Time Topic

Day 1
9 00 Hi f Q li M 9:00 am History of Quality Management
10:00 am Dynamics of Healthcare
11:00‐ 11:15 am Coffee Break
11:15 Bariars to Quality Improvements
12:15 Qualit Management Philosophies
1:15 General Discussion
Day 2
9:00 am Steps to Quality Improvement
10:00 am Value of Including Medical Staff in Quality Improvements
11:00 – 11:15  Coffee Break
11:15 am Team Building In Quality Efforts
12:15  General Discussion
Day 3
9:00 am Quality Improvement Tools, A Dash through Data
10:00 am TQM‐Six Sigma Turning Strategy into Results
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11:00 am – 11:15 Coffee Break
11:15 – 12:15 Practical Application and General Discussion
1:30 pm Groups Workshop on CQI Applications
Dr. Abdulaziz A. Saddique
Six Sigma Master Black Belt
· Course Objectives · Course Objectives
Following the attendance of this course the participants should be able to:
- Understand the history of TQM development
- Appreciate the philosophies of TQM - Appreciate the philosophies of TQM
- Appreciate the value of Team work and the full organizational Quality commitment
- Appreciate the value of CQI technique in problem solving
- Be able to conduct problem solving using CQI techniques
· Who Should Attend:
All individuals involved in Quality Management, physicians. Nurses, Pharmacists and A Q y g , p y ,
supportive services staff.
· Requirements for Course attendance.
No prior experience in Quality Management knowledge is required. No p io expe ience in Quality Management knowledge is equi ed.
Dr Abdulaziz A Saddique Dr Abdulaziz A Saddique Dr. Abdulaziz A. Saddique Dr. Abdulaziz A. Saddique
Six Sigma Master Black Belt Six Sigma Master Black Belt
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gg
Shakespeare once said: Shakespeare once said:
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Why Hospital Quality Assurance? y p Q y
· Ethics
· Customers need · Customers need
· Competition
T d f H l h C S d d · Trends of Health Care Standards
· Economical forces
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QUALITY QUALITY
f f Defined as the “Quality Of
A Product Or Service A Product Or Service
Measured By The Extent
To Which It Satisfies Our
Customer !” Customer !
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TOTAL QUALITY TOTAL QUALITY
Defined as “ The Culture Of
An Organization Where An Organization Where
Continuous Improvement Is p
Integrated Into All
Activities ” Activities.”
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2000BC
•Code of Hammurabi - 2000 BC
The Responsibility For Quality
Care Rests Solely With The
Individual Who Provides The Care
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1752AD
Benjamin Franklin - first US hospital
The Accountability Of The Governing
Body Was Limited To Fundraising
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•Brown 1-42
1854AD
Florence Nightingale
1854AD
Advocated a uniform system for
collecting and evaluating hospital
t ti ti statistics.
From statistics on the mortality of British
soldiers the improvement in outcomes soldiers the improvement in outcomes
indicated a drop in mortality rate from
32.% to 2.% within six months
•Nutting and Dock, 1907,pg142
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1860AD
Florence Nightingale -
1860AD
Early Process Standards For Nursing
Practice
- First rule of good nursing was to keep the air
the patient breathes as pure as the external air,
without chilling the patient
- Emphasized the importance of observing signs Emphasized the importance of observing signs
and symptoms of a change in the patient’s
condition
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•Nightingale -Notes on Nursing (1860)
1863AD
Florence Nightingale
i iti t d th f h it l b d t initiated the use of hospital beds to
indicators of health in order to promote
efficient and effective use of hospital efficient and effective use of hospital
beds.
From this data, specific medical and surgical , p g
treatments was correlated with diagnostic
categories and morality rates calculated
•(Brook and Avery 1975,pg3)
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1908AD 1908AD
Emory Groves, British physician
Established a follow-up system for particular
categories of diseases to allow assessment of
long-term results-
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1908AD
An industrial system called the Taylor system
was developed that separated planning from
execution This resulted in greater production execution. This resulted in greater production
but at the expense of quality
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1910AD
Dr Abraham Flexner
1910AD
Released a study of the quality of medical
schools in the united states which stimulated the
elimination of “diploma” mills elimination of “diploma” mills.
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1912AD
EA Codman -
Opened an “end results” hospital - instituting a
system of medical audit - emphasized:
(1) th i t f li tifi ti f id (1) the importance of licensure or certification of providers
(2) the accreditation of institutions
(3) the severity or the stage of the disease
(4) the issue of co-morbidity
(5) the health and illness behavior of the patient
(6) the economic barriers to receiving care. (6) the economic barriers to receiving care.
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1913AD
American College of Surgeons
Formed as an accrediting body,
- generated “minimum standards” for
medical education and performance medical education and performance
- developed the first “hospital standardization
program” (They suggested 5 standards only)
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1950
American Nurses Association -
Published A Code For Nurses
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1952
JCAHCO(Joint Commission on Accreditation of
Hospitals)
Established as responsible for the quality assurance function
succeeded the American college of surgeons
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1965
Darling vs. Charleston Community Memorial Hospital
The Governing Body And The Hospital Held Accountable
For The Selection Of Medical Staff And The Quality Of o e Se ec o O ed c S d e Qu y O
Care Rendered In The Hospital.
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1973
Health Maintenance Organization (HMO) - Health Maintenance Organization (HMO)
Legislation enacted - mandated the
implementation of a Quality Assessment
System
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Th d Pioneers of Quality The modern Pioneers of Quality are:
•W.Edward Demingg
•Philip Crosby
•Kaoru Ishikawa
•Vilfredo Pareto
•Joseph M Juran p
•Genichi Tagushi
Shigeo Shingo Shigeo Shingo
• W. A. Shewhart
•Armand V Feigenbaum
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•Armand V. Feigenbaum
1. Deming 14 Points for Management
2 Chain Reaction: 2. Chain Reaction:
Do Things right the first time
Spend less time in rework
Build trust in your products
E d i th k t d Expand in the market and
Hire More People
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Stay in Business
Philip Crosby
F lit b l t
Philip Crosby
Defined the Four quality absolutes:
- The definition of quality is conformance to requirements.
- The systemof quality is prevention The system of quality is prevention
- The performance standard is zero defects
- The measurement of quality is the price of
f nonconformance.
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Ishikawa
is best known for developing
‘ d ff t di ’ the ‘cause and effect diagram’
(also called the ‘fishbone’ diagram)
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Pareto, ,
An Italian engineer
‘P t h t’ Developed the ‘Pareto chart’
A basic but powerful tool of managerial analysis
His main
objectives was j a
that 80 % of the
Wealth sets in
the hand of the hand of
20% of the
Population
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Juran Juran
Used the pareto chart and its demonstration of misdistribution
Formulated The Pareto Principle: 80/20 Rule
-The bulk of failures (80%) being
traceable to a vital few (20%)
has since guided management has since guided management
corrective actions towards these
“vital few” and away from y
the “trivial many”
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Genichi Tagushi
Developed a methodology for minimumprototyping Developed a methodology for minimum prototyping
in product design and troubleshooting in production
Zero Defect Theory
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Shigeo Shingo Shigeo Shingo
· Created the Poka-Yoke system to ensure
zero defects in production by preventive zero-defects in production by preventive
measures.
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Armand V. Feigenbaum
· Developed concepts of 'Total Quality p p y
Control',
· Contributed to 'cost of quality' and quality
systems engineering and practice
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Shewhart Shewhart
Is responsible for the Control Chart -
Another basic tool of quality control: q y
The control chart is a chart with statistically
determined upper and lower limit, which is used to
discover the variability in a process and determine the discover the variability in a process and determine the
cause of the variability.
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1981
JCAHCO -
The joint commission required all hospitals
to have a written quality assurance plan.
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1986 1986
JCAHCO(Joint Commission) -
Launched agenda for change. The goal of this
program was to develop an outcome-oriented
it i d l ti monitoring and evaluation process
The shift fromQuality Assurance to Continuous The shift fromQuality Assurance to Continuous
Quality Improvement was dramatic as it
contained two critical elements:
1.Philosophy
2. Problem-Solving/Graphical Techniques
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1989 1989
(JCAHCO)
Published “principles of organization and
management effectiveness in healthcare g
organizations” -
articulated the concept of total quality
management (TQM)
Then, in 1992 Accreditation Manual for Hospital. , p
- The Commission initiated a
Transition to continuous quality improvement.
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1994 1994
Riyadh Quality Management Network
F d b t d f th NAHQ G t Formed by a study group for the NAHQ exam. Grew to
nearly 100 individuals from all major hospitals in riyadh
and interested corporations for presentations related to p p
quality implementation
•Then, in 2001 Healthcare Quality Management Network. e , 00 e c e Qu y ge e Ne wo .
became a chapter of the Saudi National Quality Committee
and National Association of Healthcare Quality (USA), its
activities are Kingdom wide the new name is Healthcare activities are Kingdom wide, the new name is Healthcare
Quality Management Network (HQMN).
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M h 2001 March 2001,
ISO (International Organization for
Standardization) Standardization) -
Completed a report on the guidelines for p p g
implementing ISO 9000 quality management systems
in the health care sector goal to establish a standard
for the healthcare sector accepted by north America,
Australia, British standards, European commission
and other worldwide agencies and other worldwide agencies
-organized by Canadian Standards Association / Standards Council of Canada
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Q Total Quality Management
Is the concept of a healthcare organization
measuring their effectiveness and
establishing projects to improve their
ff ti t ti th ti t d effectiveness at supporting the patients and
practitioners at the point of care
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KING SAUD UNIVERSITY
HOSPITALS & CLINICS HOSPITALS & CLINICS
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KSUH’S Mission KSUH S Mission
Th Mi i f KSUH’S i t id The Mission of KSUH’S is to provide
excellent healthcare for our patients
and the communities we serve and to and the communities we serve, and to
implement the best practice in
healthcare services and Research healthcare services, and Research.
