Quality assurance cycle

BPH 4th year
HSM

1. Quality Assurance Cycle BPH 4 th year HSM

2. Quality processes Quality Assurance Quality Control Quality Improvement Total Quality Management

3. Quality processes Quality Assurance : It is the process of assuring compliance to specifications, requirements or standards and implementing methods for conformance. Quality Control : It is a management process where actual performance is measured against expected performance, and actions are taken on the difference.

4. Quality Improvement : It is an organized, structured process that selectively identifies improvement teams to achieve improvement in products or services. Total Quality Management : It is a system of continuous improvement employing participative management and centered on the needs of customers. TQM includes QA, QC and QI.

5. Steps in Quality assurance cycle Planning for quality assurance 2. Developing guidelines and setting standards 3. Communicating standards and specifications 4. Monitoring quality 5. Identifying problems and selecting opportunities for improvement 6. Defining the problem operationally 7. Choosing a team Analyzing and studying the problem to identify its root causes 9. Developing solutions and actions for improvement 10. Implementing and evaluating quality improvement efforts

6. Roles and responsibilities in quality improvement Decision makers Health-service providers Communities and service users Critical relationships in roles and responsibilities

7. a. Role and Responsibilities of Decision Makers The main concern of quality improvement is policy and strategy development. This critical activity will need to engage the whole health system, this responsibilities is normally rest at national and regional levels. The main concerns of decision-makers at these levels will be - to keep the performance of the whole system under review - to develop strategies for improving quality outcomes which apply across the whole system.

8. Role and Responsibilities of Health service providers The core responsibilities of health-service providers for quality improvement are different. Providers may be seen as whole organizations, teams, or individual health workers. In each case, they will ideally be committed to the broad aims of quality policy for the whole system, but their main concern will be to ensure that the services they provide are of the highest possible standard and meet the needs of individual service users, their families, and communities.

9. Role and responsibilities of Communities and health service users Improved quality outcomes are not, however, delivered by health-service providers alone. Communities and service users are the co-producers of health. They have critical roles and responsibilities in identifying their own needs and preferences, and in managing their own health with appropriate support from health-service providers.

10. Equally important to recognize the connections between three parts of health system Decision-makers cannot hope to develop and implement new strategies for quality without properly engaging health-service providers, communities, and service users. Health-service providers need to operate within an appropriate policy environment for quality, and with a proper understanding of the needs and expectations of those they serve, in order to deliver the best results. Communities and service users need to influence both quality policy and the way in which health services are provided to them, if they are to improve their own health outcomes.

11. A process for building a strategy for quality improvement It contains seven activities (“elements”) within the three categories of analysis , strategy , and implementation . As a cyclical process it reflects a frequently adopted approach to quality improvement – understand the problem, plan, take action, study the results, and plan new actions in response. The main implication of this approach is that strategies for quality improvement are not ’fixed’.

12. A process for building a strategy for quality

13. Analysis This first part of the cyclical process has three elements. Element 1. Stakeholder involvement Element 2. Situational analysis Element 3. Confirmation of health goals

14. Element 1. Stakeholder involvement Quality improvement is about change. For this reason, an important early step is to determine who are the key stakeholders and how they will be involved. Key stakeholders - include political and community leaders, service users and their advocates, health-care delivery organizations, regulatory bodies, and representative bodies for health workers. A further central group of stakeholders would be the senior officials responsible for quality within the ministry of health.

15. formation of a board or steering group drawn from the stakeholder groups, that would remain involved in all stages of the process, including implementation and the review of progress. The board or steering group could provide the main focus for accountability and preparing advice to decision-makers, as well as wider communication with all interested parties. Clear terms of reference would be essential. To avoid confusion, those leading the process would need to know clearly from the outset who would make policy decisions and determine the range of new quality interventions.

16. Element 2 Situational analysis Situational analysis is a mapping process which allows a clear baseline to be established before any new interventions are considered or existing ones adapted. The situational analysis will need to cover many areas, such as - Current structures and systems within the ministry of health relating to quality improvement. - Current policies in health and across sectors - Current health goals and priorities. - Current performance of the health system. -Current quality interventions.

