Lecture 6. Defining the quality of health-care services Ass. Prof. PhD . Daina Lucia

Managementul calității

Daina Lucia

Lecture 6. Defining the quality of health-care services

Ass. Prof. PhD. Daina Lucia


Daina Lucia

DEFINING QUALITY

All characteristics of an entity, which confer it the capacity to satisfy the known and the potential needs of users.

The ISO Standard 8402/1995

To do something correctly, at the right time.Deming, 1979

.. The quality of medical care relates to the application of medical science and technology, so that the benefits of care increase, without increasing risks as well.

Donabedian, 1930


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DEFINING QUALITY

Making the appropriate interventions, which are known as being safe, may be reimbursed by the respective society and may have an impact upon mortality, morbidity, invalidity and malnutrition.

WHO, 1988

Offering affordable, reliable and optimal professional services, while always taking into account the available resources and aiming to obtain users’ solidarity and satisfaction.

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Why priorities for quality?

• A health system that is still unsafe

• Important variations in terms of performance, practice and results

• Inefficient or barely efficient medical technologies and services

• Unaccepetable losses

• Dissatisfaction of clients/patients

• Unequal access to health services

• Longer waiting time

• Higher costs for society

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Who is interested?

• The supplier• The patient• The third-party payer• The Ministry of Public Health• ?

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The Dimension of Quality

• Professional quality

• Quality from the point of view of the customer (patient satisfaction)

• Total quality management

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Patients’ rights

• Are related to human rights

• Express the demands, related to the quality of medical care, of each individual

• Technical + interpersonal quality

• The patient becomes an active actor within the health-care system

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Total Quality Management

• The quality of services + the quality of the system

• Involves general participation with the view of planning and implementing a process of continuous quality improvement

• 90% of the problems are process-related

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The TQM Principles

• Focus on the customer,

• The constant improvement of quality,

• Team-work.

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Definitions of quality

• “The quality of the health-care system represents the level of attaining the intrinsic aims of the health-care system, in order to improve health and the capacity to respond to the general expectations of the population.”

W.H.O.

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Definitions of quality

• “The quality of health-care services refers to those services that are meant to maximize the patients’ well-being, taking into account the balance between expected profits and loses, which appear during all the stages of the health-care process.”

Donabedian

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THE CLASSIFICATION OF NEEDS

• Expressed needs, the ones that reflect the customers’ points of view and are expressed by them in their particular language;

• Real needs, which motivate customers’ behavior; they might not coincide with the expressed needs;

• Perceived needs, based on differences in perception between customers and suppliers, as regards the notions of product and quality;

• Cultural needs, namely the need for self-esteem, respect for the others, preserving certain customs, traditions, practices, which are specific to a particular society;

• Needs generated by a different way of using the product than the use specified by the producer.

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QUALITY CONTROL

Quality control is the managerial method through which:

• the real result is measured (the product obtained);

• it is compared with the established objectives (standards);

• activities for the remedy of differences.

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CRITERIA A UNIT OF MEASURE MUST MEET

• Be easy to understand;

• Provide an accepted basis for making decisions;

• Have a large applicability;

• Lead to some uniform interpretation;

• Be acceptable form the financial point of view;

• Be compatible with the existing detectors.

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THE QUALITY AUDIT APPROVES IF:

• Quality-related activities and results are in accordance with the pre-established standards and provisions;

• The provisions are efficiently implemented and able to meet quality-related objectives;

• The completion of task is in accordance with the procedure;

• The quality of products ensures the satisfaction of customers;

• The quality of products is competitive on the market;

• The costs associated with inappropriate quality are reduced;

• The performance of the company is optimized.

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STAGES IN THE IMPROVEMENT OF QUALITY

• The creation of the infrastructure that is necessary for the constant improvement of quality;

• The elaboration of projects for improvement, after identifying what really needs improvement;

• Setting up a team with responsibilities for each project;

• Providing human resources, which are trained and motivated for diagnosing causes, find remedies and ensure means of control, in order to maintain the progress obtained.

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THE QUALITY CIRCLES - STAGES • Identifying the product;

• Describing symptoms;

• Elaborating theories after gathering and analyzing data;

• Identifying the cause;

• Suggesting remedies;

• Putting into practice remedies;

• Testing the remedy;

• Determining the control system.

