, performance testing, and quality audits required by a
regulatory body.
 blind testing and quality audits of the service provider performed by
the user of the service.

13.  The operational techniques and activities that are
used to fulfill requirements for quality.
 Examples of QC:
 routine (i.e. daily)
 various statistical analyses used to verify continued
system performance.
Quality Control

14. Quality improvement
• Identifies gaps exist between services actually provided and expectation
of services
• lessens these gaps not only to meet customer needs and expectation, but
to exceed them and attain unprecedented level of performance
• QI focus on the Client, Systems and process, teamwork, and the use of
data

15. Total Quality Management (TQM
• Total Quality Management (TQM) is a comprehensive and
structured approach to organizational management that seeks
to improve the quality of products and services through
ongoing refinements in response to continuous feedback

16. TQM concepts
• 1.It involved in all stages of system approach ie. input, process
and output stages
• 2.Participation of all stakeholders
• 3.Linkage with problem solving approach and accountability
• 4.Key process is PDCA / PDSA(Continuing Improvement)
• 5.Standardization .(Accreditation/certification/Benchmark)

17. What is Total Quality Management
(TQM)?
• A management approach for an organization ,centered on
quality, based on the participation of all its members and
aiming at long-term success through customer satisfaction,
and benefits to all members of the organization and to society.
(ISO definition)

18. • 2.The 5 key principles of TQM initiative (a)management
commitment (b)employee
commitment (c)fact based decision
making (d)continuous
improvement (e)customer focus

19. The elements of TQM
• 1.Ethics
• 2.Integrity
• 3.Trust
• 4.Training
• 5.Teamwork
• 6.Leadership
• 7.Recognition
• 8.Communication

20. The TQM pyramid.

21. Attaining Six Sigma Quality
• Six sigma
• A philosophy and measurement process developed in the 1980s
at Motorola.
• To design, measure, analyze, and control the input side of a
production process to achieve the goal of no more than 3.4
defects per million parts or procedures.
• A philosophy and measurement process that attempts to design
in quality as a product is being made.
• one percent of health care providers in the United
States have deployed Six Sigma methods.
•

22. Methodological Sequences of Six
Sigma
• Methodological sequences: DMAIC—define, measure,
analyze, improve, and control; or DMADV—define, measure,
analyze, design, and verify. DMAIC is generally used to
improve existing systems that have fallen below Six Sigma
levels, DMADV is used to design and develop new processes
or products at Six Sigma levels
• Six Sigma projects require to have expertise in basic statistical
tools such as Pareto Diagrams, descriptive and higher level
statistics including regression, and statistical modeling
techniques as well as control processes

23. • The essence of Six Sigma methodologies is both improvement
of the knowledge and capability of employees, and also
behavior changes through training.
• Thus, Six Sigma employs a classification system that identifies
education and training for employees, project managers and
executives

24. Lean methodology
• The term lean was coined as a word to describe a system
(Toyota’s)that managed to get by with half of everything and
far fewer than half of the defects and safety incidents.
• All we are doing is looking at timeline from the moment a
customer gives us an order to the point when we collect the
cash. and we reducing that timeline by removing the non-
value-added wastes(Toyota’sTaiichi Ohno

25. Definitions of lean
• Toyota Triangle
Lean is an integrated system of human development, technical
tools, management approaches ,and philosophy of that creates
a lean organizational culture.

26. The core values of Lean
management theory
• 1.respect for people (eg, patients, staff members, managers,
physicians),
• 2. continuous improvement (eg, easier, better, faster,
cheaper), and
• 3.human development.

