Healthcare Quality Concepts (1)

“The balance of health benefits and harm is the essential core of a definition of quality.” (Donabedian, 1990).

Healthcare Quality Concepts

What is healthcare quality?

Quality is the optimal achievement of therapeutic benefit and avoidance of risk and minimization of harm. (Joint Commission).

Definitions of Quality in Healthcare

Classic Definition

1. Quality refers to the ability of a product or service to consistently meet or exceed customer expectations.

2. Issue: Who is the customer?

Institute of Medicine (1990) Definition

“Quality is the extend to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

The Juran Institute

defines quality as both “Freedom from deficiencies” and “Product features that attract and satisfy patients”.

Definitions of Quality in Healthcare

In practice:

• Doing right things right the first time
• The right care for every person every time
• First No harm

Three Aspects of Quality

MAP

1. MEASURABLE
2. APPREIATIVE
3. PERCEPTIVE

Aspect of Quality Care	Description	Measured by
Measurable Quality	Judged by comparing actual performance to a set of standards.	Compliance with/adherence to established standards.
Appreciative Quality	Judged by experienced practitioners based on their expertise and experience, in addition to standards.	According to the judgment of peer review bodies (experts with similar specialized knowledge).
Perceptive Quality	Judged by the recipient of care based on their perception and experience.	As perceived by the recipient of care (patient/client satisfaction).

The ideal organizationwide healthcare quality strategy is effective in tracking measurable quality while understanding the value and necessity of appreciative quality and actively fostering perceptive quality. 

But the ideal healthcare quality strategy is also well-supported by the governing body, by physicians and other independent clinical practitioners, by the chief executive officer, by senior and middle management, and by all employees.

CUSTOMER

A customer is anyone who receives our service or dependent on me as a supplier. 

Identifying customers: 

"Wheel and spoke" or "sundial “. 

Customer lists by type: Internal and external. 

Identifying customer needs: Surveys and interviews. Research. Brainstorming.

Within the organization INTERNAL CUSTOMER 1) Admitting/reception/front office staff 2) Administrative staff 3) Administrative services staff 4) Ancillary staff/technicians 5) Care coordination/social services staff 6) Communications staff 7) Human resources staff 8) Facilities staff 9) Finance staff 10) Medical/clinical record staff 11) Nurses, aides, medical assistants 12) Performance improvement, QM 13) Pharmacists 14) Physicians, med. directors

Outside the organization EXTERNAL CUSTOMER 1. Patients/families 2. Physicians 3. Purchasers 4. Insurance companies and health plans 5. Employers 6. Government agencies 7. Regulators and accrediting agencies 8. Vendors/suppliers (goods and services) 9. Other providers 10.Educational institutions

Products and Services

Products:

1. Tangible
2. Measure Output “objects”
3. Homogenous
4. Can be stored or resold
5. Can be patented

Services

• Intangible
• Measure Outcome “performance”
• Heterogenous
• Perishable “cannot be stored or resold”
• Very difficult to patent

Key Dimensions of Quality Care Performance

1. Safe
2. Timely
3. Effective
4. Efficient
5. Equitable
6. Patient-centered
7. Efficacy
8. Appropriateness
9. Availability
10. 1Continuity
11. Respect and Caring

Appropriateness

The degree to which the care and services provided are:

1) Relevant to an individual's clinical needs.

2) Correct: Doing the right things in accordance with the purpose (Medical necessity).

3) Suitable resource utilization as judged by peers.

Timeliness

The degree to which care is provided to the individual at the most beneficial or necessary time.

Availability

The degree to which appropriate care and services are accessible and obtainable to meet an individual's needs.

Competency

The degree to which the practitioner adheres to professional and/or organizational standards of care and practice.

Continuity

• The coordination of needed healthcare services for a patient among all practitioners and across all involved organizations over time.

• The delivery of needed healthcare as a coherent unbroken succession of services.

Effectiveness

• The degree to which care is provided in the correct manner, given the current state of knowledge, to achieve the desired or projected outcome(s) for the individual".

Effectiveness = Achieved/ Desired 

Efficacy

• The potential capacity, or capability of the care to produce the desired effect or outcome, as already shown, e.g., through scientific research (evidence-based) findings.

• The power of a procedure or treatment to improve health status.                   

Efficiency

• The relationship between the outcomes (results of care) and the resources used to deliver care.

• "The relationship of outputs (services produced) to inputs (resources used to produce the services)".

Prevention – Early Detection

The degree to which interventions, including the identification of risk factors, promote health and prevent disease.

Respect and Caring

• The degree to which those providing services do so with sensitivity for the individual's needs, expectations, and individual differences.