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The dimensions of quality

• professional competence• accessibility• effectiveness• efficiency • interpersonal relations• continuity• safety• physical infrastructure and comfort• choice

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The instruments of quality

• A coherent set of practical devices used with the view of improving either performance or a particular service, or with the aim of understanding a complex situation, the identification of causes and making of decisions

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Brainstorming

• Technique that uses the power of a group’s collective thinking, in order to generate ideas to which no single member of the group would have thought of by himself/herself.

• Is efficient especially in small-group activities• The “why-because” technique can be used• It is used for:-identifying problems-analyzing causes-emphasizing possible solutions• Helps to avoid conflicts generated by the divergence of ideas

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Histogram• Simple graphic representation of a continuous variable distribution.

• Allows viewing the recurrence of these values at different categories. The abscissa of the graph indicates the classes of values, while the ordinate shows the frequency of these values.

• It is one of the 7 basic instruments of quality

• It is used for the purposes of a quantitative study on a continuous process

• It is used for representing graphically the distribution of a group of data or measures. The variables must be continuous.

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The Paretto Diagram• Is a histogram that classifies, in a descending order, the causes of a certain problem, with

the purpose of indicating the main causes of that particular problem.

• Starts from Paretto’s empiric principle, according to which about 20% of the causes explain 80% of the problems.

• Represents graphically the relative importance of different causes of a particular problem

• Requires the existence of previously gathered data

• It is used for the classification and visualization of the group of potential causes associated with a certain problem.

• The basic condition is the interdependence of causes.

• It is used mainly prospectively.

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QQUQCQQQuis, quid, ubi, quibus auxilis, quomodo, quando

• Technique used for structuring the information about a subject starting from the following questions: “Who, what, where, when, how, why?” It is used for process investigation

• It is a systematic research of information related to a problem that should be known better

• The problem must be identified beforehand

• It uses the brainstorming technique.

• It presents arguments for each stage in the identification and implementation of solutions

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The Ishikawa cause-effect diagram

• Allows the quality team to identify, explore and graphically represent in detail all the possible causes related to the presence of a certain problem, in order to eventually identify the essential causes of the problem.

• The basic technique used in the construction of this diagram is the repetition of the following question: “Why does this phenomenon occur?”

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Problem

Methods Money

People Materials Environm

ent

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The tree diagram

• Is used to determine “how” a problem actually occurs, in order to find the most efficient means for attaining a goal. It allows the division of an element in sub-elements

• It is employed :- for highlighting key points concerning activities- for resuming the affinities diagram- for setting up quality policies- for highlighting roles and responsibilities- for re-organizing the cause-effect diagram.

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The expectations of the hospitalized patient

Rapid response

Efficient treatment

Auxiliary staff

Correct intervention

Correct observations

Correct and quick diagnosis

Pain relief

Correct and rapid treatment

Adequate drugs and equipments in the unit supplying services

trust

empathy

Providing correct information

care

alleviation

Finding and communicating with relatives

Quick hospitalization

Quick access to medical care

The tree diagram

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Instruments for the improvement of quality

• PDCA (planning, implementing, monitoring, making decisions)

• The quality circles (teams made up of 5-12 persons form the same medical unit, with similar activities)

• Benchmarking

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Benchmarking

Benchmarking is the process of identifying the best practices anywhere in the world, in order to obtain information that would help the organization adopt those measures that would improve its performance.

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The benchmarking methodology

• Selection of the process

• Selection of the team

• Study and documentation

• Determining the measuring method

• Identifying the organization that would help in the implementation of benchmarking

• Collaboration

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Standards - definitions

Standards represent the level of performance that is observable, achievable, measurable, approved by professionals and appropriate for the population they refer to.

(Joint Commission of Accreditation of Health Care Organization).

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The characteristics of a good standard

• be measurable and easy to monitor

• be expressed clearly

• be realistic and achievable in relation to the existing conditions

• represent an indicator of quality

• be in accordance with the values and the aims of the organization

• be practical and easy to put into practice and evaluate.

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Criteria

• Are descriptive elements of performance, behavior, circumstance or clinical state.