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Vision Vision
KSUH’S will be a leader in providing KSUH S will be a leader in providing
comprehensive, convenient and excellent
healthcare services to the people in our
communities by continuously improving the y y p g
quality, access, and value of our services.
As employees, and physicians, we will continue to
deliver exceptional healthcare and customer p
service to those choosing KSUH’S and its Clinics.
We will serve as the model of partnership between
physicians, hospitals and communities to create a
comprehensive regional healthcare network comprehensive regional healthcare network.
We will be committed to professional and
organizational excellence; and, we will serve others
with compassion and respect for individual dignity with compassion and respect for individual dignity.
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Quality Management Plan Quality Management Plan
PPurpose:
Identify the organization’s y g
procedures and priorities for
assessing and improving quality and
to define the mechanisms designed
to re-prioritize efforts in response
d to emerging needs
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Goals and Objectives: j
1 Establishment of an 1. Establishment of an
infrastructure i.e. Standards,
Policies and procedures,
d d h k Indicators and Benchmark
2. Characterization of the
operating standards
3. Setting up new Standards 3. Setting up new Standards
4. Policy and procedure
Reengineering Reengineering
5. Clinical Bylaws development
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Goals and Objectives (Cont.) j ( )
6 Position Catalog Development 6. Position Catalog Development
7. Indicators development
S ff S f 8. Improve Staff Satisfaction
9. Benchmarking setting
10. Top and middle management
training
11. Staff training
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P f A Performance Assessment
The QM will assess and improve the The QM will assess and improve the
following components:
× P ti t h lth d × Patients health process and
outcome
× N d d t ti f × Needs and expectations of
patients
× Di i f f × Dimensions of performance
× View of the staff regarding
improvement activities
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Performance Assessment
™ Key process of all important ™ Key process of all important
functions, specifically high risk,
high volume, and/or problem g , p
prone
™ Surgical and invasive procedures g p
™ Use of medications
™ Use of Blood/Blood products ™ Use of Blood/Blood products
components
™ Utilization review
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Performance Assessment
™Results of autopsies Results of autopsies
™Risk management activities
™Quality control for services ™Quality control for services
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Quality Management Functions
+ St d d tti d it i + Standards setting and monitoring
+ Infection control
+ Risk management
+ Clinical data abstractingg
+ Clinical Audit
+ C ti d ti d lit + Continuous education and quality
management training
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Quality Management Process Quality Management Process
o Hospital wide monitoring program
for all services provided
o Incidence reports, patients or non
patients related incidents
o Continuos quality improvement
system
o Patients satisfaction reviews
o Audits, internal and external o Audits, internal and external
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Quality Management Process Quality Management Process
C i d l f h ¬Continuos development of the
services based on the hospital
performance performance
¬Implementation of Standards and
difi ti f th modification of the necessary
services, functions, policies and
procedures to comply with the procedures to comply with the
international and the local
regulations regulations
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Key Components for Success y p
· Vision and values driven · Vision and values driven
· Leadership
h l · Physician involvement
· Customer-focused
· Continuous improvement
infrastructure
· Communication
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Leadershipp
· Vision to unify all the quality · Vision to unify all the quality
improvement projects
· Chief motivators during the massive · Chief motivators during the massive
change in philosophy as a result of
applying TQM applying TQM
· They have the power to change the
systems before crisis is reached systems before crisis is reached
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Leadership Leadership
· They have the ability to allocate · They have the ability to allocate
resources necessary for solving the
problems and affecting continuous g
improvement
· Priority for quality improvement can
be attained only if top management be attained only if top management
wishes for it
· Allocate adequate training time for q g
every level of the organization
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Medical Staff Involvement Medical Staff Involvement
d l ff Medical staff are:
· The driving force of the healthcare
f ilit facility
· The heads of the healthcare teams
Th t f th i ti · The operators of the organization
· Carry the responsibility of the well
being of the patients being of the patients
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Customer Focus
Healthcare is a business:
· In business the customer is always right
· Customer satisfaction is the main
objective of the healthcare facility objective of the healthcare facility
· Without patients there will be no
healthcare facilities healthcare facilities
· We are for the service of the patient
We are all c stomers for one another · We are all customers for one another
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Continuous Improvement Continuous Improvement
Healthcare is a dynamic system · Healthcare is a dynamic system,
continuously changing therefore, we
have to have a flexable system that have to have a flexable system that
allows adaptation of the changes and
improving the services as they improving the services as they
develop.
· Monitoring is the key to improvement · Monitoring is the key to improvement,
to identify problems or pending
problems before they take place. problems before they take place.
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Communications Communications
S ff i l ' h h Staff involvement's through:
· Top management vision
i i communication
· Suggestion programs
· Teams
· Problem solving feedback & g
monitoring
· Quality improvement programs Q y p p g
· Training
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Quality Management Procedure Q y g
· Top and Middle Management
Orientation and training
St ff i t ti · Staff orientation
· Key group training
CQI i l i · CQI implementation
· Teams forming and training
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“QUALITY PRODUCTS SURVIVE
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AND SPEAKS FOR ITS CREATORS”
Dr. Abdulaziz Saddique Pharm.D., CPHQ, CSSMBB
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Facts About Healthcare Facts About Healthcare
· Healthcare is a service that is provided to
our patients to cure disease, decrease p
suffering, improve the quality of life or
prolong life.
· The trial for better care is a never ending
process.
· Clinical Research is the key to development
of new procedures, new drugs, or defining
the pathophysiology of diseases the pathophysiology of diseases.
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Facts About Healthcare Facts About Healthcare
Th JCAHO i i i it t d d f · The JCAHO is revising its standards of
care practically every year to keep up
with the new development in healthcare with the new development in healthcare.
· Governments and individuals are
complaining about the increasing cost of complaining about the increasing cost of
healthcare.
· New means to decrease cost are being New means to decrease cost are being
devised
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The Paradox of Healthcare
× Highly trained practitioners; widespread state-of-
the-art technology; unparalleled biomedical gy p
research; unequaled expenditures; excellent care
for some individuals
× Care fragmented and difficult to access; too many
people not assured access; uncertain value of
di i di h i h expenditures; growing disenchantment with care
process by patients, practitioners and payers;
serious and systemic quality problems serious and systemic quality problems
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Dr. A. Saddique
65
“Medicine used to be simple Medicine used to be simple,
ineffective and relatively safe.
Now it is complex, effective and
potentially dangerous.” p y g
Sir Cyril Chantler, former Dean y ,
Guy’s, King and St. Thomas’s
Medical and Dental School, Lancet
1999
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“C i d d h “Current practice depends upon the
clinical decision making capacity g p y
and reliability of autonomous
individual practitioners for classes individual practitioners for classes
of problems that routinely exceed
the bounds of unaided human the bounds of unaided human
cognition.”
Daniel R. Masys, MD
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Daniel R. Masys, MD
October 15, 2001
IOM Annual Meeting
Why Healthcare?? Why Healthcare??
· Defects in healthcare are deadly
· Rapidly developing system p y p g y
· Very Costly and the cost is escalating
· In US healthcare consumes 12% of the
GNP
· In Saudi Arabia healthcare consumes
10% of the GNP and increasing
· New technology is very costly
· The potential for waste is great
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D i f H lth Dynamics of Healthcare
· Development of the diagnostic procedures,
techniques and understanding of the
pathophysiology of diseases pathophysiology of diseases.
· Improvement of Monitoring procedures
· Development of Drug Industry p g y
· Development of healthcare performance
standards
G ti E i i d t t t f · Genetic Engineering and treatment of
hereditary diseases.
· Escalation of Healthcare Cost Escalation of Healthcare Cost
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D i f H lth Dynamics of Healthcare
P ti t’ d d t Q lit S i · Patient’s demand to Quality Service.
· Patients and Governments demand to
decrease cost decrease cost.
· Governments demand to know more
about the cost of Healthcare about the cost of Healthcare.
· Global Quality Awareness.
Ch i t ti l it i t · Change is not optional it is a must.
· Healthcare is a Business.
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Why is the Change ? Why is the Change ?
B d ll h D d · Based on all the Demands.
· More Shifting to Privatization.
· The Competition.
· The New JCAHO Standards.
· Overall World Economy
· The Japanese Experience. The Japanese Experience.
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D fi i i f Q li I H l h Definition of Quality In Healthcare
· American Medical Association
Care which consistently contributes to Care which consistently contributes to
improvement of /or maintenance of
quality and / or duration of life quality and / or duration of life
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D fi iti f Q lit I H lth Definition of Quality In Healthcare
JCAHO d fi i i · JCAHO definition:
“The degree of adherence to generally
i d d d recognized contemporary standards
of good practice and achievement of
anticipated o tcomes for partic lar anticipated outcomes for particular
service, procedure or clinical problem”
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Definition of Quality In Healthcare
· According to CQI Quality is: According to CQI Quality is:
The continuous efforts to The continuous efforts to
improve the services provided to
meet our patients expectations.
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Model for Change Model for Change
Regardless of which model is chosen by the
Organization it should contain the following:
- Knowledge of systems
- Knowledge of Variation
K l d f P h l d - Knowledge of Psychology; and
- Theory of Knowledge
i e Linking professional knowledge with i.e. Linking professional knowledge with
improvement knowledge
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Change Strategy Change Strategy
· To meet the changing demand of
healthcare marketplace the organization
h must have:
- Short-term initiatives:
Improve effectiveness, time MGMT,
efficiency, and other dimensions of
f f h performance of the major processes
in their basic services.
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Change Strategy (cont ) Change Strategy (cont.)
- Long-term initiatives:
Cultural change process that Cultural change process that
create customer-focused, learning
flexibility to adapt to changes in flexibility to adapt to changes in
healthcare system.
