Step by Step

of
(QAP)
Dr Suhazeli Abdullah
Objectives
Understand the concept
Run the projects
Facilitates others
Recommend the outcome of the project
Share with others
What is QAP
MOH’s vision……
with emphasis on
quality
innovation
health promotion and
respect for human dignity,

which promotes
individual responsibility and
community participation

towards an enhanced quality of life

Quality activities of MOH
Registration
Doctors & Paramedicals

Licensing
Hospital, Pharmacy

Accreditation
Credentialling

Code of conduct, code of ethics

Quality activities of MOH

Morbidity & mortality reviews

Perinatal MR, MMR, POMR

Committee meetings
Infection control, OT, Drug

Audits
Medical, Nursing
Quality activities of MOH
Reviews
Utilisation, Peer, CPC
Investigations
Sentinel events, public complaints

Guidelines
 CPG, SOP, checklist

ISO, QCC, TQM, PKPA, HTA

 QA APPROACHES
National Indicator Approach (NIA)

Hospital Specific Approach (HSA)

District Specific Approach (DSA)

 NIA Indicators
Indicator Std.
1. AMI CFR <34.7%
2. AGE CFR in children <0.6%
3. Head injury CFR <7%
4. ARI CFR <3.1%
5. Lab specimen rejection rate <0.86%
6. Proportion of urgent lab test <19.6%
7. Proportions of Ops undergoing x-rays <8%
8. Proportions of Ips undergoing x-rays <70%
9. Proportions of x-ray films rejected <10%
Communicable Disease
TB Sputum Conversion Rate 85%

Average Notification Time Index for Typhoid

<14 days

Morbidity Index for Typhoid <2

Vector Borne Disease
Dengue Notification Time Index
80% within 24 hours

Dengue Outbreak Control Index

100% controlled within 14 days of 2nd case

Dengue Law Enforcement Index

80% positive premise taken legal action

Malaria Death No death

Family Health
Incidence Rate of Eclampsia
8 per 10,000 deliveries

Incidence Rate of Severe Neonatal Jaundice

< 100 cases per 10,000 live births

Incidence Rate of Tetanus Neonatorum

0 case per 10,000 live births
 ABNA
Ideal With unlimited resource

}
100 ideal level of care
Optimum
Optimal Achievable Level
75
ABNA targeted level within
means
50
Actual ABNA
difference between OA &
25
present level
QA aims at narrowing or
0 eliminating the gap
 Problem
identification

Problem
Prioritisation

Re-evaluation of the
Problem
Quality Problem
Assurance Analysis

Cycle
Implementation of
Remedial Actions Quality
Assurance
Study

Identification of
Remedial Actions
Problem Identification
Kenal pasti Masalah

Kapasit
Kapasit
Berla ●
● Aduan
Aduan
●
● Keewangan
Keewangan Model
Model
Dilihat
ii ●
● Tenaga
Tenaga
●
● Sumber
Sumber terbaik
terbaik
ku
●
●
Dilihat ●
Infrastruktur Idaman
Idaman
Optima
Optima
●
Infrastruktur
 MASALAH

Other Kualiti

Practical daily life Scientific Interest

Do Nothing Buat Sesuatu

ABNA Prioritise
Magnitude

Besar kecil

Lain cara KAJIAN QA

Feasible? (people) Study

Possible? (methods) Design
Cost effective? Module

GO Abandon
Sumber-sumber ‘masalah’

Isu dari Mesy&JKpandangan
Cadangan lain daripada anggota
- Kawalan infeksi
- JK Perolehan Ubat
Masalah / isu yang dibangkitkan semasa mesyuarat
- JT Dewan Bedah

Rekod
 Aduan pesakit /
Perubatan komuniti
Laporan Tahunan
Kesimpulan daripada Mesy Morbiditi & Mortaliti
Sesi ‘Brainstorming’

Maklumbalas NIA
Masalah
Kelewatan mendapatkan bekalan “stationery” dari
pejabat.
Penyimpanan rekod latihan dalaman yang tidak
sistematik
Ambulan kerap rosak.
Poor control of visitors outside visiting hours
Kes NNJ meningkat.
Kes Anemia dikalangan ibu hamil meningkat
Kes Denggi meningkat di PLKN
Saintifik???
Poor control of Hypertension among elderly man
treated with labetolol.