27. Lean Thinking
Fundamentals
• Specify value – from the standpoint of the end customer (the
patient)
• • Identify the value stream – all value-added steps across
departmental boundaries (the value stream), eliminating
steps that do not create value
• • Make value flow continuously – eliminate causes of delay,
such as batches and quality problems
• • Let customers pull value – avoid pushing work onto the
next process or department; let work and supplies be pulled
as needed
• • Pursue perfection – through continuous process
improvement

28. Sort
Clear out rarely used
Items by Red Tagging
Straighten
Organise and Label a
Place for Everything
Shine
Clean ItStandardise
Create Rules to Sustain
the first 3 5’S
Sustain
Use Regular Management
Audits to Stay Disciplined Eliminate
Waste
5 S’s

30. 5 S
• Seiri – Sorting
• Seiton – Straighten or Set in order
• Seiso – Sweeping, shining or cleaniness
• Seikestu – Standardising
• Shitsuke – Sustaining the discpline

31. Quality of health care
Donabedian concepts
• Efficacy (Power or capacity to
produce a desired effect)
• Efficiency (value for
money)(lowest amount of inputs,
greatest amount of outputs)
• Effectiveness
• Optimality (balancing
improvements with costs)
• Acceptability (to patients and
families)
• Legitimacy (ethical issues-follow
through to treatment)
• Equity (access, fairness,
appropriateness)
The U.S. Institute of Medicine
concepts
• Patient safety to provider safety
to Environmental safety
• Effectiveness (scientifically
proven appropriate care)
• Patient centeredness (respect
and responsiveness)
• Timeliness (minimal delays
barriers to getting access to care)
• Efficiency (minimal waste of
equipment, supplies, ideas, and
energy)
• Equity (care provided consistently
across genders ,ethnic groups,
locations and socioeconomic
classes)

32. WHO

33. • three dimensions of Quality of Care i.e. professional technical
aspect of care, interpersonal aspects of quality and social
aspects of quality.
• Professional Technical Aspects
• Accuracy of diagnosis
• Efficacy and efficiency of treatment
• Excellence according to professional standard
• Necessity of care
• Appropriateness
• Continuity of care
• Consistency (Uniformity, Reliability)

34. • Inter-personal aspects
• Patient Satisfaction
• acceptability
• Time spent with provider
• Attitudes of provider and staff
• Amenities
• Social Aspects
• Efficiency
• Accessibility – including financing

35. Accreditation
• Accreditation is an external quality evaluation through which
an accrediting organization formally recognizes that an
institution meets certain standards. “a voluntary process by
which a government or nongovernment agency grants
recognition to health care institutions which meet certain
standards that require continuous improvement in structures,
processes, and outcomes.” In English, the terms accreditation,
• certification, and licensure are often mistakenly used as
synonyms
• Benchmarking.

36. Accreditation/Certification
• Accreditation means official approval given by an organization
stating that somebody/something has achieved in required
standard
• Certification means confirmation that some fact or statement
is true through the use of documentary evidence

37. Standardization
• Popular standards
• ISO 9000 Quality management
• ISO 14000 Environmental management
• ISO 3166 Country codes
• ISO 26000 Social responsibility
• ISO 50001 Energy management
• ISO 31000 Risk management
• ISO 22000 Food safety management
• ISO 27001 Information security management
• ISO 45001 Occupational health and safety

38. Benchmarking
• A measurement of the quality of an organization's policies,
products, programs, strategies, etc., and their comparison
with standard measurements, or similar measurements of its
peers.
• The objectives of benchmarking are (1) to determine what and
where improvements are called for, (2) to analyze how other
organizations achieve their high performance levels, and (3)to
use this information to improve performance.

39. Clinical In-Service Training
• Clinical in-service training is a broad category of quality
improvement strategies, including all training for health
professionals who have
already completed their formal credentialing process.
In-service training is meant to either reinforce important
concepts and practices or to introduce new knowledge about
how a health professional should work.

40. COPE® (client-oriented,
provider-efficient services)
• designed for quality improvement in family planning and is
now also used in maternal, child, and reproductive health.
• uses group problem solving and self-assessment to identify
problems and set priorities for quality improvement starts
with an orientation for managers at the worksite, followed by
a self-assessment where participants identify and rank their
main problems.
• COPE® is meant to be implemented with other tools for
continuous quality improvement, such as supervision and
training

41. Improvement Collaborative
• use a continuous quality improvement process
• iterative problem solving, encourages prompt process
improvements
• Collaboratives usually last about 9–24 months, during which
time the participating teams analyze a problem and its causes;
plan changes
• Collaboratives can be used to improve processes for patients
and providers ,teams, organizations, or systems.

