Healthcare Quality Concepts (2)

table of contents

1. Healthcare Quality Concepts
2. Total Quality Management (TQM) Deming’s 14 Point Plan for TQM
3. SYSTEMS THINKING IN HEALTHCARE
4. Complex System Theory: A "complex adaptive system (CAS)
5. Donabedian Paradigm (Systems approach)
6. Performance measures/ indicators (most common) is a tool used for measuring performance
7. Customer- Supplier relationship (Triple role)
8. TQM Philosophy Promotes:
9. TQM is a management philosophy results in:
10. Four cornerstones for value-based healthcare improvement
11. 1999: To Err is Human 
12. 2001: Crossing the Quality Chasm 
13. Six key areas (IOM aims or attributes of care)
14. Patient-centered
15. Berwick
16. To build a Patient-Centered Culture
17. Institute of Medicine: Crossing the Quality Chasm (2001)

Healthcare Quality Concepts. A number of attributes can characterize the quality of healthcare services. As we will see, different groups involved in healthcare, such as physicians, patient, and health insurers, tend to attach different levels of importance to particular attributes and, as a result, define a quality of care differently.

Healthcare Quality Concepts (2)

Healthcare Quality Concepts

Dr. W. Edwards Deming 

Born on October 14, 1900, Dr. W. Edwards Deming was an eminent scholar and teacher in American academia for more than half a century.

He published hundreds of original papers, articles and books covering a wide range of interrelated subjects—from statistical variance, to systems and systems thinking, to human psychology. He was a consultant to business leaders, major corporations, and governments around the world. 

His efforts led to the transformation of management that has profoundly impacted manufacturing and service organizations around the world.

Dr. Deming’s 14 Points for Management

The principles were first developed with products in mind, not services. There is need for further adaptation in healthcare because a patient is a person, not a product. 9 out of 14 are related to behavior, psychology and ethics.

Edwards Deming's Fourteen Points for Managing Quality

1. Create constancy of purpose toward improvement of product and service, with the aim to become competitive.
2. Adopt the new philosophy— things to be done right the first time through effective training.
3. Cease dependence on inspection to achieve quality. Focus more on systems than individuals and can place much more emphasis on improving services than finding fault.

4. End the practice of awarding business on price tag alone. Move toward a single supplier for any one item, on a long-term relationship of loyalty and trust.
5. Improve constantly and forever every process for planning, production, and service, to improve quality and productivity.
6. Institute training on the job. employees are an institution's most precious assets.
7. Adopt and institute leadership; leadership should be to help people and machines to do a better job.
8. Drive out fear, so that everyone may work effectively.
9. Break down barriers between departments. Emphasize teamwork, not competition.
10. Eliminate slogans, exhortations. Concentrate on improving the system to make it easier for the worker to do a better job.
11. Eliminate numerical goals for management. Emphasize quality and methods, not quantity.
12. Remove barriers that rob people of pride of workmanship. Promote the worker's sense of pride in a job well done.
13. Institute a vigorous program of education and self-improvement for everyone. Quality begins and ends with education.
14. Put everyone to work to accomplish the transformation. The transformation is everyone's job.

Total Quality Management (TQM)
Deming’s 14 Point Plan for TQM

1	Create constancy of purpose	8	Drive out fear
2	Adopt the new philosophy	9	Eliminate boundaries
3	Cease inspection, require evidence.	10	Eliminate the use of slogans
4	Improve the quality of supplies	11	Eliminate numerical standards
5	Continuously improve production	12	Let people be proud of their work
6	Train and educate all employees	13	Encourage self-improvement
7	Supervisors must help people	14	Commit to ever-improving quality

TQM fosters a belief in the value of:

1. Customers. 
2. Employees/Staff. 
3. Management. 
4. Teamwork.

AN INTEGRATED PERSPECTIVE

Activities associated with improving organization performance involve much more than the clinical aspects of care.

All the interrelated processes and services impact the quality of care and affect patient outcomes: governance, managerial, and support activities, as well as clinical activities.

SYSTEMS THINKING IN HEALTHCARE

1. Systems are multiple, interconnected (interrelated) components: people, machines, processes, and data which operate toward a common purpose.

2. "The goal of a system is to maximize the output of the whole components (system), not the output of each of its components. “ Health systems are considered "macrosystems." Each clinical unit and support unit is a "microsystem.“

Complex System Theory: A "complex adaptive system (CAS)

A healthcare organization, is:

1) complex because it is diverse and comprised of many interconnected elements
2) adaptive because it can learn from experience and change.

Donabedian Paradigm (Systems approach)

Causal relationship

“probabilities, not certainties; presence of individual factors”

1. Structure

Is the evidence of the organization’s capacity to provide care.

Structure Examples

• Staff no.

o Adequate nurse: patient ratio.

o Trained nursing staff.

• Staff qualifications. Physicians, pharmacists have Certificates.

• Organizational chart.

• Resources (equipment, budget, beds....).

o Computer systems available.

o Updated treatment guidelines.

