TATA KELOLA KLINIS (CLINICAL GOVERNANCE)

KULIAH 4:
QUALITY QUALITY SYSTEM QUALITY STRATEGY
Jakarta, 28 September 2012 Jam 13.00 14.40 WIB

Dody Firmanda

What is Quality?
Quality of care must be defined in the light of the
providers technical expectations. standards and patients

While no single definition of health service quality applies in all situations, the following definitions are helpful guides:
Patients Quality Expectations.

Professional Standards

Donabedian:

What is Quality?

The quality of technical care consists in the application of medical science and technology in a way that maximizes its benefits to health without correspondingly increasing its risks.
The degree of quality is, therefore, the extent to which the care provided is expected to achieve the most favorable balance of risks and benefits.

BENEFITS

RISKS

Odds NNT 95% CI Ratio NNH

Donabedian A. Explorations in Quality Assessment and Monitoring, Ann Arbor, MI:Health Administration Press, 1980, 5-6.

What is Quality?
Roemer MI, Montoya-Aguilar C:
.proper performance (according to standards) of interventions that are known to be safe, that are affordable to the society in question, and that have the ability to produce an impact on mortality, morbidity, disability, and malnutrition.

P(erformance) = M(otivation)XC(ompetency)XB(arriers)
SAFETY = 1 /RISKS Insured vs Uninsured Prevalence and Burden of Disease(s)
Roemer MI, Montoya-Aguilar C. Quality Assessment and Assurance in Primary Health Care,. WHO Offset Publication No., 105, World Health Organization, Geneva, Switzerland, 1988.

The most comprehensive and perhaps the simplest definition of quality is that used by advocates of total quality management: Doing the right thing right, right away..

LETS TAKE A MINUTE BREAK

PRIOR TO DISCUSS THE PREVIOUS FOUR SLIDES WITH THE IMPLEMENTATION OF DAY TO DAY EXAMPLE(S)

Wants Demands Needs

PNPK PPK CP
Health Needs Assessment

RINGKASAN KULIAH 1: INTRODUKSI 7 SEPTEMBER 2012

Healthcare Systems: 1. Policy 2. Provision (Provider) 3. Financing (Purchaser)

1. Donabedian 2. Maxwell 3. Don-Max

1. Efficient 2. Effective 3. Benefits (Value)

DALY QALY
Value = Quality / Cost

QUALITY SYSTEM

TOTAL QUALITY MANAGEMENT (TQM) 1. Understanding the hospital business 2. Understanding the customers 3. Continuous Quality Improvement 4. Quality (Management/Service) Systems 5. Quality Tools

3
QUALITY ASSURANCE (QA) 1. Setting the standards 2. Conform those standards 3. Continuous Quality Improvement

QUALITY CONTROL (QC) Seven Quality Tools

1 INSPECTION

Newsweek edisi 7 Desember 2009 hal. 42 - 45

Total Quality

Continuous Quality Improvement (CQI)

Quality Assurance

Kuncinya: LEADERSHIP

TOTAL QUALITY MANAGEMENT (TQM) 1. Understanding the hospital business 2. Understanding the customers 3. Continuous Quality Improvement 4. Quality (Management/Service) Systems 5. Quality Tools

External: o Patients o Stakehoders o Suppliers o Students Internal: Staff

1. Pelayanan 2. Pendidikan 3. Penelitian

TOTAL QUALITY MANAGEMENT (TQM) 1. Understanding the hospital business 2. Understanding the customers 3. Continuous Quality Improvement 4. 4. Quality (Management/Service) Systems 5. Quality Tools

Dalam Bentuk Dokumen: 1. Quality Policy (Kebijakan) 2. Quality Manual (Pedoman) 3. Work Instructions (SOP)
1 2 3

QUALITY ASSURANCE (QA) 1. Setting the standards 2. Conform those standards 3. Continuous Quality Improvement

Cara Maxwell

Cara Donabedian

QUALITY ASSURANCE (QA) 1. Setting the standards 2. Conform those standards 3. Continuous Quality Improvement