High incidence of Diabetic Retinopathy: Insulin verses

Metformin

Oral Hypoglycemia agent lead to Poor control of

gestational diabetes
PROBLEM PRIORITISATION
Pengutamaan masalah
 Problem
identification

Problem
Prioritization
Re-evaluation of
the Problem
Quality Problem
Analysis
Assurance
Cycle
Implementation of
Remedial Actions Quality
Assurance
Study

Identification of
Remedial
Actions
Basis of Ranking - SMART criteria
SERIOUSNESS / SPECIFIC
Nyawa terancam?
Menyebabkan kecacatan ?
Kesakitan?

Causing distress to
patient?

Impak atas pesakit,

komuniti & imej hospital /
pejabat kesihatan
Basis of Ranking - SMART criteria
SERIOUSNESS /
SPECIFIC
Impak atas kos &
sumber (resources)
Kekerapan kejadian
walaupun tidak begitu
serious
Berapa jurang ABNA -
worth a study?
Basis of Ranking - SMART criteria
Measurable (Boleh diukur)

Boleh kumpul data

Boleh buat perbandingan sebelum & selepas
Indikator boleh dikenalpasti
Basis of Ranking - SMART criteria
Appropriateness (Kesesuaian)

Relevant (relates to your core business)

The proposed opportunity for improvement has direct
impact
Berkaitan penjagaan pesakit?
Basis of Ranking - SMART criteria
Remediable (Boleh dibaikpulih)

Ada cara penyelesaian

Terlalu mudah atau Terlalu sukar
Sosial, Politik, Ugama, Etika
Basis of Ranking - SMART criteria

Timeliness (Ketetapan dengan masa)

Improvement diperlukan sekarang dan boleh
diselesaikan dengan kadar masa yang berpatutan.
No current operational, financial or political issues
which might affect the succes.
PRIORITIZATION
Several methods

Nominal Group Technique

Brain Storming
Multivoting
Concensus
Brainstorming
Structured (SWAT Analysis)

Unstructured
Multivoting
Use to short-listed the problem that has been
identified.
Choose the relevant problems
Combine or group the items
Choose the most important problems.
Problem - Prioritising Technique
 Nominal group technique
THE GROUP
Common interest ----> quality improvement

NUMBER : 7 - 12
< 7 : Inadequate expertise
>12 : Too many
• Unsatisfactory group dynamics
• Few loud-mouth, many nodders & sleepers
Problem-prioritising Technique
 Nominal group technique
THE CHAIRMAN
Senior person with interest & authority
Can solve the problem

SOURCE OF INFORMATION
Surat khabar, Hearsay, Majalah, Pesakit, Pengalaman
ahli kumpulan
Nominal Group Technique
1. Chairman requests cooperation of EVERYBODY

2. Focus on Problem Identification & NOT problem

solving

3. Silent generation of ideas

Nominal Group Technique
4. List down all problems in exact words

5. Serial discussion:

Clarify, Elaborate, Defend, Dispute

6. Problems maybe :

Reworded, Grouped, Deleted or Modified
Nominal Group Technique
7. Rank the problem - Vote (1 - 5)
8. Announce result
9. Discussion of vote, Reprioritise
10. Revote

Final choice may need approval from people with

financial & administrative authority
Eg.of problems: Rephrasing into QA problem
format
Kadar
Severesevere
Neonatal
NNJJaundice
yang tinggi
Tinggi