17. Element 3. Confirmation of health goals The third element in the process of analysis is to confirm the wider health goals of the health system. This activity is important to deal as a separate element because: it is critical for any new interventions in quality improvement to be seen by stakeholders as aligned with and serving the broader health goals of the system; the situational analysis may cause some health goals to be called into question by policy-makers and other stakeholders; without clear and agreed health goals, the focus and purpose of any new quality intervention is questionable.

18. The health goals of any health system will normally be set through a political process, and may be wide-ranging. They might fall within the following broad categories. Reducing mortality Reducing morbidity Reducing health inequalities Improving outcomes for a particular disease Making health care safer

19. Building the strategy: Choosing interventions for quality The second part of the cyclical process is concerned with the development of new strategies in response to analysis, Element 4 - development of quality goal Element 5 -choosing interventions for quality Element 6- planning for their implementation

20. Element 4 - the development of quality goal The choice of quality goals will be driven by the agreed health goals, and will relate to the different dimensions of quality. The questioning process in relation to the health goal will be to ask the following. What are the deficiencies in effectiveness? What are the deficiencies in efficiency? What are the deficiencies in accessibility? What are the deficiencies in acceptability? What are the deficiencies in equity? What are the deficiencies in safety?

21. The examples illustrate the connections between broader health goals and related quality goals . Health goal: improve health outcomes for rural populations. Quality goals: improve local access to health services; improve the acceptability of those services. Health goal: reduce avoidable mortality from preventable risks. Quality goals : reduce medication errors by 50%. Health goal: improve outcomes for people with cancer. Quality goals: improve access to diagnostics and early treatment; improve effectiveness through evidence-based practice; ensure continuity of care.

22. Element 5 -choosing interventions for quality This element moves attention from the “what” to the “how”. It calls for judgements to be made about interventions, and agreement to be reached about the process of implementation. To assist this process, it is helpful to follow a simple ‘map’ of the domains where quality interventions could be made (and where current quality problems might be located).

23. Mapping the 'Domains' It identifies six domains, are intended to help policy-makers address quality issues at a more strategic level. a. leadership b. information c. patient and population engagement d. regulation and standard e. organizational capacity f. models of care

24. Six Domains of quality interventions

25. Element 6- planning for their implementation Another important outcome to be achieved in this part of the cycle is agreement about the plan for implementation of the agreed interventions. Any implementation plan will need to meet local considerations, but there are generic issues which need to be considered, such as those suggested in the following questions. Who will lead the change process? What resources will be available to support implementation? What technical expertise will be available to support implementation?

26. How will accountability work? Who has the authority to amend the implementation plan? Will the change process start with pilot projects? What will be the plan for scaling up? What will be the timetable for implementation? How will decision-makers communicate with stakeholders? What will be the key milestones? How will progress be monitored?

27. Implementation The third part of the cyclical process is concerned with the management of agreed quality strategies, and with reviewing progress and the impact of changes as an input to the continuing activity of ANALYSIS. It consists of Element 7. Implementation process Element 8. Monitoring progress

28. Element 6. Implementation process This element moves the focus to managing the implementation process. The strategy will have identified a framework for implementation and covered key issues such as leadership and accountability, timescales and milestones, and the monitoring of progress. The success of the interventions will then depend on maintaining a clear focus on implementation, sustaining interest and commitment, and having the capacity to make tactical decisions to modify activities in response to feedback.

29. The responsibilities of board for sustainability Having a programme board or steering group with appropriate stakeholder representation and terms of reference could be an effective way of sustaining a intervention for quality strategy. The core responsibilities of such a board might include: keeping under review progress on implementation, adherence to timetables, and achievement of targets and goals; redirecting resources; providing an account of progress to interested parties; modifying timetables and milestones;

30. preparing the health system for scaling up where a phased approach is planned; keeping new evidence under review and modifying plans to take account of that evidence.

31. Element 7. Monitoring progress The final element is to maintain a focus on the delivery of the improved outcomes and benefits being sought. This focus is important because: if results are not those that were expected, it will be important to make early decisions about how the strategy and its selected interventions might be modified to achieve better results;

32. any investment of effort and resources in quality improvement can only be justified in terms of improved outcomes – giving proper account to stakeholders for that investment can only be done with information about changing outcomes; and maintaining the motivation and commitment of stakeholders in the change process will be helped by being able to point both to progress and achievements, and to the delivery of the quality goals to which they have subscribed.