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Healthcare management system
Specifications Specifications
Dynamic System to match the rapid · Dynamic System to match the rapid
development in healthcare.
· Allows staff participation to empower · Allows staff participation to empower
staff and maximize their productivity, as
well as their sense of belonging. well as their sense of belonging.
· Provide means for Continuos
improvement. p
· Provide integration of Professional
knowledge with improvement g p
knowledge.
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THE GOLDEN RULE THE GOLDEN RULE
PUT THE HORSE BEFORE PUT THE HORSE BEFORE
THE CARRAGE NOT THE THE CARRAGE NOT THE
CARRAGE BEFORE THE
HORSE HORSE
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Quality Standards Quality Standards
Are pre set measures defined by the · Are pre-set measures defined by the
government’s organizations to assure
the quality of services provided. q y p
· Standards are essential in the developed
countries, however, in developing
i i i id d i countries it is considered as ties to
individual’s activities.
· Quality is quite variable form one culture · Quality is quite variable form one culture
to another, and this affects the
understanding of Quality.
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Quality Improvement means Quality Improvement means
· Continuous Quality improvement efforts
and not just Quality Assurance.
A li ti f t t · Application of a management system
which meets the continuous quality
improvement based on patients needs.
· Determination of customers needs base
on competition.
· Provide Services to our customers with · Provide Services to our customers with
minimal cost by maximal utilization of
the available resources.
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Examples of Quality Improvement and Cost
C i ff Containment efforts
· Pentagonal Quality Circle: · Pentagonal Quality Circle:
- Change from problem driven to Goal-oriented
management.
C d ti li - Credentialing.
- Information management utilizing Statistical
methods to evaluate performance and
removal of error removal of error.
- Case management and evaluation of services
based on preset standards, to achieve
expected performance level expected performance level.
- Integration of all these systems in a complete
database.
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Proposal for Quality Improvement in Saudi
Arabia
I t ti f ll i ithi th t · Integration of all services within the government
hospitals and avoidance of duplication.
· Development of Purchasing system for the Development of Purchasing system for the
Government to decrease cost of Medical
equipments and Pharmaceuticals.
· Development of a maintenance system for all
equipments and enforcement of its application.
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Proposal for Quality Improvement in Saudi
Arabia
I i h d d l · Investment in human resources and development
of training programs to achieve Saudization.
I l t ti f TQM h it i th · Implementation of TQM program, where it is the
only system that support the dynamics of
healthcare and promotes CQI healthcare and promotes CQI.
· Concentration on Quality not Price when
awarding Government tenders, to improve the awarding Government tenders, to improve the
services and decrease cost.
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REMEMBER REMEMBER
TQM is The
Answer Answer
FIDO DIDO
Thank you & See
S you Soon
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D Abd l i S ddi Dr. Abdulaziz Saddique
Six Sigma Master Black Belt
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Quality Improvement Quality Improvement
“A i d Phil h th t k · “An organized Philosophy that seeks
to meet client needs and exceeds
expectations with a minimum of effort expectations with a minimum of effort
, rework and waste , by using a
structured process that selectively structured process that selectively
identifies and improves all aspects of
care and services on an ongoing basis” care and services on an ongoing basis
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Quality Improvement promotes: Client
1. Identification of clients, their needs,
expectation expectation
2. Response to changes in client needs
and expectations and expectations
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QI Promotes Leadership
1 Organizational culture 1. Organizational culture
2. Planning
3. Resources
4. Quality
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QI Promotes Teamwork QI Promotes Teamwork
1 Effective communication among team 1. Effective communication among team
members and between teams
2 F i t t t ’ 2. Focus on improvements to team’s
functioning
3 C f i l/I di i li 3. Cross functional/Interdisciplinary
representation
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QI Promotes Processes and Outcomes QI Promotes Processes and Outcomes
1 Development selection and 1. Development ,selection and
monitoring of indicators
2 R ti f i di t it i 2. Reporting of indicator monitoring
and results
3 F db k i di l 3. Feedback on indicator results
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Accreditation Accreditation
Is: Is:
· Voluntary and not mandatory
· Private
· commitment to safe , high–quality
service
3/ 27/ 2008 Dr. A. Saddique 94
What is Accreditation In QI What is Accreditation In QI
1 A process to evaluate against a pre 1. A process to evaluate against a pre-
set Standards and improves the
quality of services quality of services
2. Involves examining everyday
activities and services against activities and services against
standards of excellence
3/ 27/ 2008 Dr. A. Saddique 95
Benefits of Accreditation
1. Shows commitment to Quality
2. Supports learning across organization
3. Encourages self-reflection
4. Improves communication, collaboration
d i i d and integration among departments
3/ 27/ 2008 Dr. A. Saddique 96
Also
Promotes team building · Promotes team building
· Increases credibility
· Demonstrates accountability
· Improves productivity
· Obtain valuable advice from
surveyors,….
3/ 27/ 2008 Dr. A. Saddique 97
The Value of Accreditation
Accreditation may benefit health care institution by:
Gi i h i i d · Giving them a competitive advantage
Accreditation provides evidence of quality patient care that
helps level the playing field for organizations doing the same
type of procedures type of procedures
· Strengthening community confidence
Achieving accreditation is a visible demonstration to patients
and the community that your organization is committed to and the community that your organization is committed to
providing the highest quality services
· Assisting recognition from insurers , associations ,
employees and other stakeholders employees, and other stakeholders
Increasingly, accreditation is becoming a prerequisite for
eligibility for reimbursement, for association membership ,
for community awareness, and for contract or grants y , g
3/ 27/ 2008 Dr. A. Saddique 98
In addition
· Validating Quality Care to Patients
A dit ti St d d f l R i i th Accreditation Standards are focus on one goal. Raising the
safety and quality of care to the highest possible level.
Achieving accreditation is a strong validation that u have
taken extra steps to meet a high level; of safety and quality taken extra steps to meet a high level; of safety and quality
· Helping you organize and strengthen your improvement
efforts
d f h f Accreditation encompass state of the art performance
improvement concepts that help you continuously improve
quality
· Enhancing staff education
The survey process is design to be educational, not punitive .
Accreditation surveyors are trained to help you improve your
internal procedures and day to day operation
3/ 27/ 2008 Dr. A. Saddique 99
Also
· Improving Risk Management
By enhancing risk management efforts ,accreditation may
improve access to or reduce the cost of liability coverage It improve access to, or reduce the cost of liability coverage . It
can also assist in lowering adverse events or outcomes for
the organization ,and more importantly, for the patient the
organization o ga at o
· Facilitating Staff Recruitment
As Staff recruitment become more difficult , achieving
accreditation as a demonstration of your organizations accreditation as a demonstration of your organizations
commitment to quality and patient safety will enhance
recruitment efforts
Promoting team b ilding skills staff · Promoting team building skills staff
The process of obtaining and maintaining accreditation
demands a team approach to good patient care. Establishing
d h hi d i i processes and systems that support this demonstration is
achieved through good team activities
3/ 27/ 2008 Dr. A. Saddique 100
People make a difference People make a difference
Each staff member must play a role in · Each staff member must play a role in
achieving accreditation
E h t ff b h l · Each staff member can help ensure a
safe environment where high quality
care is the norm care is the norm
3/ 27/ 2008 Dr. A. Saddique 101
To get Accreditation
is
to Change to Change
3/ 27/ 2008 Dr. A. Saddique 102
Change g
is
The process of transforming the · The process of transforming the
manner in which an individual or
organization acts from one set of organization acts from one set of
behaviors to another
· A process of transitions alterations · A process of transitions ,alterations
and becoming different
3/ 27/ 2008 Dr. A. Saddique 103
Change Change
maybe
1 Planned : Any alteration to the status 1. Planned : Any alteration to the status
quo of the organization initiated by
the top management and must the top management and must
impact either or both the work and
work environment of an individual work environment of an individual.
2. Unplanned : any change to the status
quo of the organization that occurs quo of the organization that occurs
on a random . It takes long time
3/ 27/ 2008 Dr. A. Saddique 104
Factors Enforcing Change
•WTO
•IMF
•WHO Globalization
•World Bank
•Economic
developments
ff t ll
Governance Citizens / Industry
effects all
•Laws
•Rules
•Regulations
Local Governance
•Guidelines
•Implementation
•Performing
3/ 27/ 2008 Dr. A. Saddique 105
Performing
•Execution
why organizations need to Change? y g g
· Improve quality care · Improve quality care
· Improve market share
· Increase effectiveness
· Increase learning
· Improve public image
· Increase client satisfaction
· Improves outcomes ,…
3/ 27/ 2008 Dr. A. Saddique 106
Forces that pushes organizations to
Change
1. External changes
2 Internal changes 2. Internal changes
3. Environmental factors
3/ 27/ 2008 Dr. A. Saddique 107
External changes External changes
· Changes in law and regulations
· Changes in customer needs and want
· Changes in technology
3/ 27/ 2008 Dr. A. Saddique 108
Internal changes Internal changes
· Organizational arrangement or power · Organizational arrangement or power
structure such as new changes.
· Power of human resources looking for · Power of human resources looking for
better work environments
3/ 27/ 2008 Dr. A. Saddique 109
Environmental factors
Increase of environmental turbulences · Increase of environmental turbulences
with the improvement of information
communication and transportation ,communication and transportation
technology . All leading to increase in
the speed of individual events
· Environmental complexity : p y
organizations become very complex
3/ 27/ 2008 Dr. A. Saddique 110
One of nastiest and most debilitating
workplace cancers is Resistance to change workplace cancers is Resistance to change
There is not a more potent killer of
progress and good intention than progress and good intention than
Resistance to change
3/ 27/ 2008 Dr. A. Saddique 111
Resistance to Change is one of the
main Barriers to quality main Barriers to quality
· Positive resistance is based on rational
opposition when followers provide opposition when followers provide
evidence that the cost of change
exceeds the benefits exceeds the benefits
· Negative resistance based on emotions
of the followers who ignore the benefit of the followers who ignore the benefit
of the outcomes of change because of
their personal needs or fears p
3/ 27/ 2008 Dr. A. Saddique 112
Why resistance ? Why resistance ?
