BHM – QUALITY IN HEALTH CARE - Healthcare Professional

MODULE – I

INTRODUCTION

Quality in healthcare refers to the degree to which health services provided to individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. It involves ensuring patient safety, efficiency, effectiveness, equity, timeliness, and patient-cantered care. Healthcare quality is essential for improving patient satisfaction, reducing medical errors, and optimizing resources.

In today’s complex healthcare environment, ensuring quality has become a priority for healthcare providers, policymakers, and regulatory bodies. Various frameworks, such as those provided by the World Health Organization (WHO) and Institute of Medicine (IOM), emphasize a systematic approach to improving healthcare services through evidence-based practices and continuous monitoring.

FUNDAMENTAL OF QUALITY MANAGEMENT

INTRODUCTION:

What is Quality?

The standard of something as measured against other things of a similar kind.

In manufacturing, a measure of excellence or a state of being free from defects, deficiencies and significant variations.

It is brought about by strict and consistent commitment to certain standards that achieve uniformity of a product in order to satisfy specific customer or user requirements.

B. Notable definitions

Quality means different things to the different people.

The common element of the business definitions is that the quality of a product or service refers to the perception of the degree to which the product or service meets the customer’s expectations. Quality has no specific meaning unless related to a specific function and/or object.

The business meanings of quality have developed over time. Various interpretations are given below:

American Society for Quality: “A combination of quantitative and qualitative perspectives for which each person has his or her own definition; examples of which include, “Meeting the requirements and expectations in service or product that were committed to” and “Pursuit of optimal solutions contributing to confirmed successes, fulfilling accountabilities”. In technical usage, quality can have two meanings:
The characteristics of a product or service that bear on its ability to satisfy stated or implied needs;

A product or service free of deficiencies.

Philip B. Crosby: “Conformance to requirements. He enlightened the Zero defect concept, means, “Number of defects per million opportunities.

W. Edwards Deming: concentrating on “the efficient production of the quality that the market expects, and he linked quality and management: “Costs go down and productivity goes up as improvement of quality is accomplished by better management of design, engineering, testing and by improvement of processes.
Peter Drucker: “Quality in a product or service is not what the supplier puts in. It is what 5 the customer gets out and is willing to pay for.

ISO 9000: “Degree to which a set of inherent characteristics fulfils requirements. The standard defines requirement as need or expectation.
Joseph M. Juran: “Fitness for use. Fitness is defined by the customer.
Noriaki Kano: “Products and services that meet or exceed customers’ expectations.”
Gerald M. Weinberg: “Value to some person”.
Quality of a product or needs services is its and expectations of the customer. ability to satisfy the

Concept of Quality Care and Quality Management

In the healthcare industry, quality of care is more than a concept. It has become essential to patient well-being and financial survival. Imagine a hospital with no hospital-acquired infections, no staff-related oversights leading to complications during difficult deliveries, no wrong-site surgeries, and no medication errors. A system that demonstrates this type of success has lowered the cost of providing care while maximizing the quality of care. We all want to be treated at such an institution.

Employers would demand that their patients use this system because they no longer wish to bear the cost of poor outcomes, complications such as congestive heart failure following inadequate or delayed reperfusion of a coronary vessel in an acute heart attack, or hospital-acquired infections. Clearly, hospitals and physicians that provide cost effective quality care will have made the business case for quality of care and be rewarded with higher volumes of patients and better reimbursement.

C. Quality in Health Care

The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Quality in hospital may indicate to –

Safe-avoiding injuries to patients from the care that is supposed to help them.
Effective – providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse).
Patient- centered – providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.
Timely reducing waits and sometimes harmful delays for both those who receive and those who give care.
Efficient – avoiding waste, in particular waste of equipment, supplies, ideas, and energy.
Equitable providing care that does not vary in quality because of personal characteristics, such as gender, ethnicity, geographic location, and socioeconomic status.