33. Plan for monitoring The quality measures to be used will have been agreed earlier in the process,when health goals and related quality goals were set. Wherever possible, existing information sources should be used to monitor progress and outcomes; the Implementation plan should include arrangements for collecting new data if required. Tools such as questionnaires, matrix can be used

34. Example-A matrix for mapping quality interventions at country level

35. Quality Control Quality control (QC) has a narrower focus than quality assurance.  Quality control focuses on the process of producing the product or service with the intent of eliminating problems that might result in defects. QC includes the operational techniques and the activities which sustain a quality of product or service that will satisfy given needs; also the use of such techniques and activities.

36. Quality control is the function of ensuring that the product or service quality conforms to predetermined standard. Once the standard have been determined, the acceptability of the actual work can be compared with expected standard. If there is a serious lack of conformity, corrective measures may be neccery.

37. Five activities implies in Quality Control Process Determining tolerance i.e. range within which deviation in actual quality from standard will be acceptable. Conducting inspection and tests of materials, processes and products. Isolating acceptable units from those, which do not conform to quality standards. Bringing causes of deviations to the attention of the concerned manager Suggesting ways and means of improving the quality

38. Methods/ Techniques of Quality Control Two main techniques of quality control - a. Inspection- involves periodic checking and measuring before, during and after the production process, aims to detect and isolate defective work and prevent it occurring in future. b. Statistical quality control-statistical techniques is applied for the maintenance of quality standard. It is based on the theory of sampling and laws of probability.

39. Total Quality Management : Total Quality Management or Quality management is a system of continuous improvement employing participative management and centered on the needs of customers. TQM includes QA, QC and QI. It is the totality of functions involved in the determination and achievement of quality

40. Total quality management is a management approach centred on quality, based on the participation of an organisation's people and aiming at long term success (ISO 8402:1994). This is achieved through customer satisfaction and benefits all members of the organisation and society.  In other words, TQM is a philosophy for managing an organisation in a way which enables it to meet stakeholder needs and expectations efficiently and effectively, without compromising ethical values. TQM is a way of thinking about goals, organisations, processes and people to ensure that the right things are done right first time. This thought process can change attitudes, behaviour and hence results for the better.

41. Definitions TQM is a cooperative form of doing business that relies on the talents and contributions of both labour and management to continually improve quality and productivity using teams. Josep R. Jablonski 1991 TQM is creating an organizationl culture committed to the continuous improved of skills, teamwork, process, product and service quality and consumer satisfaction. Arthur R. Tenner and Irving J. DeToro 1997 TQM is continuous, customer-oriented, employee-driven improvement. Richard Schonberger 2002

42. The principles of quality management There are eight principles and elements of quality management: customer-focused organization leadership involvement of people process approach system approach to management continual improvement factual approach to decision making mutually beneficial supplier relationships

43. TQM Techniques Benchmarking -process of continually comparing. Two types of benchmarking. i. Internal ii. External ISO Standards - series of number 9000 to 9004. In the 1990s, another system introduced-ISO 1400. In Nepal, the Nepal Bureau of Standards and Metrology NBSM, ISO 9000 has adopted, as a international assessment criteria, 'ISO 9000 certification' Quality circles- viewed as increase of worker involvement and powerful method of employee empowerment

44. Responsiveness - responds over their competitors. If The organization responds quickly, it is faster than competition. Faster organizations are more likely to be the winners, better and smarter. Outsourcing - process of contracting out for some functions of an organization to outside firms. It increases efficiency, reduces cost and time, enhances productivity of resources and improve quality.

45. SIX SIGMA- is a statistical model coupled with specific quality tools. It is fact-based, data driven philosophy of quality improvement that values defect prevention over defect detection. Six sigma attempts to design quality rather than measuring the quality after production, the premise behind Six Sigma is to design, measure, analyze and control the input of production process to achieve the goal of no more than 99. 99% defects per million procedure. Kaizen- is a Japanese term, is the elimination of waste.