Individual level Individual level
· Economical insecurity Economical insecurity
· Fear of unknown
· Social relations
· Habits
· Failure to recognize the need for change
3/ 27/ 2008 Dr. A. Saddique 113
continue
· Loss: change has unacceptable personal
costs
· Inadequacy : the benefit from the change
are not seen as sufficient
· Anxiety : fear of being unable to cope
with the new situation
3/ 27/ 2008 Dr. A. Saddique 114
Organizational level
· Threat to existing balance of power
· Structural inactivity
· Work group inactivity
· Previously unsuccessful efforts
3/ 27/ 2008 Dr. A. Saddique 115
Other sources
of
Resistance to Change
· Ignorance : a failure to understand the
situation or the problem situation or the problem
· Mistrust : motives for changes are
considered suspicious considered suspicious
· Disbelief : a feeling that the way forward
will not work
· Power –cut : a fear that sources of
influences and control will be eroded
3/ 27/ 2008 Dr. A. Saddique 116
Other sources
of
Resistance to Change
· Comparison : The way forward is dislike
b l i i f d because an alternative is preferred
· Demolition : Change threatens the
d i f i i i l k destruction of existing social network
3/ 27/ 2008 Dr. A. Saddique 117
Types of Resistance Types of Resistance
Functional Resistance Dysfunctional Resistance Functional Resistance
C iti ll i
Dysfunctional Resistance
A idi d li ith · Critically assessing
whether change will
lead to improvement
· Avoiding dealing with
urgent and pressing
issues lead to improvement
· Exploring the
issues
· Declining to work on · Exploring the
personal
consequences of
· Declining to work on
what really needs to be
done co seque ces o
change
do e
3/ 27/ 2008 Dr. A. Saddique 118
Key elements of effective Change Key elements of effective Change
· Change agent skills
· Teamwork
· Supportive organization culture
· Implementation plan
3/ 27/ 2008 Dr. A. Saddique 119
Characteristics of change agents Characteristics of change agents
Every one is a change agents when the Every one is a change agents when the
organization goes through a structural
change change
· Understand the resistance to change · Understand the resistance to change
· Address the resistance to change
U ti i ti h · Use a participation approach
· Communicate the change effectively
3/ 27/ 2008 Dr. A. Saddique 120
continue
Place change success ahead of · Place change success ahead of
personal agenda
B ild d i t i it t · Build and maintain commitment
· Monitor to ensure compliance
· Predict the likely impact of change on
the organization
3/ 27/ 2008 Dr. A. Saddique 121
For a Successful Change For a Successful Change
Process
· There must be clear agreement among · There must be clear agreement among
influential mangers and workers on
compelling need to change
A b d i i i f k f b · A broad participation of work force must be
engaged and committed for change
initiatives
· Management must constantly communicate
mission, vision, philosophy, process and
other details of change initiatives other details of change initiatives
· Change and process improvement takes
time and is a never ending process
3/ 27/ 2008 Dr. A. Saddique 122
continue
I i h l t bl · Ignoring change only causes trouble
· Change is happening everywhere ,whoever
adjust to it quicker benefits more adjust to it quicker benefits more
· The sooner the change is addressed the
less adjustment is necessary j y
· To change is to be fearless
· Adapt to the new change behavior p g
· Enjoy being flexible to the changing
environment
3/ 27/ 2008 Dr. A. Saddique 123
According to Dr. Spencer Johnson in “who moved my
Ch ” Cheese”
· Change Happens · Change Happens
· Anticipate Change
· Monitor Change · Monitor Change
· Adapt to Change quickly
· Change · Change
· Enjoy Change
· Be Ready to Change quickly And Enjoy it Be Ready to Change quickly And Enjoy it
again and again
3/ 27/ 2008 Dr. A. Saddique 124
Machiavelli and the Difficulty of Change
Thi s quot e f r om chapt er si x of The Pr i nce on i ni t i at i ng
change,
"We must bear in mind, then, that there is nothing
more difficult and dangerous or more doubtful of more difficult and dangerous, or more doubtful of
success, than an attempt to introduce a new order of
thi i t t F th i t h f things in any state. For the innovator has for
enemies all those who derived advantages from the
old order of things, whilst those who expect to be
benefited by the new institutions will be but
lukewarm defenders.
3/ 27/ 2008 Dr. A. Saddique 125
Machiavelli and the Difficulty of Change
· This indifference arises in part from fear of their
adversaries who were favored by the existing laws,
and partly from the doubt of men who have no faith
in anything new that is not the result of well-
established experience. Hence it is that, whenever p
the opponents of the new order of things have the
opportunity to attack it, they will do it with the zeal opportunity to attack it, they will do it with the zeal
of partisans, whilst the others defend it but feebly,
so that it is dangerous to rely upon the latter '' so that it is dangerous to rely upon the latter.
3/ 27/ 2008 Dr. A. Saddique 126
D r A S a d d i q u e D r A S a d d i q u e D r . A . S a d d i q u e D r . A . S a d d i q u e
3/ 27/ 2008 127
Abdulaziz Al-Saddique Pharm.D., CPHQ, CSSMBB
129
Quality Assessment Levels Quality Assessment Levels
o Inspection
o Quality Control
o Quality Assurance
o Total Quality Management
3/ 27/ 2008 Dr. A. Saddique 130
Inspection Inspection
× Inspection
× Inspection is defined as (ISO8402) p ( SO8 0 )
דActivity such as measuring, examining,
testing, or gauging one or more
characteristics of an entity and comparing
th lt ith ifi d i t i the results with specified requirements in
order to establish whether conformity is
achieved for each characteristic”
× Application points within the process × Application points within the process
×Third party inspection or operator self
inspection
×Decisions scrap rework modification ×Decisions scrap, rework, modification,
concession
× After-the-event screening process
3/ 27/ 2008 Dr. A. Saddique 131
Inspection
×Lowest level of quality development
d h d ×Key product characteristics examined
×Compared to known standard
×Lack of ownership ×Lack of ownership
×After the event
×Lack of feedback to source
×Inspection will not provide any basis for
process improvement process improvement
×Debatable if it provides an effective screening
against defects reaching the external customer
3/ 27/ 2008 Dr. A. Saddique 132
Quality Control
×Defined as (ISO8402) ( )
דOperational techniques and activities that are
used to fulfil requirements for quality”
×Developed from inspection of methods,
systems and tools & techniques
h f db k ×More emphasis on feedback
×Main mechanism still inspection based
×Ph i l h i i f d ×Physical characteristics of product
3/ 27/ 2008 Dr. A. Saddique 133
Quality Control
· The second level of quality development
· Implied use of control systems
· Raw materials, drawing issues, inspection reports
l f d · Development of inspection procedures
· Calibration, limited quality audits
· Use of basic QM tools · Use of basic QM tools
· Defect recording and analysis
· Quality costs still unknown
· Limited use of operator self inspection
· Still largely based on goods inwards inspection
· Reliance on inspection to catch non-conforming work · Reliance on inspection to catch non-conforming work
3/ 27/ 2008 Dr. A. Saddique 134
Quality Control
· QC is the systematic assessment of
goods and services to check their
conformance
· It will not improve quality, just
highlight when it is not present
· In many cases QC does not identify
the root cause of the non-
conformance
3/ 27/ 2008 Dr. A. Saddique 135
Quality Assurance
×Defined as (ISO8402)
דAll the planned and systematic activities
implemented within the quality system, and
d t t d d d t id d t demonstrated as needed to provide adequate
confidence that an entity will fulfil
requirements for quality” requirements for quality
×Issues of progression from QC to QA p g Q Q
×Change in emphasis from product to process
3/ 27/ 2008 Dr. A. Saddique 136
Quality Assurance
×Third level of quality development
×Represents a shift from detection to prevention
×Planned and systematic actions defined
f l ×Existence of mature quality system
×Greater use of QM tools - SPC, QFD, FMEA
×Known levels of quality performance and costs ×Known levels of quality performance and costs
×ISO 9000 or major customer approval
×Most mature manufacturers at at this level
3/ 27/ 2008 Dr. A. Saddique 137
Quality Assurance
×QA systems aim to proceduralise ×QA systems aim to proceduralise
organizational activities to increase
uniformity and conformity uniformity and conformity
×Ad i d f hi d ×Adoption and use of third party
approval, such as a major customer
3/ 27/ 2008 Dr. A. Saddique 138
Total Quality Management
×Represents the most advanced stage of
li d l quality development
×A Management philosophy
×Application of QM to all aspects of business
×Focused on the requirements of the customer
×Recognizes the importance of suppliers
×Company wide approach
×Continual improvement
×Integration of all quality systems and procedures
×D l t f i ti l lt ×Development of organizational culture
3/ 27/ 2008 Dr. A. Saddique 139
TQM Principles
×Internal customer supplier relationship
×Continuous Improvement
×Teamwork
×Employee participation/ development
×Training and education ×Training and education
×Suppliers and customers integrated into
the process the process
×Honesty, sincerity & care
3/ 27/ 2008 Dr. A. Saddique 140
Modern Quality Gurus Modern Quality Gurus
· W. Edward Deming · Shigeo Shingo g
· Philip Crosby
· Kaoru Ishikawa
g g
· W. A. Shewhart
· Armand V Kaoru Ishikawa
· Vilfredo Pareto
· Joseph M Juran
Armand V.