• Hospital good geographical location.

2. Process

Are the procedures/ sequence of steps done to provide care intending to produce a desired outcome.

Process Examples 

Services (registration, lab, pharmacy...)
Clinical processes (ttt , assessment, medication...)
Administration and management.

3. Outcome 

Are the results of care 

Outcome Examples: 

Clinical (complication rate, mortality rate.). 

Functional (long term health status.). 

Perceived (patient satisfaction, peer acceptability).

Performance measures/ indicators (most common) is a tool used for measuring performance

Types of performance indicators:

• Outcome.
• Process.
• Who puts the indicator? Who approves it?
• Steps for developing an indicator:
• Characteristics of a performance measure: Valid, Reliable, Specific, Sensitive

Four factors influence the degree to which healthcare services achieve desired health outcomes:

1. Disease process and severity;
2. Processes of care;
3. Patient compliance; and
4. Random and unidentified variables. 

In healthcare, we have the greatest control over the second factor: process(es) of care.

The Basic Elements of a Process

They Include:

·      Inputs by Suppliers.

·      A sequence of steps by Processors.

·      Outputs to Customers.

·      Suppliers            Processors               Customers

Inputs   =>   Sequence of Steps   =>   Outputs

Customer- Supplier relationship (Triple role)

Each person in the organization is a part of one or more processes.

The support staff is a:

1. Customer of all those supplying inputs.
2. Processor, performing managerial, technical, or administrative tasks using the inputs.
3. Supplier to customers by delivering products or services (outputs).

Healthcare practitioners are also

• Suppliers, providing degrees of experience, commitment, empowerment, satisfaction, time.
• Processors of care certainly.
• Customers, dependent on others in each process.

The patient has a triple role as:

• Customer: ask for and receive services, with needs and expectations.
• Processor: perform tasks such as taking medications, learning diet and exercises, self-care skills, diabetic management, etc. 
• Supplier: of characteristics such as age, sex, socioeconomic status, and perceptions of care, in addition to clinical history and symptoms, etc.

TQM Philosophy Promotes:

1. An increased top-down and bottom-up emphasis on quality, with top managers demonstrating leadership for the constant improvement of quality care, being responsive rather than directive.
2. A decreased emphasis on inspection, surveillance, and discipline and a focus on systems rather than individuals.
3. A substantially increased investment of managerial time, capital, and technical expertise.
4. An increased investment in education, study, and training at all levels.
5. A steadfast, long-term vision.
6. Cautious use of "minimal" standards of care. The healthcare organization that seeks merely to meet minimal standards may not ever reach any higher, and certainly will not achieve excellence. 
7. Continuous, ongoing quality improvement.

TQM is a management philosophy results in:

1. Increased customer satisfaction.
2. Increased productivity.
3. Increased profits.
4. Increased market share. Decreased costs.

Value = Quality + Outcome of care / Cost of care 

The goal from a value-based healthcare system Is transparency enabling consumers to compare the quality and price of healthcare services and make informed choices.

Four cornerstones for value-based healthcare improvement

• Develop interoperable health information technology (HIT): Sharing electronic health record information requires setting national HIT standards and a certification process.
• Measure and publish quality information.
• Measure and publish price information.
• Promote quality and efficiency of care: offering pay-for-performance incentives to all providers.

1999: To Err is Human 

One death in every 343 to 764 admissions. 

In comparison, aviation averages one death for every 8 million flights.

2001: Crossing the Quality Chasm 

The report described America's health system as "a tangled, highly fragmented web that often wastes resources by duplicating efforts. “

Should create new methods to monitor and track quality in six key areas (IOM aims or attributes of care).

Six key areas (IOM aims or attributes of care)

STEEEP

1. Safe care.
2. Timely care.
3. Effective care.
4. Efficient care.
5. Equitable care.
6. Patient-centered care.

Patient-centered

Providing care that is respectful of and responsive to individual patient preferences, needs, and values.

Patient Satisfaction Surveys examines communication with nurses and physicians, staff responsiveness, cleanliness and noise levels, pain control, and quality of discharge instructions and medication information.

Berwick

describes three maxims:

1. The needs of the patient come first.
2. Nothing about me without me.
3. Every patient is the only patient.

To build a Patient-Centered Culture

1. Emphasize patient centered care as a quality dimension.
2. Change the locus of control: patients and families control over all decisions about care.
3. Expand transparency. 
4. Design for individualization and customization: creating flexible systems that can adapt to the needs and circumstances of individual patients.

The report challenges private and public purchasers, healthcare organizations, clinicians, and patients to work together to redesign healthcare processes according to these rules:

Institute of Medicine: Crossing the Quality Chasm (2001)

In many forms at all times

1. Care based on continuous healing relationships
2. Care based on patient needs and values
3. Patients as the source of control
4. Patients access to medical information and clinical knowledge
5. Evidence-based decision making
6. Patient safety
7. Transparency of information
8. Anticipation of needs
9. Continuous decrease in waste
10. Cooperation among clinicians

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