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House of Quality Analysis in Health Care

House of Quality Analysis in Health Care

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Background: Adopting a formal and reliable method for linking patient requirements with the relevant performance measures of a care process is a top priority for high quality clinical care.
Objective: To describe the concept and process employed in house of quality analysis, the heart of quality function deployment, by providing a step-by-step methodology and a case study from the maternity ward of Fayazbakhsh hospital in Iran.
Methodology: We considered the house of quality analysis as a process with both input and output data. Major input data were patient requirements that were converted to key performance measures and targets, as principle output data, by two matrices including a relationship matrix and a correlation matrix.
A case study: We illustrate the steps of translating the top 20 maternal requirements into six key performance measures throughout the house of quality analysis. Based on identified key performance measures, we also identified six necessary organizational functions to meet the 20 selected maternal requirements and increase maternal satisfaction.
Discussion: The house of quality analysis provides a unique and rigorous method to translate patient information into relevant process performance measures. This is a key step in clinical process improvement. However, it is time-consuming and complex to adopt. Decreasing the amount of input data can simplify the house of quality analysis.
Background: Adopting a formal and reliable method for linking patient requirements with the relevant performance measures of a care process is a top priority for high quality clinical care.
Objective: To describe the concept and process employed in house of quality analysis, the heart of quality function deployment, by providing a step-by-step methodology and a case study from the maternity ward of Fayazbakhsh hospital in Iran.
Methodology: We considered the house of quality analysis as a process with both input and output data. Major input data were patient requirements that were converted to key performance measures and targets, as principle output data, by two matrices including a relationship matrix and a correlation matrix.
A case study: We illustrate the steps of translating the top 20 maternal requirements into six key performance measures throughout the house of quality analysis. Based on identified key performance measures, we also identified six necessary organizational functions to meet the 20 selected maternal requirements and increase maternal satisfaction.
Discussion: The house of quality analysis provides a unique and rigorous method to translate patient information into relevant process performance measures. This is a key step in clinical process improvement. However, it is time-consuming and complex to adopt. Decreasing the amount of input data can simplify the house of quality analysis.

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Published by: spitraberg on Jan 13, 2009
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08/04/2013

 
 
- 1 -
House of Quality Analysis in Health Care
Siamak AghlmandDepartment of Health Management and Economics, School of Public Health, TehranUniversity of Medical Sciences, Iran,saghlmand@razi.tums.ac.ir&Rhonda SmallMother & Child Health Research, Faculty of Health Sciences, La Trobe University, Australia,r.small@latrobe.edu.au
Abstract
 Background:
 Adopting a formal and reliable method for linking patient requirementswith the relevant performance measures of a care process is a top priority for highquality clinical care.
Objective:
To describe the concept and process employed in house of quality analysis,the heart of quality function deployment, by providing a step-by-step methodology and acase study from the maternity ward of Fayazbakhsh hospital in Iran.
 Methodology:
We considered the house of quality analysis as a process with both input and output data. Major input data were patient requirements that were converted to key performance measures and targets, as principle output data, by two matrices including arelationship matrix and a correlation matrix.
 A case study:
We illustrate the steps of translating the top 20 maternal requirements intosix key performance measures throughout the house of quality analysis. Based onidentified key performance measures, we also identified six necessary organizational functions to meet the 20 selected maternal requirements and increase maternalsatisfaction.
 Discussion:
The house of quality analysis provides a unique and rigorous method totranslate patient information into relevant process performance measures. This is a keystep in clinical process improvement. However, it is time-consuming and complex toadopt. Decreasing the amount of input data can simplify the house of quality analysis.
  Keywords:
Quality, quality function deployment (QFD), house of quality (HoQ),maternity care, Iran
 
