Leader s Using Quality Assurance principles in emergency planning

LeadeLeadersrsUsing Quality Assurance

principles in emergency planning

Task for this afternoonTask for this afternoon

Think about quality in disaster management Defining what quality is What does this mean for disaster programs? What are some principles in improving quality? How can these be used in disaster programs? Applying this at St David’s hospital

Defining QualityDefining Quality

What does “Quality” mean?

Defining QualityDefining Quality

The Degree of Excellence—the dictionary definitionExcellence implies--- It is made of good materials It is better than other similar things to which it is compared Meets expectations people have of it It does what is intended of it The results are worth the investment (value for money) To achieve excellence takes work

Doing the right thingDoing the right thing Quality is sometimes said to be

doing the right thing in the right way



Thing

Way

wrong right

wrong

right



Wrong thingWrong way

Thing

Way

wrong right

wrong

right




Right thingwrong way

Thing

Way

wrong right

wrong

right




Right thingwrong way

Wrong thingRight way

Right thingRight way

Thing

Way

wrong right

wrong

right

The right thing at the right The right thing at the right timetime

Quality is sometimes said to be doing the right thing at the right time



Thing

Time

wrong right

wrong

right



Wrong thingWrong time

Right thingwrong time

Wrong thingRight time

Right thingRight time

Thing

Time

wrong right

wrong

right



Wrong thingWrong time

Right thingwrong time

Wrong thingRight time

Right thingRight time

Thing

Time

wrong right

wrong

right

Right thing and right timeRight thing and right time

Both have a major importance for disaster managers Many problems with disaster management

Improving efficiency and Improving efficiency and effectivenesseffectiveness

Assessing the performance gap

What could be achieved



What could be achieved Our vision—where we could be




What is presently being

achieved

Our vision—where we could be

Where we are now





achieved

}The PerformanceGap





achieved

}The PerformanceGap

The challenge:Close this gap with accessible resources





achieved

}The PerformanceGap

We may have tochange the way we do things to

get here

If you continue to do things the same way as you always have, you will ___________________

___________________.

A famous person said…

Meeting expectationsMeeting expectations

Activities may Fall short of expectations Meet expectations Exceed expectations

What are expectations? Whose expectations?

Disaster managers Politicians Ordinary citizens

Changing expectations—how to do?

Defining Quality by Defining Quality by standardsstandards

Defining Quality Many definitions which often overlap Quality is measured by standards and performance

Q = PS

Quality is measurable against standards But who sets the standards?

Where do we get the Where do we get the standards?standards?

International standards PAHO FEMA

Country standards Organizational standards Standards change







Creating a vision for Creating a vision for excellenceexcellence

Where do you want to go? What do you want your organization to be What do you want its quality to be? How are you going to get there Make up you own standards

Or adapt others for your needs Be prepared to change these regularly

Thinking about qualityThinking about quality

Quality methods got started when inspection wasn’t doing it

Thinking about qualityThinking about quality

Quality methods got started when inspection wasn’t doing it

More inspectors stopped faulty products leaving the factory, but did not improve their quality

Looking for ‘root causes’Looking for ‘root causes’

Industry started looking for root causes of poor quality The cause turned out usually to be in the process of making

something If we want to make something better

we look at the individual steps needed to make it

Looking for ‘root causes’Looking for ‘root causes’

Industry started looking for root causes of poor quality The cause turned out usually to be in the process of making

something If we want to make something better

we look at the individual steps needed to make it not usually at changing the people

Causes of poor quality

Processes Processes 85%85%

People People 15%15%

Emphasis on quality has Emphasis on quality has brought changes in brought changes in management styles management styles From an inspection—small “span of control” structure



To a more ‘horizontal” team-based management structure


To a more ‘horizontal” team-based management structure

What has this meant for What has this meant for disaster management?disaster management?

