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Atatürk University Medical Faculty, Class 203.10.2012

Quality in Health Care Quality in Health Care andand

Basic Tools of QualityBasic Tools of Quality

Zekeriya Aktürkaile.atauni.edu.tr

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Objectives

• At the end of this session, the trainees should be able to;– define terms related with quality

– express the benefits of quality

– explain the quality diagram Plan-Do-Check-Act

– discuss ways to improve quality in primary care

– describe quality circles/peer review groups

– describe workflow

– describe processes

– explain the seven tools of quality improvement

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2000 BC: Eat this root...

1000 AC: The root is useless, come do this prayer...

1850 AC: Prayer is superstition...Take, drink this elixir...

1940 AC: The elixir is snake oil...Use this drug...

1985 AC: The drug is ineffective...Take this antibiotic..

2000 AC: Antibiotics are not working...“Eat this root..."

The Story of Drugs

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What is Quality?

• peculiar and essential character

• an inherent feature

• degree of excellence

• a distinguishing attribute Websters Dictionary

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• Appropriateness for work.

(Dr. Joseph Moses Juran)

Quality

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• Appropriate for the conditions.

(Philip Bayard Crosby)

Quality

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• The level you can cover the needs.

Quality

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• Meeting the requirements at the first time, all the times and at the correct time.

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• Customer satisfaction.

Quality

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Some terms

• ISO 9001:2000• Quality assurance• Quality improvement• Total quality management• Process • Procedure• Instructions• Documentation• Quality circles

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Stakeholders

PatientsManagers

QUALITY

Workers

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Quality Cycle

W. Edwards Deming

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Quality is a process

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Corrective system

1

2

3

4

Analyze customer needs

Corrective actions

Control the process

Marketing

Quality approaches

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Preventive System

1

2

3

4

Analyze customer needs

Design and improve

Control the process

Marketing

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Three areas in quality

• Structure– The structure of health system is important.

Economical and political restrictions will effect the quality of services

• Process– What are we doing for our patients in reality? Can we

accomplish our responsibilities?

• Outcomes– Is our practice really making any change? What about

patient satisfaction, mortality, morbidity…?

Rajakumar MK. Asia Pacific Family Medicine 2002; 1: 74–78

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• “I think I have said enough to show how we have progressed and how each one of us is only a link in a chain that began long before us and will continue long after we have gone. Therefore, we must honor our predecessors and delight in those who shall follow.”

• “Quality is very simple. It is love – love of knowledge, love of man, and love o God.”

Avedis DonabedianSpanish Journal of Health Care and Quality, 1999

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Basic Tools of Quality

1. Cause and effect diagram

2. Check sheet

3. Control chart

4. Flow chart

5. Histogram

6. Pareto chart

7. Scatter diagram

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1 - Cause and effect diagram

• A Cause-and-Effect Diagram is useful in examining the factors that have contributed to the problem. To develop the Cause-and-Effect Diagram, we have to go through four steps, namely: – identify the problem's characteristics – brainstorm the reasons why the problem is occurring using a

Causal Table (also known as the Why-Because Technique) – group the causes by relationship using an Affinity Technique – create a Cause-and-Effect Diagram

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S1: Identify the problem's characteristics

Question Answer

1. What is this problem about?

Delay in attending to users.

2. Who is affected by this problem?

One-fourth (25%) of patients wait more than 90 minutes for care.

3. When does this problem occur?

Waiting time increases beginning midmorning on Mondays and Fridays.

4. Where does it occur? In the health center, mainly at the registration

desk, in the doctor's waiting room, and in the laboratory.

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Step 2: Brainstorm

• Next, the team participates in brainstorming sessions to analyze the causes of the waiting-time problem.

• After the team is finished with brainstorming, we have a list of possible causes for the problem.