42. SBM-R (Standards-Based
Management and Recognition)
• SBM-R is a management method developed by Jhpiego that
aims to improve quality of care by improving health worker
performance.
• It adapts the four main elements of the continuous quality
improvement cycle (plan, do, study, act) to standardize, do,
study, and reward
• 1.Assessment-standardsAction-self assessment ,internal
assessment and External assessments.
• recognized for their efforts; rewards, such as feedback, praise,
and social recognition,

43. Supportive Supervision
• Supportive supervision refers to a process of working with
staff to set goals, identify and correct problems, and monitor
staff performance.
• It generally takes one of three forms: managerial, clinical, or
educational.

44. Achieving Quality Improvement
• TQM / SQI = Professionalism x Motivation x
Leadership x Management x
Partnership
a. Practice professionalism by all categories of health
professionals
b. Fulfill basic and social needs to motivate professionals
c. Develop leadership quality
d. Better management and use management tools
• Establish strong partnership both internal and external
users 44
Prof.Dr Mya Oo

45. • The governance means the process of decision making and
the process by which decisions are implemented

46. Clinicalgovernanceisasystematicapproachtomaintainingandimproving
thequalityofpatientcarewithinahealthsystem.
Clinical
Governance
Risk
Management
Guidelines
Cl. Standards
Ethical Stand
Audit &
Cl. Meeting
CPC
Information
Management
Patient
Safety
Openness /
Truthfulness
Education
and
Training
Research
Clinical
effectiveness &
Efficiency
Responsibility
&
Accountability
Enabling
Environment
Patient
Satisfactions

47. CLINICAL AUDIT
• Clinical audit is a process that has been defined as "a quality
improvement process that seeks to improve patient care and
outcomes through systematic review of care against explicit
criteria and the implementation of change“
• The key component of clinical audit is that performance is
reviewed (or audited) to ensure that what should be done is
being done, and if not it provides a framework to enable
improvements to be made

48. Health Promotion Hospital
• WHO HPH movement focuses on four areas: promoting the
health of patients, promoting the health of staff, changing the
organization to a health promoting setting, and promoting the
health of the community in the catchment area of the
hospital. These four areas are reflected in the definition of a
health promoting hospital:

49. Health Promotion hospital
• A health promoting hospital does not only provide high quality
comprehensive medical and nursing services, but also
develops a corporate identity that embraces the aims of
health promotion,
• develops a health promoting organizational structure and
culture, including active, participatory roles for patients and all
members of staff, develops itself into a health promoting
physical environment, and actively cooperates with its
community”

50. Spectrum of approaches to quality
improvement
Increasing complexity
Individual
problem
solving
Rapid team
problem
solving
Systematic
team
problem
solving
Process
improvement

51. Problem solving & QI
Approach
• Step1. Identify -Determine what to improve
• Step 2.Analyse -understand the Problem
• Step3.Develop -Hypothesize about what changes will
improve problem
• Step4. Test/Implement- Test the hypothesized solution to see
if it yeilds improvement; based on the results, decide
whether to abandon, modify, or implement solution.

52. Comparison of QI approaches
Individual Problem
solving approach
Rapid Team Problem
solving approach
When to use the
approach
When you know the
problem is dependent on
only one person
When the team needs
quick results and has a
lot of intuitive ideas
Teams Unnecessary Ad hoc
Data Almost none Can succeed with little
data
Time Little Little

53. Comparison of QI approaches
Systematic Team
problem solving
approach
Process improvement
approach
When to use the
approach
When the problem is
complex or recurring,
requiring analysis
When a key process or
system requires ongoing
monitoring or
continuous improvement
Teams Ad hoc Permanent
Data Need data to understand
the causes of problem
Data from continuous
monitoring, may need to
collect more
Time Limited to the time
necessary
continuous

55. To consider if you want to
apply
• 1. cost-effectiveness,
• 2.The method’s affordability
• 3.The feasibility of the method—
• 4.it is realistic to implement
• 5.the replicability of results in new settings and
• 6.the scalability, or ease of expansion,
• 7.Lastly, the sustainability of the method, or the extent to
which a program can be integrated into existing system,.

56. THANK YOU FOR YOUR ATTENTION
dr.swewin1969@gmail.com