How to improve health care

How to improve health care

1. Prof. Dr Swe Win Honorary Professor Professor and Head(retired) Health policy and management Department UPH How to improve Quality of Health care in hospital 19.3.2016 Hospital Administration Society

2. To know the various approaches of quality improvement in health care services and to select the appropriate approach applied in hospital. Aims of Presentation

3. 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) HEALTH CARE PROBLEM Source: Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary;NAP

4. 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 Quality (fundamentally relational)

5. 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 Quality

6. 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 Quality = Degree of performance The standard set empowerment standards satisfaction

7. 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 Attributes of Quality

8. Evolution of Quality Management Total Quality Management

9. 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 Evolution of Quality Management

10. 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 Evolution of Quality Management

11. Dimension of Quality Quality assessment Quality assurance Quality control Quality improvement QUALITY OF ORGANIZATION

12. 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 Quality Assessment

13. 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.

14. 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

15. 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 Quality improvement

16. 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 Total Quality Management ( TQM

17. 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) TQM concepts

18. 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) What is Total Quality Management (TQM)?

19. 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

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

21. The TQM pyramid.

22. 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.   Attaining Six Sigma Quality

23. 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 Methodological Sequences of Six Sigma

24. 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

25. 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’s Taiichi Ohno Lean methodology

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

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

28. 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 Lean Thinking Fundamentals

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

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

31. 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) Quality of health care

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 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. Accreditation

36. 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 Accreditation/Certification

37. 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 Standardization

38. 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. Benchmarking

39. 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. Clinical In-Service Training

40. 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 COPE ® (client-oriented, provider-efficient services)

41. 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. Improvement Collaborative

42. 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, SBM-R (Standards-Based Management and Recognition)

43. 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. Supportive Supervision

44. TQM / SQI = Professionalism x Motivation x Leadership x Management x Partnership Practice professionalism by all categories of health professionals Fulfill basic and social needs to motivate professionals Develop leadership quality Better management and use management tools Establish strong partnership both internal and external users Achieving Quality Improvement 45 Prof.Dr Mya Oo

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

46. Clinical governance is a systematic approach to maintaining and improving the quality of patient care within a health system . 1.High standard of care 2.Constant dynamic process for improvement 3.An enabling working environment with functioning 4.Transparent, responsible and accountable for high standard

47. Clinical Effectiveness Research & Development Openness Risk Management Education & Training Clinical Audit In 1990s, the UK introduced clinical (including doctors, nurses and therapists) audit programs to assess the performance of clinical process and to educate the health workforce concerned. This form of self regulation activities should be welcome. We should avoid blame culture and develop our learning from those experiences. This form of clinical audit should be introduced and promoted in central tertiary care hospitals.

48. 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 CLINICAL AUDIT Definition was announced by the NHS executive:“ Clinical audit is the systematic analysis of the quality of healthcare, including the procedures used for diagnosis, treatment and care, the use of resources and the resulting outcome and quality of life for the patient."

49. 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: Health Promotion Hospital

50. 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 ” Health Promotion hospital

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

52. 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. Problem solving & QI Approach

53. 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 Comparison of QI approaches

54. 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 Comparison of QI approaches

55. 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,. To consider if you want to apply

56. THANK YOU FOR YOUR ATTENTION [email protected]