We have a much more ‘decentralised’ structure More work is being done as teams

Less by committees These teams may cross various functions

Practice and drills are needed more than ever There is a greater sense of accountability to the “users” “Stakeholders” part of almost all activities now

Parts of Quality AssuranceParts of Quality Assurance

QualityAssurance

Parts of Quality AssuranceParts of Quality AssuranceQuality Design

Quality Improvement Quality Control

QualityAssurance



QualityAssurance

Trying to fix

existing activities



QualityAssurance

Trying to fix

existing activities

Inspecting for

compliance



QualityAssurance

Trying to fix

existing activities

Inspecting for

compliance

Building quality in from the

beginning

How can these new How can these new approaches affect disaster approaches affect disaster

mgmtmgmt Time to look again at each part of the disaster cycle Quality design

New plans and new systems (can we do it in a new and better way?)

Quality improvementChanging policies (fixing things, applying lessons learnt)

Quality controlWe assure quality by certifying standards are met

Phases in a disasterPhases in a disaster

The disaster cycle

preparedness

Disaster

response

rehabilitation

mitigation

Phases in a disasterPhases in a disaster

The disaster cycle

preparedness

Disaster

response

rehabilitation

mitigation

Quality Assurance methods can be

used at each point

Principles of Quality Principles of Quality AssuranceAssurance

Focus on needs of the users

Strengthen the process through which services are provided

Use of data to improve services

Teams to improve quality

Improving communication

Who are the users of our services? What does the user want and need for our service? How do we know this? Get control of quality close to the user

Establishing a dialogue between providers and users to meet needs of the user

A system has both internal users and external (ultimate) users.

Unless needs of internal users are meet, then the ultimate user is not likely to have needs satisfied

Focus on the needs of the Focus on the needs of the useruser

Who are the users of our services? What does the user want and need for

our service? How do we know this? Get control of quality close to the user



Provider User

ProviderUserProvider

UserProvider

User Provider

User






Provider User


UserProvider

User Provider

UserExternal or ultimate customer






Provider User


UserProvider

User Provider


Internal customers






Provider User


UserProvider

User Provider


Internal customers


Unless needs of internal users are meet, then the ultimate or external user is not likely to have needs satisfied


How does this apply to disasters? Who are the stakeholders in disaster management? Who are the internal customers?

What are their needs?What is being “provided” and “used”

Who are the external customersWhat are their needs?How do we know?

Can the external users judge quality?or is that the job of the disaster professional only?


This is the role of “Assurance” in “Quality Assurance” Basic standards are used to ensure quality The user is “assured” of the quality of services

Building a sense of trust

input output outcome impact1 2 3 4 5 6

process

Strengthen the process Strengthen the process through which services are through which services are providedprovided

Quality Assurance depends on a systems approach In order to have good outputs, outcomes and impact…

The inputs must be appropriate The process effective and efficient

This type of approach very suitable for disaster planning Standardization and error-proofing of the process Aim is to reduce variation

input output outcome impact1 2 3 4 5 6

process


Quality Assurance depends on a systems approach In order to have good outputs, outcomes and impact…

The inputs must be appropriate The process effective and efficient

Inspectorshere cannotimprove theprocess

input 1 2

process


If the inputs are inappropriate or substandard, then increasing the amount is not going to improve quality

input 1 2

process


Cloudy or unclear activities lead to poor or inconsistent results

3

input 1 2

process


Cloudy or unclear activities lead to poor or inconsistent results Uncertain steps lead to a breakdown in the process

3?

??

input 1 2 3 45 6

process


Parallel processes often have an uncertain outcome Even if both processes work, this adds uncertainty and

inefficiency Unnecessary steps reduce the efficiency

5 6 7

7 8output outcome impact

?

input output outcome impact1 3 4 6

process


Look for error prone steps Steps where things often fall apart Or need extra attention to make them work

2 5

process

input outputoutcome impact1

2

34

5

6


Circumstances often strain the process Process for emergencies must be robust Must be able to be easily adjustable for new circumstances

Data is the key to quality, as quality definition must be measurable Data is needed for all aspects of disaster management

Disaster programmes must have their own information system a base for quality improvement activities

What have we learnt from the last disaster? Does our disaster plan need updating? What is our state of preparedness? How is recovery progressing? Are mitigation measures being implemented?