Purata
Lewat notifikasi
masa notifikasi
kes tifoid
tifoid melebihi 14 hari

Masa
Lambat
menunggu
dapat rawatan
di UPL
dilama
UPL
Senarai Masalah
Peratusan kelulusan pelatih jururawat rendah
Delay admission of premature baby to NICU
Notifikasi kes-kes HIV yang tidak sistematik
Hypertensive cases are poorly optimized before
elective operation
Discharge summary are not done in time
Senarai masalah
Penggunaan Antibiotik yang banyak di Unit Pesakit
Luar Klinik Kesihatan
Fizikal stok tidak sama (tally) dengan Bin kad.
Liputan imunisasi rendah di kalangan toddler di
kawasan operasi
Delay in HPE reporting
Terlalu kerap ‘on call’
Kadar defaulter tinggi untuk kes antenatal berisiko
tinggi
 Ranking of problems by VOTE
A B C D E Total
High incidence of nosocomial infection in ICU.
1 1 3 3 1 9
Kadar severe neonatal jaundice tinggi
5 4 4 5 5 24
High incidence of needle prick injury among student nurses.
3 5 5 4 3 20
Kekurangan penderma darah di Hospital.
4 3 2 2 4 15
Peningkatan kes-kes bukan kecemasan yang mendapat rawatan di A & E.
2 2 1 1 2 8
 Ranking of problems by VOTE
REVOTE AFTER RESULTS TO CONFIRM
PRIORITY

A B C D E Total
High incidence of needle prick injury among
3 1 3 3 3 13
student nurses.
Kekurangan penderma darah di Hospital. 2 2 2 1 1 8
Kadar severe neonatal jaundice tinggi 1 1 1 2 2 7
 Prioritization by giving weightage
to the SMART criteria
Problem Seriousness Measureable Appropriate Remediable Timeliness Total

Kadar peritonitis
yang tinggi selepas 3 3 3 3 3 15
Peritoneal dialysis

Poor quality of 3 1 3 1 2 10
Discharge summary
by HO

Kadar jangkitan 2 3 2 3 3 13
selepas T & S tinggi
Kadar penggunaan
antibiotik yang tidak 3 1 2 1 3 10
sesuai tinggi

1 = Tidak utama 2= Sederhana 3= Paling utama

Bil Tajuk Masalah S M A R T JUM

1 Discaj “AOR” Yang Tinggi Di Wad Pediatrik 30 30 30 30 29 149

2 Kesilapan Tagging Semasa Triage 27 30 30 30 29 146

3 Peningkatan Ujian Makmal Rutin Selepas 26 30 26 24 28 134

Waktu Pejabat.

4 Preskripsi Bertindih 25 30 30 18 25 128

5 Keputusan Ujian Radiologi (CT Scan, 15 30 16 30 23 117

Ultrasound, MRI, X-Ray Biasa) Yang Tidak Di
Semak Oleh Pegawai Perubatan.

6 Kes-Kes Bukan Kecemasan Yang Datang 18 30 6 6 15 75

Selepas Waktu Pejabat Ke Jabatan Kecemasan.

7 Rujukan Ke Unit Fisioterapi Berulang Kali 13 30 6 12 14 75

Untuk Masalah Yang Sama.

1 2 3 4 5 6
 Tajuk QAP
Mengurangkan Kadar Discaj “AOR” Di Wad
Pediatrik di Hospital Setiu
Bengkel 1
 Problem
identification

Problem
Prioritization
Re-evaluation of
the Problem
Quality Problem
Analysis
Assurance
Cycle
Implementation of
Remedial Actions Quality
Assurance
Study

Identification of
Remedial
Actions
what,
who,
when
why,
how
(4 Wives + 1 Husband)
Purpose of Problem Statement
To digest the problem by the
team/department/hospital
To collect appropriate data
To correlate with existing MOGC
To perform appropriate remedy
STRUCTURE – PROCESS -
OUTCOME
High incidence of Gingivitis in district A.
What – high incidence of gingivitis
Who - Children in district A
When – Jan – Jun 2007
Why – too few school visit by dental team
How – Process of dental surveillance and education
High incidence of return for treatment of
asthma within 1 week
What – repeat asthma treatment
Who – Asthmatic patients
When – within 1 week of being seen
Why – poor pt compliance, poor care
How – Process of asthma treatment and patient
education
High incidence of recurrent convulsion
due to inadequate management of
high BP
What – Inadequate management of high BP
Who – Pregnant women with PIH
When – During hospital admission for severe PIH
Why – Inadequate control of BP, inappropriate
treatment given and inadequate monitoring.
How – Process of MANAGEMENT OF HDP
Bubble chart (cause - effect)
Simplified diagram display in bubbles
Possible cause to the problem
The effect of the problem
Identify variables
 Secondary causes