D. Objectives of Quality Management

There are two basic objective of Quality Management

1) Customer satisfaction:

2) Performance superiority:

Speed
Cost
Dependability
Flexibility

3) Others objectives:

Making the organization market and customer focused
Guiding the organization by its values, vision, mission, and goals set through ‘strategic planning processes
Changing the organization from function focused to customer focused, where customer priorities come first in all activities.
Making the organization flexible and learning oriented to cope with change
Making the organization believe in – and seek-continuous improvement as a new way of life.
Creating an organization where people are at the core of every activity, and are encouraged and empowered to work in teams.
Promoting a transparent leadership process to lead the organization to excellence in its chosen field of business.

The primary objectives of quality in healthcare:

Patient Safety: Preventing harm to patients through error reduction and improved safety measures.

Effectiveness: Ensuring treatments and interventions are based on scientific evidence and best practices.

Efficiency: Optimizing the use of resources to prevent waste while maintaining high standards of care.

Timeliness: Reducing waiting times and delays in treatment for better health outcomes.

Equity: Providing healthcare services fairly and without discrimination.

Patient-Centered Care: Addressing patients’ preferences, needs, and values to enhance their experience and satisfaction.

Continuous Improvement: Using feedback, data analysis, and innovation to enhance healthcare quality over time.

E. Objectives of Quality Management in Hospital

Identify and focus on processes and outcomes important to the customers’ needs and expectations
Develop performance objectives that are specific, measurable, actionable, relevant and timely (SMART)
Develop methods to measure continuous improvement of patient outcomes and patient satisfaction
Analyze data and identify opportunities for improvement, making adjustments as necessary
Utilize internal and external benchmarks and regulatory standards to evaluate performance
Utilize tools such as Root Cause Analysis (RCA) to investigate processes or System, factors in response to sentinel events, in critical incidents related to risk
Create a culture of open communication, collaboration and teamwork
Educate, involve and empower staff to improve work and quality of patient care given

F. Different dimensions of Quality Management

1. Performance: Performance refers to a product’s primary operating characteristics. This dimension of quality involves measurable attributes; brands can usually be ranked objectively on individual aspects of performance.

2. Features: Features are additional characteristics that enhance the appeal of the product or service to the user.

3. Reliability: Reliability is the likelihood that a product will not fail within a specific time period. This is a key element for users who need the product to work without fail.

4. Conformance: Conformance is the precision with which the product or service meets the specified standards.

5. Durability: Durability measures the length of a product’s life. When the product can be repaire 5. estimating durability is more complicated. The item will be used until it is no longer economical to operate it. This happens when the repair rate and, the associated costs increase significantly.

6. Serviceability: Serviceability is the speed with which the product can be put into service when it breaks down, as well as the competence and the behaviour of the serviceperson.

7. Aesthetics: Aesthetics is the subjective dimension indicating the kind of response a user has to a product. It represents the individual’s personal preference.

8. Perceived Quality: Perceived Quality is the quality attributed to a good or service based on indirect measures.

9. Empathy: Do Staff provide caring individualisation attention.

Dimensions of Quality in Helath Care

Appropriateness: The degree to which the care and services provided are relevant to the individual’s clinical needs, given the current state of knowledge.

Availability: The degree to which the care and services are accessible and obtainable to meet the individual’s clinical needs.

Competency: The practitioner’s ability to achieve both desired clinical outcomes and patient’s satisfaction.

Continuity: The provision of seamless care through the coordination among all practitioners and across all the involved settings over time.

Effectiveness: The degree to which care achieves the desired outcomes.

Efficacy: The potential capacity produces the desired outcomes. the capability of care to

Efficiency: The optimum utilization of resources to produce the desired outcomes..

Prevention: The degree to which care promote health and prevent disease.

Respect and Caring: (Empathy) The degree to which those providing care and services do so with sensitivity for the Individuals’ needs, expectations, and differences. This may also include the provision of equitable care to all patients.

Safety: The degree to which the risk of an intervention and risk in the care environment are minimized for patients, visitors, and staff.

Timeliness: The degree which cares is provided to the individual at beneficial necessary time.