Feigenbaum
· Masski Imai
· Joseph M Juran
· Genichi Tagushi
Masski Imai
· Taichi Ohno
3/ 27/ 2008 Dr. A. Saddique 141
W. EDWARDS DEMING
3/ 27/ 2008 Dr. A. Saddique 142
W. Edwards Deming
×Defined quality as continual q y
improvement of a stable system.
×Most quality problems (90%) are
caused by poor systems, not by
workers. Management is responsible.
×H d h TQM ×Hated the term TQM.
×14 points of management must be
applied as a system (can’t pick and applied as a system (can’t pick and
choose).
3/ 27/ 2008 Dr. A. Saddique 143
Deming’s 14 Points
1 Create constancy of purpose toward 1. Create constancy of purpose toward
improvement of products and
services with the aim being to services with the aim being to
become competitive and staying in
business for the long-run (thereby business for the long run (thereby
creating jobs), rather than short-run
profits. profits.
3/ 27/ 2008 Dr. A. Saddique 144
Deming’s 14 Points
× Two problems 1) problems of today,
and 2) problems of tomorrow, for the
company that hopes to stay in
business business.
× Problems of tomorrow require
constancy of purpose to: constancy of purpose to:
× Innovate
× Invest in research and education est esea c a d educat o
× Constantly improve design of product
and service. Customer is the most
important part of the production important part of the production
process.
3/ 27/ 2008 Dr. A. Saddique 145
Deming’s 14 Points Deming s 14 Points
2 d h h l h b 2. Adopt the new philosophy by
refusing to allow commonly accepted
levels of mistakes defects delays levels of mistakes, defects, delays,
and errors. Accept the need to
establish leadership for change. The p g
new philosophy must start at the top,
with senior management, if it is to
h dibilit ith t have credibility with customers,
suppliers, and employees.
3/ 27/ 2008 Dr. A. Saddique 146
Deming’s 14 Points
3. Cease dependence on mass inspection.
Rely instead on building quality into the
product in the first place and on
statistical means for understanding statistical means for understanding,
controlling, and improving quality.
- 100% is planning for defects 100% is planning for defects.
- 100% inspection is not 100% perfect.
- It is too late. You can’t inspect quality into p q y
the product.
- It is reactive vs. proactive.
3/ 27/ 2008 Dr. A. Saddique 147
Deming’s 14 Points
4. End the practice of awarding p g
business on price tag alone. Instead,
minimize total cost. Reduce the
b f li b li i ti number of suppliers by eliminating
those who cannot provide evidence
of statistical control of processes of statistical control of processes.
× Cannot leave quality, service, and price
to the forces of competition for price
l alone.
× Price has no meaning without a measure
of the quality being purchased of the quality being purchased
3/ 27/ 2008 Dr. A. Saddique 148
Deming’s 14 Points
5. Improve constantly, and forever, p y
systems of production to improve
quality and productivity and thus
constantly reduce costs.
- Design quality in, using teamwork in
ddesign.
- Continually improve understanding of
the customer’s needs and of the way she the customer’s needs and of the way she
uses and misuses a product.
- There is no substitute for knowledge. There is no substitute for knowledge.
3/ 27/ 2008 Dr. A. Saddique 149
Deming’s 14 Points Deming s 14 Points
×Continuous: going on or extending ×Continuous: going on or extending
without interruption or break.
×Constant: ×Constant:
×1) not changing, remaining the same,
specifically
×a) remaining firm in purpose,
×b) remaining steady in loyalties,
×c) remaining free from variation or change;
stable.
×2) going on all the time; persistent ×2) going on all the time; persistent.
3/ 27/ 2008 Dr. A. Saddique 150
Deming’s 14 Points
6. Institute training on the job for all g j
employees.
× Management needs training to learn
b t th ll th f about the company, all the way from
incoming material to the customer.
× Central problem is need for × Central problem is need for
appreciation of variation.
× Money and time spent for training will × Money and time spent for training will
be ineffective unless inhibitors to good
work are removed (point 12).
3/ 27/ 2008 Dr. A. Saddique 151
Deming’s 14 Points
7. Focus management and supervisors
on leadership of their employees to
help them do a better job.
- Management must work on the sources
of improvement, the intent of quality of
product and service and on the product and service, and on the
translation of the intent into the design
and actual product.
- Focus on outcomes (e.g. MBO, zero
defects, performance appraisal) must be
b li h d l d hi i i l abolished, put leadership in its place.
3/ 27/ 2008 Dr. A. Saddique 152
Deming’s 14 Points
× Remove barriers that make it impossible for
the worker to do his/her job with pride of
workmanship.
× Leaders must know the work they supervise.
× Help workers get the training and tools they p g g y
need to understand and improve their
processes, then either empower them to p p
implement their improvements or act on their
suggestions.
3/ 27/ 2008 Dr. A. Saddique 153
Deming’s 14 Points
8. Drive out fear. Don’t blame employees for
problems ith the s stem Enco rage problems with the system. Encourage
effective, two-way communications.
Eliminate management by control.
× Fear leads to loss from impaired
performance and padded figures.
× Uncertainty breeds fear Share × Uncertainty breeds fear. Share
information and give people the
training they need to understand their g y
processes themselves and to take
action to improve them.
3/ 27/ 2008 Dr. A. Saddique 154
Deming’s 14 Points
9. Break down barriers between 9 ea do ba e s bet ee
departments (functional silos).
Encourage teamwork among g g
different areas such as research,
design, manufacturing,
i d l accounting, and sales.
× Draw a flow chart so that
everyone can see the system.
× Recognize internal customers.
3/ 27/ 2008 Dr. A. Saddique 155
Deming’s 14 Points
10. Eliminate programs, exhortations, and
slogans that ask for new levels of
productivity without providing better
methods. methods.
× Slogans never helped anyone to do a better
job.
× B d th ti th t k × Based on the assumptions that workers
could, if they just wanted to, do a better job
(e.g. do it right the first time, zero defects,
i d ti it ) Th i t improve productivity). There is not
substitute for knowledge.
× Demoralizing. g
3/ 27/ 2008 Dr. A. Saddique 156
Deming’s 14 Points
11. Eliminate arbitrary quotas, work
standards and objecti es that interfere standards, and objectives that interfere
with quality. Instead, substitute
leadership and continuous
i f k improvement of work processes.
× Ceiling on performance.
× Encourages cheating. × Encourages cheating.
× Goals without methods are folly. (how?)
× If system is stable – no use, you get what
the system is capable of If system is not the system is capable of. If system is not
stable – again no use, there is not way to
know what the system will produce.
3/ 27/ 2008 Dr. A. Saddique 157
3/ 27/ 2008 Dr. A. Saddique 158
Deming’s 14 Points
12. Remove barriers (poor systems and p y
poor management) that rob people of
pride in their work.
× People inherently want to do a good job and × People inherently want to do a good job and
be proud of their work.
× Stabilize the system (gather × Stabilize the system (gather
data over time, remove special
causes of variation, and stop , p
tampering) and remove barriers
that inhibit intrinsic motivation.
3/ 27/ 2008 Dr. A. Saddique 159
Deming’s 14 Points
13. Encourage life-long education and 13. Encourage life long education and
self-improvement of all employees.
× Education helps good employees
improve.
× Employees that know how to learn are
more flexible and open to the frequent more flexible and open to the frequent
changes that come from continual
improvement.
d lf ff × Education can encourage self-efficacy.
Motivation requires knowing what to do,
believing you can do it, and feeling that g y , g
it is worth doing.
3/ 27/ 2008 Dr. A. Saddique 160
Deming’s 14 Points
14. Put everyone to work on implementing
these 14 points these 14 points.
× Total involvement. Include all employees
and eventually be willing to focus on all and eventually be willing to focus on all
processes.
× Credibility.
× Patience. The biggest change is cultural,
and this takes lots of time.
× Without all 14 you do not have a system × Without all 14, you do not have a system.
× What is the most important process that
needs to be changed?
3/ 27/ 2008 Dr. A. Saddique 161
Metanoia
OA shift of mind OA shift of mind
OThe first process that must be
transformed is in the minds of transformed is in the minds of
managers. It involves how they
perceive the business and their p
relationships with customers,
suppliers, and employees.
h f d OThis transformation is discontinuous.
3/ 27/ 2008 Dr. A. Saddique 162
Deming's Seven Deadly Diseases
1. Lack of constancy of purpose
2. Emphasis on short-term profits
3. Evaluation of performance, merit rating, or
l i annual review
4. Mobility of top management
5. Running a company on visible figures alone
("counting the money")
6 Excessive medical costs 6. Excessive medical costs
7. Excessive costs of warranty, fueled by
lawyers that work on contingency fees lawyers that work on contingency fees
3/ 27/ 2008 Dr. A. Saddique 163
Deming’s Action Plan
1 Management struggle over 14 points 7 1. Management struggle over 14 points, 7
Deadly Diseases, Obstacles
2. Management takes pride and develops
courage for new direction
3. Management explain to personnel in the
company why change is necessary company why change is necessary
4. Divide every company into stages identifying
h ‘ h ’ the next stage as ‘the customer’
3/ 27/ 2008 Dr. A. Saddique 164
Deming’s Action Plan
5 Start an organisation to guide quality control 5. Start an organisation to guide quality control
(using Deming Cycle)
6. Everyone can take part in a team to improve
input and output at any stage input and output at any stage
7. Embark on construction of organisation for g
quality (involving knowledgeable
statisticians) statisticians)
3/ 27/ 2008 Dr. A. Saddique 165
Deming's Obstacles
1. Neglect of long-range planning and 1. Neglect of long range planning and
transformation
2. The supposition that solving problems,
t ti d t d hi ill automation, gadgets, and new machinery will
transform industry
3 Search for examples 3. Search for examples
4. Our problems are different
O 5. Obsolescence in schools
6. Reliance on quality control departments
7. Blaming the workforce for problems
3/ 27/ 2008 Dr. A. Saddique 166
Deming's Obstacles
8 Quality by inspection 8. Quality by inspection
9. False starts
10. The unmanned computer
11 M ti ifi ti 11. Meeting specifications
12. Inadequate testing of prototypes
13. "Anyone that comes to try to help us must
understand all about our business" understand all about our business
3/ 27/ 2008 Dr. A. Saddique 167
Deming’s System of Profound
Knowledge
1 Appreciation for a system 1. Appreciation for a system
2. Knowledge of statistical theory
3. Theory of Knowledge
4. Knowledge of Psychology
3/ 27/ 2008 Dr. A. Saddique 168
Philip Crosby p y
3/ 27/ 2008 Dr. A. Saddique 169
Quality is Free - Crosby
דQuality is free. It’s not a gift, but it is free.