Primary causes

Primary causes
Effect of the
Primary causes Problem/Complication

Primary causes
Secondary cause
 CARTA
CARTA PENGANALISAAN
PENGANALISAAN MASALAH
MASALAH
Kurang aktiviti
Penguatkusaan
Pelupusan
Akta
sampah
( APSPP 75 )
tidak sistematik
Sistem simpanan
Air tidak tertutup
Banyak tempat
Kurang pembiakan
Pengetahuan aedes
Masyarakat mengenai Kurang kajian
pencegahan denggi Aedes dilakukan

Kurang kerjasama KEJADIAN Persekitaran

drp. penduduk & DEMAM DENGGI & topografi yg.
pengurusan FELDA berbukit
TINGGI DI FELDA

Tiada jawatankuasa Tiada aktiviti

Khas ditubuhkan Penghapusan tempat
Kurang aktiviti Pembiakan aedes
pencegahan

Pendidikan kesihatan Kurang aktiviti

Kurang berkesan Pendidikan kesihatan
 Masalah Yang Mungkin
Husband not Lack of
supportive
Stay very far
Knowledge
Low Education Refuse Treatment
Status PREGNANT
MOTHERS
Not Cooperative

LOW COVERAGE
OF ANTENATAL CASES
FAMILY HEATH
DENTAL STAFF
TEAM
Inadequate Inappropriate
KAP Referral
Lack of staff
Poor
monitoring
 Ke arah
Ke arah
Mengurangkan
Mengurangkan
Risiko “Retained
Risiko “Retained
Swab” Selepas
Swab” Selepas
Prosedur Jahitan
Prosedur Jahitan
Luka Perineum
 Masalah
Kelakuan
Masalah Doktor dan
Kurang
praktis kakitangan
pengetahuan
Doktor dan
tentang SOP
kakitangan

Masalah
KAP doktor
& jururawat
Keperluan Kurang / tiada
kerja penyeliaan

Senario
SOP Sistem
Tiada
Pengurusan “swab” Penyeliaan
Tekanan Kerja kurang Pemantauan
tidak dipatuhi Tidak Optima
Beban kerja kondusif

Tiada sistem
Kurang Penggunaan Yang jelas
Kakitangan SOP
Bermasalah

Sumber
Tiada naskah Informasi
SOP Kurang Tidak
di lokasi Kesedaran Sistematik
Ishikawa Chart (Fishbone)
SYSTEM /
PROCEDURES
PEOPLE

THE
PROBLEM

EQUIPMENTS /
FACILITIES POLICIES
SKOP KAJIAN
Daripada banyak-banyak penyebab masalah, yang
mana satu akan diberi tumpuan :

Contoh:
1. Hanya faktor ‘KAP’ pegawai / kakitangan
pergigian dan faktor kelemahan
pengurusan KKIK akan disiasat dalam
menentukan sebab-sebab kurang liputan
rawatan pergigian antenatal

Thursday, December 09, 2021 QUALITY ASSURANCE (DENTAL)

SKOP KAJIAN
Contoh:
 Hanya faktor berkaitan “Dentist” akan disiasat
dalam menentukan sebab-sebab tingginya kadar
infeksi selepas cabutan

Thursday, December 09, 2021 QUALITY ASSURANCE (DENTAL)

 “OPPORTUNITY
STATEMENT”
PENYATA MASALAH

Thursday, December 09, 2021 QUALITY ASSURANCE (DENTAL)

PENYATAAN MASALAH /
OPPORTUNITY STATEMENT
Opening statement of the project
Explaining what it is – evidence if any
What are the effects (BAD)
What are the possible causes
Why we want to do with the study