46. TQM Tools include: Pareto analysis Control chart Cause and effect diagrams Flowcharting Others- - histogram/ bar graph - check list -check sheets

47. Pareto Principle Pareto Principle                                                                                                               

48. The Pareto principle suggests that most effects come from relatively few causes. In quantitative terms: 80% of the problems come from 20% of the causes (machines, raw materials, operators etc.); 80% of the wealth is owned by 20% of the people etc. Therefore effort aimed at the right 20% can solve 80% of the problems. Double (back to back) Pareto charts can be used to compare 'before and after' situations. General use, to decide where to apply initial effort for maximum effect.

49. Control Charts/ SPC

50. Control charts are a method of Statistical Process Control, SPC. (Control system for production processes). They enable the control of distribution of variation rather than attempting to control each individual variation. Upper and lower control and tolerance limits are calculated for a process and sampled measures are regularly plotted about a central line between the two sets of limits. The plotted line corresponds to the stability/trend of the process.

51. Cause and Effect , Fishbone, Ishikawa Diagram

52. The cause-and-effect diagram or fishbone diagram is a method for analyzing process dispersion. The diagram's purpose is to relate causes and effects. Three basic types: Dispersion analysis, Process classification and cause enumeration. Effect = problem to be resolved, opportunity to be grasped, result to be achieved. Excellent for capturing team brainstorming output and for filling in from the 'wide picture'. Helps organize and relate factors, providing a sequential view. Deals with time direction but not quantity. Can not demonstrate interrelationships.

53. Flow Charts A Flow charts is a pictorial representation that shows pictures, symbols or text coupled with lines, arrows on lines show direction of flow. This chart can be used when the managers are trying to identify problems/opportunities and decision points. This chart presents ideal path of a work. Any deviation from ideal path is detected. A flow charts is useful tools for planning and control of quality

54. Measurements After using the tools and techniques an organisation needs to establish the degree of improvement. Any number of techniques can be used for this including self-assessment, audits and SPC.

55. TQM Process TQM processes are divided into four sequential categories: plan, do, check, and act (the PDCA cycle ). Act Plan Check Do

56. Plan -In the planning phase, people define the problem to be addressed, collect relevant data, and ascertain the problem's root cause; Do - in the doing phase, people develop and implement a solution, and decide upon a measurement to gauge its effectiveness; Check- in the checking phase, people confirm the results through before-and-after data comparison; Actin the acting phase, people document their results, inform others about process changes, and make recommendations for the problem to be addressed in the next PDCA cycle.

57. Advantages of Quality Studies in Health Care Accomplishments of the programme will be listed. Weak points in the programme will be identified. Process of quality assessment itself will improve quality of care. Health care financing will be more focused. Determines the utilization pattern of health care services. Aspects of care that can maximize effectiveness may identified. Reflects changing and emerging needs in health care.

58. Steps in Conducting A Quality Assessment Study Identify the objectives of the programme to be evaluated Identify the indicators of quality for the objectives Develop standards for the indicators Identify the methods of assessing quality Sampling in quality assessment need not be strictly representative. After data collection organize the data in terms of the indicators. Compare it with standards developed

59. Techniques of Conducting Quality Assessment Review of statistics Review of records Special studies Patient surveys Household surveys Assessment of consumer satisfaction Observation

60. Types of Qualit y Product based quality : product’s attributes e.g. sweet mangoes, soft silk etc. User based quality: the ability of the product to meet the user’s needs and expectations. Value based quality : cost benefit relationship. It is the ratio of what the customer gets and gives. Manufacturing based quality : Conformance to established standards. Transcendent based quality: It is inherent value apparent to the customer. “Beauty lies in the beholder’s eyes”

61. STANDARDS A Standard is a statement of expected level of quality. It states clearly the inputs required to deliver a service, how things should be done (process) and what the output or outcome should be. When we compare what is expected in the standards to what we do, we shall be able to identify any quality gaps and then make plans to improve upon it.