Introduction
In view of the fact that meeting or exceeding ‘customer’/patient needs and requirements is essential toimprove quality of care processes (Iacobucci
et al.
, 1995), patient satisfaction has gained widespreadrecognition as a measure of quality in many health care organizations since the late 1980s.Nevertheless, care providers have given less attention to converting patient data into a set of usefuldecision-making information for quality improvement strategies to occur. The process for translatingpatient information into organizational terms for the improvement of care has become one of the keychallenges in health care settings (Williams, 1994).Lack of action is partly attributable to entrenched attitudes, lack of interest, limited resources,restricted time, structural and cultural barriers, fear of negative experiences, and lack of experience inusing quality tools and techniques (Bamforth
et al.
, 2002 and Dodek 
et al.
, 2004).Quality function deployment (QFD) is a well-known product/service/process planning approach. Itensures that customer requirements are systematically taken into account throughout theproduct/service/process planning and design stages (Dodek 
et al.
, 2004 and Garon, 1992). QFD
 
 
- 2 -
emerged in Japan in the late 1960s and it was subsequently used by both manufacturing and serviceindustries worldwide, yet its concept is still new in the health care arena (Akao
et al.
, 2003).The house of quality (HoQ), as the heart of QFD, is a matrix that provides a conceptual map forprocess design and quality improvement. It is used as a construct for establishing priorities for processperformance measures to satisfy customer requirements (Büyüközkan
et al.
, 2004). Performancemeasures or quality attributes/characteristics specify what should be measured to predict customersatisfaction so that they are used to evaluate whether or not customer requirements are fulfilled(Madu, 2006). In summary, HoQ translates customer requirements into performance measures andtheir operational targets, in order to meet customer requirements and improve satisfaction with care(Terninko, 1997). Once customer requirements are combined with the process performance, theprobability of experiencing real improvement is significantly increased (Lloyd, 2004). The result of HoQ analysis can derive the best combination of performance measures along with their target levelsto design a process based on important customer requirements (Lin
et al.
, 2006).HoQ also studies the relationship between the various elements of a system. According to generalsystems theory, external and internal environments interact with each other. In addition, the internalparts of a system interact with each other, and the interest of any part may conflict with the interestsof other parts (Bertalanffy, 1950). HoQ quantitatively analyses the interaction between the outside of an organization (customer requirements) and the inside (performance measures). It also assesses thesynergies and conflicts among the internal parts of an organization (Shin
et al.
, 2000).The main objective of this paper is to convey the conceptual content and process of HoQ analysis andillustrate its application in a clinical area by providing a step-by-step methodology and a case studyfrom the maternity ward of Fayazbakhsh hospital, an Iranian Social Security affiliated hospital inTehran.
Methodology
HoQ is a process with both input and output data (Figure 1). The input data are:1.
 
Important customer requirements along with their weight2.
 
Important performance measures3.
 
Benchmarking data (benchmarks)The output data are:1.
 
The weight and correlation values of performance measures2.
 
Key performance measures (with high-weight and high-correlation)3.
 
Target level for each key performance measure (Chaplin
et al.
, 2000)Some primary activities should be performed before starting data collection. First, a cross-functionaland multidisciplinary team must be assembled based on the process to be studied. Team membershipmust include people who know the process best. Just-in-time training needs to be provided for theteam members. Topics for inclusion are the concepts and background of quality improvement,teamwork, HoQ, and the overview of statistical process control (SPC). The team members thenreview the process by creating a detailed flowchart (Brown
et al.
, 2005). Subsequently, the teamidentifies the most important customer segment of the process (e.g., patient, physician, nurse orinsurer). At this time, the team members can commence to gather the necessary input data of HoQprocess in the following order:
Important customer requirements along with their weight
This step is the most important but also the most difficult and time-consuming stage of HoQ analysisbecause all the following steps depend on this stage. This step is called the voice of customer (VoC)analysis. Here, our aim is not to explain VoC analysis in detail and we only highlight some basicmethodological issues.At the first stage, the team members interview a small sample of customers (15 to 20 people) and ask ‘why’ and ‘how’ they use the services. Customer requirements or demanded qualities (DQs) are thenextracted by re-framing customer responses as brief positive statements. Subsequently, the teamorganizes DQs on a tree diagram to rank them by ‘analytical hierarchy process (AHP)’ in which thedata are compared pairwise using a 1-9 scale (Terninko, 1997 and Chaplin
et al.
, 2000).
 