Wh h li What costs money are the un-quality
things-all the actions that involve not doing
jobs right the first time” Philip Crosby jobs right the first time Philip Crosby.
×If you do things right the first time, you will
not spend money fixing them or doing
them all over again.
×Crosby claimed that all quality
improvement pay for themselves i e that improvement pay for themselves i.e. that
quality is free
3/ 27/ 2008 Dr. A. Saddique 170
Quality is Free - Crosby
Crosby was the first to popularize quality
for top management. Crosby's quality for top management. Crosby s quality
improvement process is based upon the
four absolutes of quality management:
1 Quality means conformance not elegance 1. Quality means conformance, not elegance
2. Its is always cheaper to do the job right
first time
3. The only performance indicator is the cost
of quality
4 The only performance standard is zero 4. The only performance standard is zero
defects (ZD) - The theme of the ZD is do it
right the first time.
3/ 27/ 2008 Dr. A. Saddique 171
Quality is Free - Crosby
· In Quality is Free, Crosby defined an
additional quality building tools, q y g ,
including the Quality Management
Maturity Grid which enables a company
to measure its present quality position
and pinpoint areas that need
improvement
3/ 27/ 2008 Dr. A. Saddique 172
14-steps to Quality Improvement - Crosby
Crosby identifies fourteen steps to quality
improvement, whether you manage a
l l ll b i large plant or run a small business:
1) Make sure that management people
d l are committed to quality.
2) Gather representatives from each
department to form quality
improvement team.
3/ 27/ 2008 Dr. A. Saddique 173
14-steps to Quality Improvement - Crosby
3) Measure processes to determine
where current and potential quality
problems lie.
4) Evaluate the cost of quality and
explain its use as a management tool.
5) Rise to all employee the quality
awareness and personal concern.
6) Take actions to correct problems
identified through previous steps.
3/ 27/ 2008 Dr. A. Saddique 174
14-steps to Quality Improvement - Crosby
7) Establish progress monitoring for the
improvement process. improvement process.
8) Train supervisors to actively carry out their
part of the quality improvement program. pa t o t e qua ty p o e e t p og a
9) Let everyone realize that there has been a
change and to reaffirm management g g
commitment by holding a Zero Defects
Day.
10) Encourage individuals to establish
improvement goals for themselves and
th i their groups
3/ 27/ 2008 Dr. A. Saddique 175
14-steps to Quality Improvement - Crosby
11)E l t i t 11)Encourage employees to communicate
to management the obstacles they face
in attaining their improvement goals in attaining their improvement goals.
12)Recognize and appreciate those who
participate. p p
13)Establish quality councils to
communicate on a regular basis.
14)Do it all over again to emphasis that the
quality improvement program never
d ends.
3/ 27/ 2008 Dr. A. Saddique 176
3/ 27/ 2008 Dr. A. Saddique 177
Fishbone (Cause and Effect or Ishikawa)
×Named after Kaoru Ishikawa ×Named after Kaoru Ishikawa
×Japanese Quality pioneer
×R bl k l t f fi h ×Resembles skeleton of a fish
×Focus on causes rather than
f bl symptoms of a problem
×Emphasizes group communication
d b and brainstorming
×Stimulates discussion
3/ 27/ 2008 Dr. A. Saddique 178
Fishbone (Cause and Effect or Ishikawa)
×One of Seven basic tools of Japanese ×One of Seven basic tools of Japanese
Quality
×L d t i d d t di f ×Leads to increased understanding of
complex problems
×Vi l d i l l ×Visual and presentational tool
3/ 27/ 2008 Dr. A. Saddique 179
Fishbone (Cause and Effect or
h k ) Ishikawa)
×Typically done on paper or chalkboard ×Typically done on paper or chalkboard
×Recently some computer programs
h b t d t k Fi hb have been created to make Fishbone
Diagrams
×I hik E i t ×Ishikawa Environment
3/ 27/ 2008 Dr. A. Saddique 180
Use in Organizations Use in Organizations
×Can be used to improve any product ×Can be used to improve any product,
process, or service
×Any area of the company that is ×Any area of the company that is
experiencing a problem
×Isolates all relevant causes ×Isolates all relevant causes
3/ 27/ 2008 Dr. A. Saddique 181
Use in Organizations (2 of 2) Use in Organizations (2 of 2)
×H l b i bl i t li ht ×Helps bring a problem into light
×Group discussion and
brainstorming
×Finds reasons for quality q y
variations, and the relationships
between them
3/ 27/ 2008 Dr. A. Saddique 182
Creating Fishbone Diagrams
(1 of 4)
A - As a group:
1. Establish problem (effect)
-state in clear terms
-agreed upon by entire group g p y g p
2. Problem becomes the
“head” of the fish head of the fish
-draw line to head (“backbone”)
3/ 27/ 2008 Dr. A. Saddique 183
Creating a Fishbone Diagram
3. Decide major causes of the
problem
- by brainstorming
- if the effect or problem is part of a
process the major steps in the process can
be used be used
4. Connect major causes to
backbone of the fish with backbone of the fish with
slanting arrows
3/ 27/ 2008 Dr. A. Saddique 184
Creating a Fishbone Diagram (3 of 4)
5 Brainstorm secondary causes for 5. Brainstorm secondary causes for
each of the major causes
6 Connect these secondary causes to 6. Connect these secondary causes to
their respective major causes
7. Repeat steps 5 & 6 for sub- 7. Repeat steps 5 & 6 for sub
causes dividing with increased
specificity
- usually four or five levels
3/ 27/ 2008 Dr. A. Saddique 185
Creating a Fishbone Diagram (4 of 4)
8 Analyze and evaluate causes and 8. Analyze and evaluate causes and
sub-causes
-may require the use of statistical,
analytical, and graphical tools
9. Decide and take action
3/ 27/ 2008 Dr. A. Saddique 186
E l Example
Step 1 & 2: · Step 1 & 2:
Poor Service
(“backbone”)
(“head”)
3/ 27/ 2008 Dr. A. Saddique 187
E l Example
Step 3 & 4: · Step 3 & 4:
Responsiveness Responsiveness
Appearance
Poor Service
Reliability Attention
3/ 27/ 2008 Dr. A. Saddique 188
E l Example
Step 5 6 & 7: · Step 5, 6, & 7:
Responsiveness
Appearance
time
personnel
facility
equipment
Poor Service
courtesy
One on one
i
accuracy
Attention
Reliability
courtesy
service
dependability
3/ 27/ 2008 Dr. A. Saddique 189
E l Example
×Step 8 & 9: ×Step 8 & 9:
×Use tools to analyze and evaluate causes
×Pareto diagrams, charts, and graphs
×Statistical analysis for causes in processes
×Decide and take action
×U fi hb di l i d l i ×Use fishbone diagram, analysis and evaluations
to find causes that can be fixed
×Take action to eliminate and fix problem p
causes
3/ 27/ 2008 Dr. A. Saddique 190
E i Exercise
×Create a Fishbone (cause and effect ×Create a Fishbone (cause and effect,
Ishikawa) Diagram for the following:
× Management at Fish Industries has noticed × Management at Fish Industries has noticed
that the productivity of its workers is well
below the standard. After interviewing its
l it ti d th t t j it employees, it was noticed that a vast majority
felt dissatisfied and unhappy with their work.
Your boss has asked you and a group of your
fi d h f k peers to find the causes of worker
dissatisfaction . Include all possible causes to
at least the secondary level.
3/ 27/ 2008 Dr. A. Saddique 191
SSummary
Fi hb e Di m - Fishbone Diagrams
- visual diagram
- resembles fish skeleton
- identifies the causes of a problem
( ff ) d h i l i hi (effect), and their relationships
- created by Kaoru Ishikawa for
Q li M Quality Management
3/ 27/ 2008 Dr. A. Saddique 192
SSummary
×Organizational Uses ×Organizational Uses
×Increases communication about problems
×U d t i d t ×Used to improve any product, process, or
service
×Important part of quality management ×Important part of quality management
3/ 27/ 2008 Dr. A. Saddique 193
SSummary
×C i f Fi hb di ×Creation of Fishbone diagrams
×Problem or effect is head of fish
×Identify major, secondary and tertiary
causes, and attach to backbone
id tif i l ti hi identifying relationships
×Analyze and Evaluate results
f ×Act to fix the problem(s)
3/ 27/ 2008 Dr. A. Saddique 194
Vilfredo Pareto Vilfredo Pareto
× 1848 1923 × 1848-1923
× Italian Economist
3/ 27/ 2008 Dr. A. Saddique 195
The Pareto Diagram
× It is a special type of vertical bar chart × It is a special type of vertical bar chart
in which the categorized responses
are plotted in the descending order of p g
their percentages, and combined with
a cumulative percentage polygon on
the same scale.
× Useful when there are many
categories
× Vertical axis shows the %, horizontal
axis categories.
3/ 27/ 2008 Dr. A. Saddique 196
Pareto Diagram Pareto Diagram
Pareto diagram
Axis for bar
30
40
50
80
100
120
chart shows
% invested
in each
10
20
30
20
40
60
in each
category.