Statistical and analytic tools for data use

Using data to improve Using data to improve qualityquality

All projects need to have clear objectives Data critical for monitoring progress Data central for the evaluation of the project outcomes “SMART” Objectives belong in every project

Data key to better project management Risk assessments (new computerized programs) Vulnerability assessments Careful analysis of previous events

Need for archiving data

Using data to improve Using data to improve qualityquality

Most quality improvement methods depend on teams Teams are usually more effective than the individual As management becomes more horizontal, bigger spans of

control have developed Less supervision possible Role of a supervisor changes to facilitator to assist teams in

problem solving In some things, particularly the quality control activities, teams

not used Self-directed work teams becoming more common

Use teams for better Use teams for better qualityquality

Teams may be— Functional: consisting of people working in a particular activity or

department These usually function easily—everyone is familiar with the

tasks Cross functional: these teams are formed to tackle problems

which cut across organizational boundaries Making these work is much harder since there are many new

faces, and ground to guard Teams are not committees


Well functioning teams need to have— People who work in the process People who control the process Leadership to keep the team moving

The team process may take time to get moving efficiently; this is normal though frustrating

Teams have ups and downs, also normal If teams are already part of management and work structures,

build on these existing teams for quality issues Don’t start new teams & create parallel structures


Teams have their ups and Teams have their ups and downsdowns

…and this is completely normal

Poor communication is at the bottom of much low quality Communication not the strong point of public health personnel Science seems to breed a certain arrogance about the need for

communication

“Let the numbers speak for themselves.”

But there is a lot of competition to be heard Disaster management, more than about anyone else needs good

communication

improving improving communicationcommunication

Several forms of weak communication Poor communication to the public

Public look to disaster offices for information Often this is not provided-relying on the police or others The absence of information is rumor Controlling rumor is

really hard


Results are that public is at risk What we know we don’t share Sometimes it is because we don’t know how to share We don’t know what people are thinking In some emergencies, the police or the army, take responsibility

for public information People forget about the disaster managers


The disaster The disaster management office management office had little to say after had little to say after this national disasterthis national disaster

Communication within the organization and between organizations

Disaster management by its nature involves many groups Keeping them together on the same page may be hard Staff are commonly unaware of organizational goals & activities Communication moves down well, but bottom-top communication

often poor Feedback is generally poorly managed Managers often don’t listen, and workers don’t tell unpleasantries A “listening organization” has the greatest advantage


Organizational Organizational communicationcommunication

ConclusionConclusion There are many definitions of quality

But whatever definition used—it must be measurable There are no systems in which quality cannot be improved Quality assurance has three components

Quality Design, Quality Improvement, Quality Control Certain basic principles apply to improving quality

Meeting the needs of the user Improving systems and processes Use of data Use of teams Improving communications

Exercise - St David’s Exercise - St David’s HospitalHospital

500 bed hospital with full specialty and diagnostic facilities The building itself is a one-storey masonry structure, constructed

in 1965 Built as a series of ward building connected by covered walkways In the 2002 tropical storm there was severe damage to the roof

structure for several wards. Several wards flooded because of poor drainage. With electric lines down, and no adequate standby power the

theatres, several wards and the laboratory were without power.

St David’s HospitalSt David’s Hospital

Admin

Polyclinic

Casualtyward

TheatreCSS

LaboratoryRadiology

Paedsward

Femalesurgical

ward

MaleSurgical

ward

Female Medical

ward

Male Medical

ward

Maternityward

Other services, kitchen, chronic diseases

Morgue

workshop

Mainentrance

ambulanceentrance


A major problem during and after the storm was poor communications There were no radio connections with the police and fire

brigades. Neither was their radio commutations with St John’s

Ambulance or its vehicles incoming with injured. Within the hospital it was difficult to communicate with wards

until the electricity was restored


The major problems was the lack of a practiced disaster plan. This was particularly evident in the causality ward and the

theatre The hospital administration were unsure of their role

Problems in the hospitals of St Paul, and particularly St Jude were similar. These hospitals were newer, and did not suffer the same physical damage as St David’s.

The absence of practiced disaster plans was the same as in St David’s

The lack of clear emergency roles meant the response did not go smoothly.

ExerciseExercise

At St David’s Hospital there is a need to improve the hospital disaster plan

Your team has to plan the process This is what you need to do—

Define what quality means in this plan What are the needs of the users of this plan? Who are they? How will you use the systems approach in making the plan? What data will you need? What teams will you constitute and how will you use them? What is the role of communications in the plan?

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Leader s Using Quality Assurance principles in emergency planning