 
- 3 -
The most highly ranked DQs, a maximum of 20, are used to conduct a baseline survey with a largergroup of customers (representative sample) to assess: (1) their preferences tied to selected DQs, (2)their satisfaction level with given services in the study organization and its competitor(s), (3) theKano levels of requirements, including assumed (basic), expected (revealed), and unexpected(exciting) requirements.The results of the customer survey are then entered into the quality-planning table (QPT), in which theweight of DQs is determined. To this end, the team identifies three variables including, target,improvement ratio, and sales point by assessing the survey results. A target value for a DQ is foundby comparing customer preference, customer satisfaction, and the Kano’s level of the DQ, which isdetermined by a 1-5 scale. The improvement ratio is the ratio of the target value to the currentcustomer satisfaction with the target organization’s services. Finally, sales point representsorganizational ability to meet a DQ. The rating scales of 1, 1.2, and 1.5 are used to express no,medium, and strong ‘sales points’, respectively. The weight of a DQ is calculated by multiplying theDQ’s importance by improvement ratio, and sales point. The weight of DQs is also expressed as apercentage (DQs’ relative weight) (Chaplin
et al.
, 2000 and Duhovnik 
et al.
, 2006).Finally, selected DQs along with their relative weight are entered into HoQ matrix (Figure 1)
Important performance measures
The team uses brainstorming to generate performance measures for each selected DQ. Brainstormingshould include a review related to categories such as people, methods, equipments, materials, and theprocess environments. An affinity diagram and a fishbone diagram (a DQ as effect and relevantperformance measures as causes) can be used to organize the generated ideas into like categories.Identified performance measures are subsequently ranked for each DQ by a set of appropriate criteria(e.g. effectiveness, cost, feasibility) using a 1-5 scale. Lastly, a few highly ranked performancemeasures, as important performance measures, are selected for HoQ analysis (Figure 1), while at leastone important performance measure is kept for each of the selected DQs (Chaplin
et al.
, 2000 andBrown
et al.
, 2005).
Benchmarking data
The last input data of the HoQ matrix are benchmarking data (benchmarks). A benchmark is ameasure of the best practice or performance standard against which an organization’s performance iscompared. The first step in benchmarking is to identify a competitor organization(s). Then, anotherteam must be organized at the competitor organization. This team assesses ‘key performancemeasures’ on their own process (this will be more fully described later) (Lloyd, 2004).As shown in Figure 1, selected DQs along with their weights, important performance measures, andbenchmarks are entered into the HoQ matrix as the input data. The output data of the HoQ process areprovided by two matrices (Figure 1):
1.
 
Relationship matrix
 The relationship matrix, as the central part of HoQ analysis, evaluates the strength of linkagesbetween DQs and performance measures. Selected DQs and important performance measures areentered into the rows and columns of the matrix, respectively. The strength of relationships is assessedby an asymmetrical four-point scale, which uses zero, 1, 3, and 9 to represent no, weak, medium, andstrong relationships, respectively. Then, the absolute and relative weights of performance measuresare calculated as follows:The absolute weight of the j
th
performance measure equals the sum of the values obtained bymultiplying the relationship with the i
th
DQ by the corresponding relative weight of that DQ. Theabsolute weight is given by Equation (1):
=
×=
niiji
 R DP
 j
1
)(
(1)Where n represents the total number of DQs, P
 j
represents the absolute weight of the j
th
performancemeasure, D
i
represents the relative weight of the i
th
DQ, and R
ij
represents the relationship between thei
th
DQ and the j
th
performance measure (Lin
et al.
, 2006).

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