(Joint Commission of Accreditation of Health Care Organization)

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The characteristics of criteria

• be measurable and concrete;• be specific to the standard they illustrate;• produce a clear description of resources, behaviors,

required or wanted processes;• be easy to identify;• be relevant for the level of performance described;• be realistic and achievable;• be clear and easy to understand;• allow possible periodical modifications.

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The classification of criteria

• structure (related to buildings, environment, infrastructure, organization, support services, pharmacy, laboratory, technology, human resources, expertise, staff abilities, informational procedures);

• process (related to prevention, diagnosis and treatment procedures, documentation, doctor-patient relationship, etc);

• result (the percentage of nozocomial infections, mortality, fatality, relation to a certain procedure etc.).

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The ISO standards

Set of basic requirements for any system of Total Quality Management.

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The requirements of ISO standards

•The existence of a well-defined purpose•Well-defined responsibilities•Clear indications for services•Clearly defined processes for the

achievement of specifications•Means of monitoring processes and their

results•Periodic evaluation of processes and of their

efficiency•Systematic rectification of errors

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Requirements of ISO standards

• systematic investigation of errors, in order to prevent their recurrence

•means for ensuring the quality of medical care• the systematic maintenance of equipments• clear identification of staff formation and training

needs• the registration of all elements mentioned

above•periodic re-evaluation of all elements mentioned

above, by the organization management

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Quality measurement

• represents the systematic identification of the current level of quality in a medical unit or system, and deals with the quantification of the performance level, in accordance with the provisioned standards.

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Quality measurement

• the internal evaluation of quality,

• monitoring quality,

• the external evaluation of quality.

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Quality evaluation

• is a stage in the process of ensuring quality, which refers to the provision of feedback, the formation and motivation of the staff and the identification of solutions for the improvement of quality.

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Quality evaluation

• ”Quality evaluation represents an approach that allows each patient to benefit from diagnosis and therapeutic acts with the best results related to health, in accordance with the current state and development of the medical science, at the best prices for the best result and with the lowest iatrogen risk and for the best satisfaction of patients with regards to procedures, results and inter-human relations within the health-care system.”

O.M.S.

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Methods of quality evaluation• observation of services

• evaluation of patient satisfaction

• the anonymous patient technique

• re-evaluation of registered data

• testing the medical staff

• survey on the medical staff

• surveys answered by patients, after the hospitalization period.

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Quality indicators

“Variables that help one measure the degree of change”. World Health Organization

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Fundamental attributes

Source: WHO • validity – measure what needs to be measured;• relevance – for the community needs or for the problem identified;• possible to reproduce – measure each time what needs to be

measured;• realistic, applicable, reliable and easy to use in practice;• measurable and observable – in the form of frequencies,

percentages, average numbers;• be familiar to and accepted by the team whose performance is

being measured;• be used continuously in time for evaluation purposes.

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1. Access indicators

• hospitalizations possible to avoid• waiting time• physical barriers (distance, absence of doctor, absence

of specialist etc.) in relation to access to medical services

• financial barriers hindering access to medical services• financial barriers for the continuation of treatment

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2. Result indicators• percentage of patients with post-surgery infections

• percentage of relapse cases

• percentage of nosocomial infections

• percentage of survival after 5 years from the surgical intervention

• the incidence of a disease after vaccination

• the incidence of cases for a specific disease after screening

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3. Indicators of patient experience• percentage of patients that received contradictory information form different

suppliers

• percentage of patients who did not receive answers to their questions

• percentage of patients who did not get information about the treatment they were subject to

• percentage of patients who were not asked for agreement in relation to treatment procedures

• percentage of patients who did not benefit from psychological/emotional support

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4. Process indicators

• percentage of patients not satisfied in relation to treatment,

• percentage of patients who needed treatment modification,

• number of births by Caesarean operation, without indication

• percentage of patients immunized after a certain age

• incidence of fever cases after immunization

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The constant improvement of quality - principles

• Focus on patients’ (customers’) needs/expectations

• Focus on systems and processes

• Focus on the creation of a data-base system, that can be used in the process of decision-making

• Focus on participation and team-work

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ICC

• Identifying potential areas for improvement• Agreement over criteria for problem-selection• The selection of the problem

Documents

Lecture 6. Defining the quality of health-care services Ass. Prof. PhD . Daina Lucia