Contribution of Quality Gurus:

Dr. William Edward Deming ( October 14, 1900 – December 20, 1993)

Introduction

W. Edwards Deming was an American statistician, engineer, and management consultant widely regarded as the father of modern quality control. He is best known for his work in post-World War II Japan, where he helped transform Japanese industry by introducing statistical quality control and management philosophies and work in revolutionizing industrial production through Total Quality Management (TQM). His ideas laid the groundwork for the Japanese economic miracle and influenced global quality practices.

Deming emphasized the importance of continuous improvement, statistical methods, and a systems approach to management. His famous 14 Points for Management provide a framework for improving quality and productivity, focusing on leadership, employee empowerment, and reducing variation in processes. He also developed the Plan-Do-Check-Act (PDCA) cycle (often credited to him, though inspired by Walter Shewhart) as a method for iterative improvement. Deming’s philosophy stressed that quality is a management responsibility, not just a worker’s task, and he advocated eliminating fear and fostering collaboration within organizations.

Contribution

The Deming Philosophy (System of Profound Knowledge):

System Thinking: Encourages healthcare providers to see hospitals as interconnected systems rather than isolated departments.
Knowledge of Variation: Helps in understanding and reducing inconsistencies in clinical outcomes and processes.
Theory of Knowledge: Promotes evidence-based practice and data-driven decision-making.
Psychology: Emphasizes understanding human behavior, teamwork, and motivation in healthcare environments.

Plan-Do-Check-Act (PDCA) Cycle:

Plan: Identify areas for improvement, such as patient safety or infection control.
Do: Implement changes on a small scale.
Check: Evaluate the effectiveness of the intervention.
Act: Standardize successful changes and continue refining processes.

14 Points for Management:

Establish a constant focus on quality and service.
Encourage innovation and leadership at all levels.
Break down silos between departments for better coordination.
Eliminate fear so staff can openly report issues and suggest improvements.
Stop relying on numerical quotas and instead focus on quality.

Focus on Reducing Variation:

Clinical practices
Diagnostic procedures
Patient care workflows

Emphasis on Data-Driven Decision Making:

Monitoring Key Performance Indicators (KPIs) like readmission rates and infection rates.
Utilizing Electronic Health Records (EHRs) for analysis.
Making strategic decisions based on statistical evidence.

Quality is Everyone’s Responsibility:

All staff, from physicians to administrative workers, are empowered to contribute to quality improvement.
Interdisciplinary teamwork is promoted.
A culture of accountability and excellence is cultivated.

Dr. W. Edwards Deming’s philosophy has had a lasting impact on quality management in healthcare. His focus on systems thinking, data analysis, continuous improvement, and human motivation has inspired global initiatives for better patient outcomes, reduced errors, and higher standards of care. Healthcare organizations that embrace Deming’s principles are better equipped to deliver safe, effective, and compassionate care.

Joseph Moses Juran ( December 24, 1904 – February 28, 2008)

Joseph M. Juran was a Romanian-born American engineer and management consultant who made significant contributions to quality management, particularly in the areas of quality planning, control, and improvement. Like Deming, Juran played a key role in Japan’s industrial resurgence after World War II, invited by Japanese leaders to teach quality principles.Juran is best known for his Quality Trilogy: Quality Planning (designing processes to meet customer needs), Quality Control (maintaining process stability), and Quality Improvement (systematically enhancing performance).

He introduced the concept of “fitness for use,” arguing that quality should be defined by how well a product or service meets customer expectations. Juran also popularized the Pareto Principle (80/20 Rule) in quality management, suggesting that 80% of problems are often caused by 20% of the issues, helping prioritize improvement efforts. His approach was practical and managerial, focusing on structured problem-solving and training.

Contribution

01 The Juran Trilogy:

Quality Planning

Identify patients’ needs and expectations.
Develop services that meet those needs.
Example: Designing a new outpatient service based on patient feedback.

Quality Control

Monitor operations to ensure care meets defined standards.
Use statistical tools to detect issues.
Example: Regular audits of hand hygiene compliance.

Quality Improvement

Eliminate root causes of problems and improve care processes.
Implement systematic changes.
Example: Reducing surgical site infections through a bundled care approach.