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Immediate Cause Root Cause

Staff arrives late to work

• staff member has a second job• staff must complete domestic chores before

coming to work • staff experiences unexpected delay in getting to

work

Too much paperwork

• disorganization of the files • complicated storage methods • complicated procedures

Lack of user cooperation

• users don't respect turns • users don't bring ID cards • users don't keep appointments

Limited space • insufficient capacity for number of users

Procedures take too long

• lack of automation of procedures • outdated methods

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Step 3: Affinity Technique

• In preparation for describing the causes graphically, the team decides to group them by relationships, or affinities, into policy and user issues.

• Working with a group of between five and eight participants, we ask each participant to write down, individually, on four or five cards, their ideas about the common factors of the causes.

• After 10 minutes, the cards are put on the wall and the ideas reordered in groups. Each participant moves any cards to group them by affinity, until all the participants are in general agreement with the grouping of ideas.

• In our example, the causes may be grouped under the following headings:– policy – personnel – user – methods/procedures

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Step 4: Create the Cause-and-Effect Diagram

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2 - Pareto Analysis

• After analyzing the causes of long waiting times, we need to choose the most important causes to solve. One way to do this is by using a Pareto Analysis

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Step 1: Frequency Analysis

• The first step of the Pareto Analysis is to gather data on the frequency of the causes.

• We can continue on the above example of waiting times. Let us interview a sample of 50 users and 20 staff members of the health center to determine which of the possible causes happen most frequently in the health center.

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Possible Causes of Long Wait Time Percent of Total

Policies require excess information on users 1

Policies require complicated procedures 1

Too much paperwork 2

Not enough funding 2

Inadequate schedules 13

Inadequate policies 2

Clinic personnel have too many chores at home 2

Clinic personnel have other jobs 2

Clinic personnel lack punctuality 6

Clinic personnel have insufficient training 2

Clinic personnel aren't motivated 1

Clinic personnel are careless 1

Clinic personnel don't follow the schedule 16

Users forget ID cards 1

Users don't keep appointments 2

Users are uncooperative 1

Delay in handing over lab results to doctors 14

Outdated methods 12

Lack of automation 9

Procedures take too long 11

Here are the results of the survey, in a table:

Clinic personnel don't follow the schedule

Delay in handing over lab results to doctors

Inadequate schedules

Outdated methods

Procedures take too long

65%

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• The Pareto Principle states that a problem can be solved by focusing on solving the most frequently occurring causes.

• Usually, there are four to six causes that lead to 80% of the problems.

• These are called the "vital few" causes.

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• To identify the "vital few" causes, we rank the causes based on the frequencies we found in the survey, we have to calculate the cumulative percentage (each percentage added to the one before it) so we can build a pareto graph.

• We construct a chart with the cause, percentage, and cumulative percentage:

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Cause % Cum. %

Clinic personnel don't follow the schedule 16% 16%

Delay in handing over lab results to doctors 14% 30%

Inadequate schedules 13% 43%

Outdated methods 12% 55%

Procedures take too long 11% 66%

Lack of automation 9% 75%

Clinic personnel lack punctuality 6% 81%

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Step 3: Pareto Graph

• Now we are ready to draw the pareto graph. We draw a horizontal axis (x) that represents the different causes, ordered from the most to least frequent. Next, we draw a vertical axis (y) with percentages from 0 to 100%.

• Now, we construct a bar graph based on the percentage of each cause. We construct a line graph of the cumulative percent.

• Finally, we draw a line from 80% on the y-axis to the line graph, and then drop the line down to the x-axis. This line separates the important causes from the trivial ones.

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3 - Check Sheet

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4 - Control chart (Shewhart chart)

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5 - Flow chart• A flowchart is a schematic representation of

an algorithm or a process

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6 - Histogram

• A histogram is a graphical display of tabulated frequencies. It shows what proportion of cases fall into each of several categories.

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Histogram of age

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7 - Scatter Diagram

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Summary• What is quality?

• Describe the quality cycle

• How did Donabedian define Structure, Process, and Outcome?

• What is ISO?

• What are quality circles?