• The degree to which the individual or a designee is involved in his or her own care and service decisions.

Safety

The degree to which the healthcare intervention minimizes risks of adverse outcome for both patient and provider.

Total Quality Management

Quality Assurance

Quality Control

Inspection 

Comparison Between Traditional Monitoring and Evaluation utilizing the three aspects of quality 
(Quality Assurance), Total Quality Management (TQM) and 
Continuous Quality Improvement (CQI)

Quality Assurance:

	QA	TQM / CQI
Objective	Outcome	Process and outcome
Focus	Statistical tail. Problem-focused methods (Actions are initiated when a problem is identified)	Entire group. (Continuous improvement process) trying to improve the process itself
Focus on	Clinical aspects of care only	Clinical and non-clinical aspects
	Departmental	Cross-departmental according to patient flow
	Frequently separating the dimensions of quality care— review of appropriateness separate from effectiveness and/or efficiency	Integrating all efforts to improve both patient outcomes and efficiency of care delivery (improving value)
	Errors are due to individual performance	Errors are due to system failure (85%)
	WHAT of care → Patient care given. The right service to the right patient at the right time and place WHO of care → Patient care giver. Competent and qualified staff who is doing the rights things right	Also, focuses to the previous ones: HOW of care → Patient care processes. Systems and their key processes, Policies, procedures, and regulatory compliance, Relationships and communications; Clinical pathways, practice guidelines, and protocols. RESULT of care → Patient care outcome

Definition of Total Quality Management [TQM]

• TQM is 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.

TQM Definitions:

1. Focusing on customers satisfaction.
2. Provides best quality product at lowest possible price.
3. Prevention of defects, target is zero defects.
4. It is the involvement of the entire organization in a process of quality improvement to provide value. 
5. All functions and all employees have to participate.
6. Focusing on meeting customer needs and organizational objectives.
7. Continuous improvement in all work, from high level strategic planning and decision-making, to detailed execution of work elements on the shop floor.
8. Provides best quality product at lowest possible price.
9. Prevention of defects, target is zero defects.
10. It is the involvement of the entire organization in a process of quality improvement to provide value. 5. All functions and all employees have to participate.
11. Focusing on meeting customer needs and organizational objectives.
12. Continuous improvement in all work, from high level strategic planning and decision-making, to detailed execution of work elements on the shop floor.

TQM - The key principles are: 

• Management Commitment.
• Employee Empowerment.
• Fact Based Decision Making.
• Continuous Improvement.
• Customer Focus.

key concepts of TQM

1. Top management leadership.
2. Creating corporate framework for quality.
3. Transformation of corporate culture.
4. Customer focus.
5. Process focus.
6. Collaborative approach to process improvement.
7. Employee education and training.
8. Learning by practice and teaching.
9. Benchmarking.
10. Quality measurement and statistics.
11. Recognition and reward.
12. Management integration.

QUALITY MANAGEMENT PRINCIPLES

• "Productive work is accomplished through processes." Each person in the organization is a part of one or more processes.
• "Sound customer-supplier relationships are absolutely necessary for sound quality management". 
• "The main source of quality defects is problems in the process."
• Poor quality is costly.
• Understanding the variability of processes is a key to improving quality.
• Quality control should focus on the most vital processes.
• The modern approach to quality is thoroughly grounded in scientific and statistical thinking.
• Total employee involvement is critical.
• New organizational structures can help achieve quality improvement.
• Quality management employs three basic, closely interrelated activities: Quality planning, quality control [quality measurement], and quality improvement.

The Joint Commission Principles of Organization and Management Effectiveness

1. The organizational mission statement clearly expresses a commitment.
2. The organizational culture.
3. Opportunities for organizational change.
4. The role of governing board, managerial, and clinical leaders
5. The governing board, managerial, and clinical leadership qualifications.
6. The qualifications, evaluation, and development of independent practitioners.
7. Human resources recruitment and retention policies and practices.
8. Sufficient support resources.
9. The monitoring, evaluation, and continuous improvement of patient care.
10. Organizational integration and coordination.
11. Continuity and comprehensiveness of care.

The ISO 9000:2005 Quality Management Principles

• ISO (the International Organization for Standardization) is a worldwide federation of national standards bodies (ISO member bodies).
• The work of preparing International Standards is normally carried out through ISO technical committees.
• https://www.iso.org/obp/ui/#iso:std:iso:9000:ed-3:v1:en

System Error

1. A central principle of TQM is that mistakes may be made by people, but most of them are caused, or at least permitted, by faulty systems and processes.
2. Mistakes can be avoided and defects can be prevented.
3. Improving capabilities to produce better results in the future.

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