02 Focus on Customer (Patient) Needs

Understand the “voice of the patient” to guide quality initiatives.
Design systems that center around patient satisfaction and outcomes.
Tailor services to meet individual patient needs and expectations.

03 Top Management Commitment

Strong leadership commitment to quality improvement.
Integration of quality goals into the hospital’s strategic plan.
Leadership accountability for patient safety and service delivery.

04 Quality by Design:

Designing patient-centered hospital layouts.
Streamlining the discharge planning process.
Creating IT systems that minimize medical errors.

05 Use of Quality Metrics and Statistical Tools:

Tools like control charts, Pareto analysis, and cause-and-effect diagrams are used.
Data is collected on indicators such as length of stay, readmission rates, and medication errors.

06 Pareto Principle (80/20 Rule) in Healthcare:

It helps identify high-impact areas for improvement.
Example: A small number of procedures may account for most hospital readmissions.

07 Teamwork and Involvement

Frontline staff play a crucial role in identifying issues.
Multidisciplinary teams are essential for implementing improvement projects.
Encouraged a culture of continuous learning and collaboration.

Approaches to Measurement of Quality

Measuring quality in healthcare is essential for ensuring effective, safe, and patient-centered services.

01 Donabedian Model: Structure, Process, and Outcome Measures

Developed by Avedis Donabedian, this model evaluates healthcare quality through three interconnected components:

Structure Measures: Assess the healthcare system’s attributes, such as facilities, equipment, and staff qualifications.
Process Measures: Examine the methods of care delivery, including adherence to clinical guidelines and protocols.
Outcome Measures: Focus on the results of healthcare services, like patient recovery rates and satisfaction levels.

This framework helps identify areas needing improvement by linking the care environment and processes to patient outcomes.

02 Six Domains of Healthcare Quality

Outlined by the Institute of Medicine (IOM), these domains provide a comprehensive approach to evaluating healthcare services:

Safe: Avoiding harm to patients during care.
Effective: Providing evidence-based services that benefit patients.
Patient-Centered: Respecting individual patient preferences and needs.
Timely: Reducing wait times and harmful delays.
Efficient: Avoiding waste of resources.
Equitable: Ensuring consistent quality across diverse patient groups.

These domains serve as a foundation for developing quality measures and improvement strategies.

03 Person-Centered Outcome Measures

This approach emphasizes assessing healthcare quality based on outcomes that matter most to patients, such as quality of life and functional status. It involves actively engaging patients in defining success, ensuring that care aligns with their values and preferences.

Techniques of Quality Management:

Ensuring high-quality patient care is paramount in healthcare. Implementing effective quality management techniques not only enhances patient outcomes but also streamlines operations and reduces costs.

Plan-Do-Study-Act (PDSA) Cycle

The PDSA cycle is a four-step iterative process used for continuous improvement:

Plan: Identify an area for improvement and develop a strategy.
Do: Implement the plan on a small scale.
Study: Analyze the results to assess effectiveness.
Act: If successful, implement the change on a broader scale; if not, refine the plan and repeat the cycle.

This approach allows healthcare teams to test changes quickly and efficiently before full-scale implementation.

Six Sigma

Six Sigma is a data-driven methodology aimed at reducing variability and defects in processes:

DMAIC Framework:
- Define: Identify the problem and project goals.
- Measure: Collect data to establish baselines.
- Analyze: Examine data to identify root causes of issues.
- Improve: Develop and implement solutions.
- Control: Monitor the process to ensure continued success.

In healthcare, Six Sigma has been instrumental in minimizing errors, such as reducing medication administration mistakes.

Lean Methodology

Originating from manufacturing, Lean focuses on enhancing value by eliminating waste:

Key Principles:
- Value: Define what is valuable from the patient’s perspective.
- Value Stream: Map all steps in the patient care process.
- Flow: Ensure that care processes run smoothly without delays.
- Pull: Deliver services based on patient demand.
- Perfection: Continuously strive for process improvement.