Axis for line
0 0
20
Axis for line
graph shows
cumulative
i d
3/ 27/ 2008 Dr. A. Saddique 197
Stocks Bonds Savings CD
% invested .
Juran’s Quality Trilogy
•Ideas similar to Deming’s but •Ideas similar to Deming s, but
highly structured
h C •Three Components:
×Quality Planning ×Quality Planning
×Quality Control
l ×Quality Improvement
3/ 27/ 2008 Dr. A. Saddique 198
Quality Trilogy Diagram
C
o
s
t
o
QUALITY
IMPROVEMENT Original Zone of QC
F
P
o
o
r
Q
New Zone of QC
u
a
l
I
Time
QUALITY
QUALITY CONTROL
3/ 27/ 2008 Dr. A. Saddique 199
t
y
PLANNING
Quality Planning
×Determine who the customers are
(classify)
×Determine the customers needs ×Determine the customers needs
(real and perceived; bank)
×Develop product features that
respond to the customers needs p
(matrix analysis)
3/ 27/ 2008 Dr. A. Saddique 200
Quality Planning (cont.)
×D l th bl t ×Develop the processes able to
produce the product features
(matrix analysis)
×Transfer the plans to the ×Transfer the plans to the
operating forces (pilot tests,
simulations) simulations)
3/ 27/ 2008 Dr. A. Saddique 201
Quality Control
×E l t t l d t ×Evaluate actual product
performance (SQC monitoring)
×Compare actual performance to
product goals product goals
×Act on the difference
3/ 27/ 2008 Dr. A. Saddique 202
Quality Improvement
×Establish the infrastructure ×Establish the infrastructure
(quality council recommended)
×Id tif th i t ×Identify the improvement
projects ("breakthrough": "Make
No Small Plans")
×Establish the project teams ×Establish the project teams
(overseen by the quality council;
not self managed) not self-managed)
3/ 27/ 2008 Dr. A. Saddique 203
Quality Improvement (cont.)
×Provide the teams with ×Provide the teams with
resources, training and
motivation to: motivation to:
×Diagnose the causes
×Stimulate remedies
×Establish the controls to "hold ×Establish the controls to hold
the gains"
3/ 27/ 2008 Dr. A. Saddique 204
QUESTIONS QUESTIONS
3/ 27/ 2008 Dr. A. Saddique 205
Abdulaziz A. Saddique Pharm.D. ,CPHQ, CSSMBB
206
:ىلاعت لاق
تح موقب ام ريغي ل ﷲ نإ ىتح موقب ام ريغي ل ﷲ نإ
مھــــــسفنأب ام اوريغي مھ وري ي
) ميظعلا ﷲ قدص (
3/ 27/ 2008 Dr. A. Saddique 207
Q li i H l h P i Quality in Healthcare: Perspective
- The right care
- At the right time
- Delivered safely
- Delivered efficiently
- At lowest possible cost - At lowest possible cost
- Constantly improved
3/ 27/ 2008 Dr. A. Saddique 208
What is Performance Improvement?
Performance Improvement is the p
process by which we assure the
delivery of Efficacious and
A i t f i di id l ti t Appropriate care for individual patient
in a Timely manner, Effective and
Coordinated with other care providers Coordinated with other care providers,
Safe and Efficient with Respect and
Caring for the patient.
3/ 27/ 2008 Dr. A. Saddique 209
Key Components for Success Key Components for Success
1. Vision and values driven
2 Leadership 2. Leadership
3. Physician involvement
4 Customer focused 4. Customer-focused
5. Infrastructure for continuous improvement
6 C i ti 6. Communication
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3/ 27/ 2008 Dr. A. Saddique 211
Not hi ng Happens Unl ess y ou hav e a
dr eam
Integration of Quality
Improvement Concepts Improvement Concepts
· Vision.
The vision of the organization
b i ith it l d hi begins with its leadership.
3/ 27/ 2008 Dr. A. A. Saddique 212
Key Components for Success Key Components for Success
1. Vision and values driven
2. Leadership
3. Physician involvement y
4. Customer-focused
5. Infrastructure for continuous improvement 5. Infrastructure for continuous improvement
6. Communication
3/ 27/ 2008 Dr. A. A. Saddique 213
Leadership Leadership
· Vision to unify all the quality improvement
projects. projects.
· Chief motivators during the massive
change in philosophy as a result of g p p y
applying TQM.
· They have the power to change the systems
before crisis is reached.
3/ 27/ 2008 Dr. A. A. Saddique 214
Leadership Leadership
· They have the ability to allocate resources
necessary for solving the problems and
affecting continuous improvement affecting continuous improvement.
· Priority for quality improvement can be
attained only if top management wishes attained only if top management wishes
for it.
· Allocate adequate training time for every oc e dequ e g e o eve y
level of the organization.
3/ 27/ 2008 Dr. A. A. Saddique 215
Key Components for Success Key Components for Success
1. Vision and values driven
2 L d hi 2. Leadership
3. Physician involvement
4. Customer-focused
5. Infrastructure for continuous improvement
6. Communication
3/ 27/ 2008 Dr. A. A. Saddique 216
Medical Staff involvement
Medical staff are:
· The driving force of the healthcare facility.
· The heads of the healthcare teams.
· The operators of the organization.
· Carry the responsibility of the well being
of the patients.
3/ 27/ 2008 Dr. A. A. Saddique 217
Key Components for Success Key Components for Success
1. Vision and values driven
2. Leadership
3. Physician involvement y
4. Customer-focused
5. Infrastructure for continuous improvement 5. Infrastructure for continuous improvement
6. Communication
3/ 27/ 2008 Dr. A. A. Saddique 218
Customer Focus Customer Focus
Healthcare is a business:
· In business the customer is always right
C t ti f ti i th i bj ti f · Customer satisfaction is the main objective of
the healthcare facility
· Without patients there will be no healthcare · Without patients there will be no healthcare
facilities
· We are for the service of the patient p
· We are all customers for one another
3/ 27/ 2008 Dr. A. A. Saddique 219
Key Components for Success Key Components for Success
1. Vision and values driven
2. Leadership
3. Physician involvement y
4. Customer-focused
5. Infrastructure for continuous improvement 5. Infrastructure for continuous improvement
6. Communication
3/ 27/ 2008 Dr. A. A. Saddique 220
Infrastructure for Continuous
improvement
E bli h f I f · Establishment of an Infrastructure.
The organization must establish an
infrastructure within which the cycle
of improvement can operate. The
JCAHO standards is the optimal
infrastructure that any health care y
facility should adopt.
3/ 27/ 2008 Dr. A. A. Saddique 221
Integration of Quality
Improvement Concepts Improvement Concepts
JCAHO infrastructure composed of: p
- Quality council of steering committee
- Quality improvement adviser or coach Q y p
and
- Quality improvement teams
3/ 27/ 2008 Dr. A. A. Saddique 222
Integration of Quality Improvement g Q y p
Concepts
Establishment of infrastructure · Establishment of infrastructure.
- Quality council or steering committee.
lit i t d i h d - quality improvement adviser or coach and.
- quality improvement teams.
Get your staff involved in the quality - Get your staff involved in the quality
improvement process.
3/ 27/ 2008 Dr. A. Saddique 223
Get first things first Get first things first
Standards · Standards
· Policy & Procedure
· Indicators
· Benchmarks
· Data
TIP TIP TIP
Stay in the solution, not the
problem. Green light thinking is
an energizing way to solve
problems and build
t i it
3/ 27/ 2008 Dr. A. Saddique 224
team spirit.
Key Components for Success Key Components for Success
1. Vision and values driven
2. Leadership
3. Physician involvement y
4. Customer-focused
5. Infrastructure for continuous improvement 5. Infrastructure for continuous improvement
6. Communication
3/ 27/ 2008 Dr. A. A. Saddique 225
Communications Communications
Staff involvement's through:
· Top management vision communication
· Suggestion programs
· Teams
P bl l i f db k & it i · Problem solving feedback & monitoring
· Quality improvement programs
· Training Training
3/ 27/ 2008 Dr. A. A. Saddique 226
QUALITY QUOTE!! QUALITY QUOTE!!
E E E PEOPLE WHO PLAN THE
BATTLE DO NOT BATTLE, DO NOT
BATTLE THE PLAN..
3/ 27/ 2008 Dr. A. Saddique 227
Integration and Application
of Performance
Improvement Improvement
3/ 27/ 2008 Dr. A. Saddique 228
JCAHO Assessment Plan JCAHO Assessment Plan
· Assessment and improvement methods
Ten Step process approved by JCAHO: Ten-Step process approved by JCAHO:
- Assign responsibility
- Delineate scope of care and service
- Identify important aspects of care and service
- Identify indicators
- Establish a means to trigger evaluation Establish a means to trigger evaluation
- Collect and organize data
3/ 27/ 2008 Dr. A. A. Saddique 229
JCAHO Assessment Plan JCAHO Assessment Plan
Ten-Step process approved by JCAHO
(cont.): ( )
- Initiate evaluation
- Take actions to improve care and service
- Assess the effectiveness of the actions and
ensure that improvement is maintained
- Communicate results to relevant individuals - Communicate results to relevant individuals
and groups
3/ 27/ 2008 Dr. A. A. Saddique 230
Execution Plan Execution Plan
Stage I:
• Organizing meeting with the departments Organizing meeting with the departments
heads and use the feedback form to assess
departments views regarding their services. p g g
• Encouraging each department to have
complete and up-to-date Policy and complete and up to date Policy and
Procedure manual.
3/ 27/ 2008 Dr. A. Saddique 231
Execution Plan Execution Plan
- Assist departments that require
assistance with the development of their p
Policy and Procedure manual, by
guidance, providing sample Policy and
Procedures from other hospitals. Procedures from other hospitals.