STANDARD

PARAMETER Kriteria

INDIKATOR

Quality System is organizational:

structure process and resources
needed to implement quality management

Quality Management is all activities of the overall management function that determine the quality policy, objectives and responsibilities and implement them by means such as quality planning, quality control, quality assurance and quality improvement within quality system

Quality Objectives

Quality Policy

Quality System

Products and Services Markets

Quality System Cycle

Quality Control Sequence

Requirement Standards Check
N

Plan

Do

Conforms

Products Services

Corrective Action

Remedial Action

P-D-C-A

Means + 2SE Quality Control

Performance

Means - 2SE
Means + 2SE

Quality Improvement

Means - 2SE 2012 2013

Time

Seven Basic Quality Tools

To be WATCH-OUT

Universal Coverage ComparativeP4P Effectiveness (Payment for Performance)

Quality Strategy Assessment Tool

Quality Strategy Assessment Tool

The 7-pages of material are copy righted for internal use and purpose only, not to be distributed

Quality Strategy Assessment Tool Dody Firmanda

Developing a successful quality strategy, can be used to: 1. Increase the awareness of whoever completes the questionnaire about the current starting point and context for quality improvement and about the institutions and processes which need to be developed. 2. Gather information, by asking different parties to complete and return the questionnaire and analyzing the responses to form a picture of the current situation with respect to factors important for quality and ideas about how to move forward. The tool is useful when used as preparation for meetings to discuss strategy development so as to help ensure a sufficiently wide range of relevant issues and approaches are discussed. The tool consists of 2 parts: 1. General features of the hospital health system relevant to choosing a strategy approach 2. Checklist for the five hospital strategies on quality and safety Part 1: General features of the hospital health system relevant to choosing a strategy approach 1. 2. 3. 4. 5. 6. 7. Type of system Funding Level of development of management and systems Quality awareness, attitudes and culture Current changes Research capacity and use Process for developing the strategy

Part 2: Checklist for the five Hospital strategies on quality and safety 1. 2. Hospital Quality and safety strategies aimed at health care professionals Hospital quality and safety strategies aimed at health care organizations

3. 4. 5.

Hospital quality and safety strategies aimed at medical products and technologies Hospital quality and safety strategies aimed at patients Hospital quality and safety strategies aimed at financiers

Part 1: General features of the hospital health system relevant to choosing a strategy approach 1. Type of system a. What percentage of primary and hospital healthcare is public or private in i. Financing ii. Provision. b. Is there high or low competition for patients and in which sectors? c. Are there alternative primary or hospital services for most patients in: i. rural, ii. urban areas? d. Do providers loose money if they attract and treat fewer patients? 2. Funding a. For the next five years, how much extra or fewer resources will be available to the health system? b. Where could funds to invest in quality improvement come from? (new or reallocated finance) 3. Level of development of management and systems a. What is the general level of management skills and management systems? b. Is there a culture of supervision and accountability or of high independence for professionals? 4. Quality awareness, attitudes and culture

a. How much are the public aware of and concerned about the safety and quality of services? b. How much time do providers spend, or would spend working on quality improvement? c. What is the degree of knowledge and concern about safety and quality among top Hospital leaders who influence what happens in the health system? d. Are there many different terms used in discussion about quality impeding on the consistency of communication? e. Are any future action to improve quality looked at with scepticism, and if so which and why? 5. Current changes a. What are the key changes which providers need to spend time on and adjust to over the next five years? b. How could quality improvement contribute to current reforms and other changes? 6. Research capacity and use a. Is there capability for quality and safety research and support to policy-makers and providers in their quality improvement? b. How much is research and evidence valued and used in decision making in health care? c. Are there other countries with similar health systems which we could learn from which are further along the quality journey, or with whom we could form a partnership to share experience and resources? 7. Process for developing the strategy a. Are the key stakeholders that will be affected by and are needed to contribute to the strategy sufficiently involved? b. Do the stakeholders know enough about the problems and different solutions and approaches which could be used in the strategy? 3

c. Is there a plan for steps, times and responsibilities for formulating, implementing and reviewing the strategy?