Thursday, December 09, 2021 QUALITY ASSURANCE (DENTAL)

Problem Statement
Patients at Hospital A Dental Clinics have long clinic waiting
times resulting in demoralization and poor public opinion of
Hospital A patient care services. (EFFECTS)

The problem is a result of inadequate of manpower resources as

well as inefficient management of clinic work processes.
(POSSIBLE CAUSES)

A study is needed to identify the major factors that influence

clinic waiting times so that a long term strategy can be made to
improve clinic waiting times at Hospital A (WHY DO WE WANT
TO STUDY)
Thursday, December 09, 2021 QUALITY ASSURANCE (DENTAL)
To improve outpatient
psychiatric follow-up rate
Major mental illnesses are relapsing in nature and may even result in patient deaths.
Current defaulter rate in HPJB is worrying (HP2001 – 13.6%) and this institution tend to
cater to high-risk cases (e.g. higher forensic workload)….
 (introduction)

 International studies have shown that regular follow up and treatment proven to
reduce relapses and readmissions. Thus better management of health care services can
reduce rate of defaulter. (desirable outcome)

 Factors that contribute to failure of psychiatric patients attending outpatient clinic

include long waiting hours, poor insight, lack of information and other psychosocial
factors. (opportunities)

 This study proposes to explore the possible causes contribute to the default rate and to
evaluate ways to improve outpatient psychiatric follow up.
 (intent to improve)

Thursday, December 09, 2021 QUALITY ASSURANCE (DENTAL)

OBJEKTIF KAJIAN
General/Umum
Berkaitan dengan tajuk
1-2 ayat

Specific/Khusus
Determine current shortfall if any
To determine the causes
To implement remedial measures
To re-evaluate the effectiveness of the remedial actions.

Thursday, December 09, 2021 QUALITY ASSURANCE (DENTAL)

 1. Outline of Problem

Example Objectives
General Objective
To reduce the number of unsatisfactory pap smears in the
Gynaecology Clinic in Hospital Seberang Jaya from 17.5% in 2002 to
5% by the year 2004.
Specific Objective
To determine the rate of unsatisfactory pap smear.
To identify the possible and contributory factors leading to
unsatisfactory pap smears.
To formulate strategies and plan appropriate remedial measures to
overcome identified problem.
To carry out remedial measures efficiently in providing quality care to
improve pap smear yield.
To evaluate the effectiveness of remedial measures implemented.

Thursday, December 09, 2021 QUALITY ASSURANCE (DENTAL)

Example Objectives
 General Objective:
Untuk mengurangkan kadar “jangkitan selepas pembedahan pergigian” bagi
pesakit diabetes di Hospital Dungun.

 Specific Objective:
1. Untuk menilai kadar kejadian “jangkitan selepas pembedahan pergigian”.
2. Untuk mengenalpasti faktor-faktor yang menyumbangkan kepada
“jangkitan selepas pembedahan pergigian” bagi pesakit diabetes di Hospital
Dungun.
3. Untuk merumuskan dan melaksanakan langkah-langkah pembaikan
bagi mengurangkan kadar kejadian “jangkitan selepas pembedahan
pergigian”
4. Untuk menilai semula keberkesanan langkah-langkah pembaikan yang
telah diambil.

Thursday, December 09, 2021 QUALITY ASSURANCE (DENTAL)

OBJEKTIF UMUM
Untuk mempertingkatkan tahap pengetahuan
penjagaan gigi di kalangan murid sekolah rendah di
Negeri Terengganu.

Thursday, December 09, 2021 QUALITY ASSURANCE (DENTAL)

OBJEKTIF KHUSUS
 -memastikan SIQ dapat ditangani dalam
pengurusan/pengendalian pendidikan kesihatan
penjagaan gigi dengan menggunakan indikator
 -untuk menyiasat faktor penyebab dan kewujudan
SIQ.
 -untuk memperbaiki kelemahan yang telah
dikenalpasti

Thursday, December 09, 2021 QUALITY ASSURANCE (DENTAL)

Bengkel 2