62. Standards can be set for any level of the healthcare system i.e. national, regional, district, sub-district. There are also international standards e.g. those developed by the WHO that can be adapted to that of the country . They can be developed for use in public health, clinical care and support services

63. Types of Standard Input Standards- Input or structure standards define the resources that must be supplied for the activities to be carried out. Process Standards -Process standards describe the tasks or steps that must be carried out until the activity is completed. Output/ Outcome Standards -Output/ Outcome standards describe the outputs or results of the activities carried out.

64. Input standards for antenatal Clinic Physical structure Equipment and supplies Staff

65. Process standards National Reproductive Health Policy, Standards and Protocols Laboratory standard operating procedures; and Medical records procedures.

66. Output/ Outcome standards Pregnant women will attend at least four times during pregnancy. Ninety percent (90%) of women attending antenatal clinic will report satisfaction with care given (client survey).

67. Uses of Standards Standards are used to: Define quality Determine, inputs, processes and outcomes, and Develop indicators to monitor quality.

68. example standards for antenatal care using the three (3) areas namely, input, process and outcome

69. Input standards These are measured in terms of quality of physical structure, equipment, supplies and staff. Physical structure- The antenatal clinic should have a reception and waiting area with adequate seating for women. A separate examination room for history and examination Staff Qualified nurse midwife(s) Support staff

70. Equipment and supplies Standing scale with Height measure Sphygmomanometer Maternal health records Fetoscope Dipstick for urinalysis Measuring tape Examination table Immunization equipmentsseparate examination room for history and examination Drugs- Folic acid, Iron, anti- malarials Laboratory for basic tests

71. Methods used for communication to staff about Standard Training of health workers (in service and on the job training) Launching of the standard Seminars/ conferences Developing job aids Support supervision.

72. Barriers of quality health services The health system environment The health system infrastructure Cost of services Socio/cultural constraints Service user's perception regarding medical care Language and education Trust by users in health care providers and procedures Service provider's attitudes and skills Lack of assertiveness and low self-esteem by users Lack of information/knowledge of available health services in community

73. monitoring quality of care; comparing and ranking performance of facilities providing technical support to regional QA teams; mobilizing resources for quality assurance.

74. Issues and challenges in quality of health care Inequity due to mal distribution of scarce health resources Shortage of trained personnel and skewed distribution Increasing expenditure in health Expansion of health business in health center Continuity of services Quality assessment, techniques and tools Monitoring and reporting system

75. Roles and responsibilities of organizational levels in Quality The role of national level is to give direction and support to regions in the implementation of quality assurance. A national QA team for the establishment of a quality assurance unit will serve the following functions: developing policies and strategies; co-ordinating countrywide quality assurance program; developing clinical guidelines and protocols; setting national standards ;

76. Socioeconomics plays an important role in a family's decision to seek medical assistance The uncertainty regarding the ability to pay for medical cost may discourage one to seeking medical help. For example, cost and prices of services, transport cost, wages of quality of staff, price of quality of drugs and other consumables. Waiting for a long period e.g. two or three-month doctor’s appointment, facing long lines, and long hours discourages individuals seeking healthcare services.

77. Language and literacy can be a barrier to healthcare. Lack of information on available health care choice/providers, the embarrassment of sharing personal information or admitting ones lacks of reading and writing skills can be a barrier to entering a medical facility. Community's culture, attitudes and norms plays a significant role in healthcare barriers through negative perceptions or fears regarding medical care. For example, culturally, patients may have difficulty with a doctor of the opposite. Another cultural barrier to medical services is an individual’s religious belief.

78. Trust plays a major role in seeking medical attention. Lack of trust by users in health care providers, making people reluctant to use the respective services. Staff absenteeism, limited opening hours that do not allow for dealing with emergencies or working times are not convenient for patients, especially working people. Negative experiences with medical staff may influence patients to postpone medical attention. For example unwelcoming staff attitude or poor interpersonal skills as well as complex billing systems at hospitals play barrier in quality of care.

79. Lack of assertiveness and low self-esteem by users from among the poor, which increased the difficulty of accessing services. The effect of non-financial barriers, such as lack of health awareness, apparent unfelt need or lack of opportunity (defined as exclusion from social and health providers) are important hindering factors to assure of quality improvement of health services.