Healthcare organizations utilize Lean to improve patient flow, reduce wait times, and enhance overall service delivery.

Root Cause Analysis (RCA)

RCA is a systematic approach used to identify the fundamental reasons for adverse events:

Process:
- Data Collection: Gather detailed information about the event.
- Causal Factor Charting: Illustrate the sequence of events leading to the issue.
- Root Cause Identification: Determine the underlying causes.
- Recommendation Development: Propose solutions to prevent recurrence.

RCA is crucial in enhancing patient safety by addressing the root causes of errors rather than just their symptoms.

Failure Modes and Effects Analysis (FMEA)

FMEA is a proactive tool designed to anticipate potential failures in processes:

Steps:
- Identify Potential Failures: List possible ways a process might fail.
- Assess Effects: Determine the impact of each failure.
- Prioritize Risks: Rank failures based on their severity and likelihood.
- Develop Action Plans: Implement strategies to mitigate high-priority risks.

By addressing vulnerabilities before they result in harm, FMEA contributes significantly to patient safety initiatives.

Statistical Process Control (SPC)

SPC involves using statistical methods to monitor and control processes:

Control Charts: Graphical tools that track process performance over time.SixSigma.us
Process Capability Analysis: Assesses whether a process can produce outputs within specified limits.

In healthcare, SPC is employed to monitor metrics like infection rates or patient wait times, facilitating timely interventions when deviations occur.

Clinical Pathways

Clinical pathways are standardized, evidence-based multidisciplinary plans that outline the optimal sequencing and timing of interventions for specific conditions:

Purpose: Reduce variability in care, ensure best practices are followed, and improve patient outcomes.

Implementing clinical pathways helps coordinate care among different providers and streamline patient management.

Benchmarking

Benchmarking involves comparing an organization’s performance metrics to industry bests or best practices:

Types:
- Internal Benchmarking: Comparing performance between departments within the same organization.
- External Benchmarking: Comparing performance with other organizations.

Improving Hospital Performance

Improving hospital performance is essential for delivering high-quality, patient-centered care while optimizing operational efficiency. Hospitals worldwide are adopting various strategies to enhance their services, reduce costs, and improve patient outcomes.

01 Embrace Data-Driven Decision Making

Utilizing data analytics enables hospitals to identify inefficiencies, monitor patient outcomes, and make informed decisions. By analyzing trends and performance metrics, healthcare providers can implement targeted improvements. For instance, predictive analytics can help in anticipating patient admissions, thereby optimizing resource allocation.

02 Implement Lean Methodologies

Lean principles focus on eliminating waste and enhancing value in healthcare processes. By streamlining workflows and reducing redundancies, hospitals can improve patient flow and reduce wait times. Adopting Lean methodologies has been shown to enhance efficiency and patient satisfaction.

03 Foster a Culture of Continuous Improvement

Encouraging a culture that values continuous improvement is vital. Engaging staff at all levels in quality improvement initiatives promotes ownership and accountability. Regular training and open communication channels empower employees to contribute to performance enhancements actively.

04 Leverage Technology and Innovation

Integrating advanced technologies, such as electronic health records (EHRs) and telemedicine, can significantly improve hospital operations. These tools facilitate better coordination of care, enhance patient engagement, and enable remote monitoring, leading to improved outcomes and efficiency.

05 Optimize Resource Management

Effective resource management ensures that hospitals can meet patient needs without unnecessary expenditure. Strategies include efficient scheduling, inventory management, and capacity planning. By aligning resources with demand, hospitals can reduce costs and improve service delivery.

06 Enhance Patient-Centered Care

Focusing on patient-centered care involves tailoring services to meet individual patient needs and preferences. This approach improves patient satisfaction and outcomes. Implementing feedback mechanisms and involving patients in care decisions are effective ways to achieve this.

07 Strengthen Leadership and Governance

Strong leadership is crucial for driving performance improvements. Leaders should set clear goals, support staff development, and foster an environment that encourages innovation and accountability. Effective governance structures ensure that quality and safety remain top priorities.

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BHM – QUALITY IN HEALTH CARE