Part 2: Checklist for the five hospital strategies on quality and safety Please provide for each question below a yes or no answer. If yes, please expand on the nature and scope of the arrangements in place in your hospital 1. Hospital Quality professionals and safety strategies aimed at health care

a. Do you have legislation and regulation for different professions (physicians, nurses, paramedical professions) practicing in health care in your hospital and their required training? b. Do you have legislation and regulation in place on the revalidation of professionals practicing in health care in your hospital to assure that they have the necessary up-to-date competences? c. Do you have legislation and regulation in place in your hospital to assure professional norms and standards? d. Do you have legislation and regulation in place in your hospital to signal and deal with misconduct amongst professionals? e. Does your hospital have registries in place that monitor the number of trained and practicing professionals? f. Does your hospital have mechanisms in place to monitor the performance of professionals? g. Does your hospital have programs in place for peer-review and Continuous Medical Education (CME)? h. Does your hospital have programs for the development of (Hospital) practice guidelines?

i. Does your hospital have policies in place to ensure working conditions that facilitate professional learning for professionals? j. Does your hospital have Hospital policies for medical workforce planning in health care (Health Manpower Planning and Management) in place? k. Does your hospital have policies in place through which the necessary competences for the various professions are described systematically? l. Does your hospital have policies in place on task substitution between professions and on the introduction of new professions? 2. Hospital quality organizations a. b. and safety strategies aimed at health care

Do you have legislation and regulation on the various types of health care organizations (licensing)? Do you have legislation and regulation on specific services that pose a risk to patients (i.e. radiology, nuclear medicine, laboratory, human tissues, disposal of hospital waste, fire regulations etc) and could you provide a list of the various domains covered? Does your hospital use performance indicators on the quality of hospital care? Does your hospital have a policy to improve the quality of health care data in general and the medical record in particular? Does your hospital use accreditation/certification programs and to which type of services do they apply? Does your hospital have Hospital support programs for quality improvement and safety in health services? Does your hospital use accreditation/certification programs for integrated delivery systems (i.e. focusing on the cooperation between various types of services and continuity of care)? 5

c. d.

e. f. g.

h.

Does your hospital have policies that promote the introduction of innovative organizational formats through which services are delivered?

3. Hospital quality and safety strategies aimed at medical products and technologies a. Does your hospital have legislation and regulation on the entrance to the health care market of new medical products and technologies? Does your hospital have legislation, monitoring and regulation in place to signal and act towards unsafe situations with respect to medical products and technologies? Does your hospital have specific technology assessment programs in place that are used for decision making on the appropriateness of medical products and technologies, including reimbursement through collective financing arrangements? Does your hospital have a Hospital policy in place to promote innovation towards medical products and technologies that address the Hospital needs?

b.

c.

d.

4. Hospital quality and safety strategies aimed at patients a. b. Does your hospital have legislation and regulation on patient rights? Does your hospital have legislation and regulation on the participation of patients/consumers/community in the design and evaluation of health services? Does your hospital have mechanisms systematically monitor patient experiences? in place to

c. d.

Does your hospital have measurement mechanisms in place to publish public performance information that can be used by patients to judge and select providers? Does your hospital have Hospital programs in place for health promotion? 6

e.

5. Hospital quality and safety strategies aimed at financiers a. Does your hospital have legislation and regulation in place that stipulate financiers (purchasers) of health care to value quality and safety? Does your hospital have measurement mechanisms in place that allow financiers to assess the performance of health care providers and to include quality and safety notions in their purchasing role? Does your hospital have specific (financial) incentives in its health care system aiming at quality and safety? Does your hospital produce regularly a hospital report on the performance of the health care system as a whole with respect to quality and safety?

b.

c. d.

Please note that all questions posed above are rather generic. This is done deliberately to limit the number of questions to the major elements of hospital quality and safety strategies. This way the person using the check-list will keep the overview of the main elements of Hospital strategies without getting lost in details. On each of the topics rose above (like accreditation, guidelines, workforce planning, patient rights, etc).

The 7-pages of material are copy righted for internal use and purpose only, not to be distributed.