3/ 27/ 2008 Dr. A. Saddique 232
Execution Plan Execution Plan
- List the hospital most common problems - List the hospital most common problems
and set a priority listing of the problems
and carry out Monitoring and and carry out Monitoring and
assessment tasks to evaluate the
operating policies and procedures operating policies and procedures.
‚ Incident reports evaluation to identify the
ibl bl possible problems.
‚ Administration views and comments.
3/ 27/ 2008 Dr. A. Saddique 233
Execution Plan Execution Plan
· Carry on three surveys to assess · Carry on three surveys to assess
patients and employees satisfaction
level level.
- In-patients survey (completed).
- Out-patients survey. Out patients survey.
- Employees survey.
· Implementing a training program Implementing a training program.
- Trainers training program.
3/ 27/ 2008 Dr. A. Saddique 234
Execution Plan Execution Plan
· Stage II:
h l d - Assessing the current policies and
procedures with respect to the
JCAHO/JCI and other hospitals operating J /J p p g
standards.
- Revising the Policies and procedures as
needed needed.
- Reengineering some of the policies and
procedures as needed. p
- This will continue along with the training
of the trainers and moving to training of
the Staff the Staff.
3/ 27/ 2008 Dr. A. Saddique 235
Execution Plan Execution Plan
· Continue monitoring of the Continue monitoring of the
problem’s lists and working with the
administrations and the departments
l i i d bl to solve existing and new problems
as they occur.
Devising and implementing on line · Devising and implementing on-line
policy and procedures.
· Development of an orientation · Development of an orientation
program for all new staff (Mandatory
for three days). y )
3/ 27/ 2008 Dr. A. Saddique 236
Execution Plan Execution Plan
· Stage III: g
- Completion of the P & P revision and
update.
R i t t - Review cost centers:
‚ Services that consume the majority of the
budget. g
‚ Services that shows inappropriate use of
the resources.
‚ Services that can be standardized ‚ Services that can be standardized.
- Establishment of policies to arrest
excessive cost.
3/ 27/ 2008 Dr. A. Saddique 237
Execution Plan Execution Plan
· Development of standardization in p
routine clinical operations.
‚ Clinical Policies.
C i i l P h ‚ Critical Pathways.
· Carry out an Auditing System:
- Internal Auditing - Internal Auditing.
- External Auditing.
· Full implementation of TQM system · Full implementation of TQM system.
3/ 27/ 2008 Dr. A. Saddique 238
Execution Plan Execution Plan
Development of an ongoing system · Development of an ongoing system
for:
Monitoring - Monitoring.
- Problem solving.
- Policies and Procedures updating - Policies and Procedures updating.
- Prepare for accreditation.
- Training and development of human - Training and development of human
resources.
3/ 27/ 2008 Dr. A. Saddique 239
Integration of Quality Improvement g Q y p
Concepts
Vision · Vision
- Quality Improvement (QI) Plan
Ed ti M d t ff - Educating Managers and staff
- Focusing QI activities
Concurrent support system - Concurrent support system
TIP TIP TIP
There is no Quality
Improvement without
a clear Vision
3/ 27/ 2008 Dr. A. Saddique 240
a clear Vision
Integration of Quality Improvement g Q y p
Concepts
Customer Survey Analysis · Customer Survey Analysis
· Information Summarization,
C di ti Di i ti d Coordination, Dissemination and
Presentation
I l i f O i i id · Implementation of Organization-wide
Monitoring and Evaluation Activities
3/ 27/ 2008 Dr. A. Saddique 241
Improvement Process Improvement Process
· Vision execution · Vision execution.
- Select the new Standards.
- Integrate your standards with monitoring - Integrate your standards with monitoring
and evaluation activities.
- Get your benchmarking.
- Document your actions.
- Get your Physicians involved.
3/ 27/ 2008 Dr. A. Saddique 242
Improvement Process Improvement Process
Vision execution (Cont ) · Vision execution (Cont.)
- Collect data
‚ Utilization review ‚ Utilization review
‚ Peer review
‚ Incident reports
‚ Data
‚ External contracted evaluators
Id if bl d f ll CQI l - Identify problems and follow CQI tools
3/ 27/ 2008 Dr. A. Saddique 243
Integration of Quality g y
Improvement Concepts
· Developing a quality improvement plan
C i ti l i CQI - Communication role in CQI
- Training for CQI
- Customer focus Custo e ocus
- Quality council role
- Quality coach/advisor
Ed i d ff - Educating managers and staff
3/ 27/ 2008 Dr. A. A. Saddique 244
Integration of Quality
Improvement Concepts Improvement Concepts
· Focusing on quality improvement
activities
· Concurrent support systems
· Quality improvement projects
· Financial considerations
3/ 27/ 2008 Dr. A. A. Saddique 245
Measuring Quality Measuring Quality
M i lit i Measuring quality requires use
of both standards and
performance measures.
TIP TIP TIP
Listening to you customers
will till you a lot about
3/ 27/ 2008 Dr. A. Saddique 246
the quality of your
services
Standards Standards
Every organization has its own Every organization has its own
operating standards even if it was not
written written.
Your responsibility is to find and
document these standards before you document these standards before you
try to change it or modify it.
3/ 27/ 2008 Dr. A. Saddique 247
Basic Steps In Performance p
Improvement
· Find your operating standards
· Understand your system
Id if bl · Identify problems
· Quantify the size of each problem
Priorities you problems · Priorities you problems
TIP TIP TIP TIP TIP TIP
People are not problems,
make your people problem
3/ 27/ 2008 Dr. A. Saddique 248
y p p p
solvers
ProblemIdentification Problem Identification
A k I Wh t W C W ? · Ask: In What Ways Can We…?
- Assess the Situation. Get the facts.
G t ibl l ti ith - Generate possible solutions with green
light, non-judgmental thinking.
- Select the best solution - Select the best solution.
TIP TIP TIP
Look at problems as
opportunities for Improvement
not just problems
3/ 27/ 2008 Dr. A. Saddique 249
not just problems
Performance Performance
Th " f " i li h · The term "performance" implies that
a responsible health care providing
entity: entity:
- Can be identified.
I h ld t bl f it b d - Is held accountable for its observed
behavior.
- Has a reasonable degree of control over - Has a reasonable degree of control over
the aspect of care being evaluated.
3/ 27/ 2008 Dr. A. Saddique 250
Performance Improvement p
Objectives
- Concentrate on the Process.
- Identify areas of improvement.
- Set priority listing for improvement tasks.
- Use a systematic approach to problem
l i solving.
- Involves people who does the work.
Selects the most appropriate solution for the - Selects the most appropriate solution for the
problem on hand.
3/ 27/ 2008 Dr. A. Saddique 251
What Is Performance Measurement? What Is Performance Measurement?
Health care performance measurement
is the process of using a tool based is the process of using a tool based
on research (a "performance
measure") to evaluate a:
- Managed care organization (MCO).
- Health plan or program.
- Hospital.
- Health care practitioner.
3/ 27/ 2008 Dr. A. Saddique 252
Performance Measurement Performance Measurement
Uses indicators · Uses indicators
· Looks at past performance
· Measures outcome
TIP TIP TIP
Look for your staff satisfaction
and use them to empower
your performance
improvement process
3/ 27/ 2008 Dr. A. Saddique 253
i p ove ent p ocess
measurement measurement
The term "measurement" implies that · The term measurement implies that
the approach being used is:
Rigorous - Rigorous.
- Systematic.
- Quantifiable - Quantifiable
3/ 27/ 2008 Dr. A. Saddique 254
Measurement Benefits Measurement Benefits
· Help consumers employers and Help consumers, employers and
purchasers make informed choices
· Increase accountability in health care y
· Compare providers
· Design health plans Design health plans
And benefit packages
TIP TIP TIP TIP TIP TIP
Teamwork empowers
people.
3/ 27/ 2008 Dr. A. Saddique 255
Measurement Benefits Measurement Benefits
· Data gives the organization the · Data gives the organization the
power to improve
· Help organizations demonstrate p g
performance
· Good data leads to action, and
b tt t better outcome
· Involves doctors in quality
improvement
TIP TIP TIP
improvement
Master the basics. High
achievers are skilled at what
they do
3/ 27/ 2008 Dr. A. Saddique 256
they do.
What Does Performance
Measurement Require?
A performance measurement tool · A performance measurement tool
must:
Be objective - Be objective.
- Be based on scientific evidence.
- Not affect or distort results - Not affect or distort results.
3/ 27/ 2008 Dr. A. Saddique 257
What Do Performance Measurement
Results Tell Us?
Performance measurement results · Performance measurement results
describe an observed level of
performance (immunization rate rate performance (immunization rate, rate
of parental satisfaction with referrals,
number of medication errors number number of medication errors, number
of morbidity or mortality secondary to
medical intervention) medical intervention)
3/ 27/ 2008 Dr. A. Saddique 258
What Types of Measures Can We Use?
· Although performance measures can · Although performance measures can
apply to various aspects of health care,
no standardized set of categories has yet
emerged emerged.
- Early Quality Categories
- Avedis Donabedian, M.D., a pioneer in the
i f i h l h li science of measuring health care quality,
established a set of quality categories
involving structure, process, and outcomes
that is still widely used today that is still widely used today.
- Structure. The resources and organizational
arrangements are in place to deliver care.
3/ 27/ 2008 Dr. A. Saddique 259
Examples
Number of nurses per patient · Number of nurses per patient.
· Percentage of physicians who are
b d tifi d board certified.
· Presence of quality improvement
programs.
3/ 27/ 2008 Dr. A. Saddique 260
Process Process
· Appropriate physician and other · Appropriate physician and other
provider activities are carried out to
deliver care.
· Examples:
- Percentage of females of specified age
recei ing mammograph receiving mammography.
- Percentage of patients with asthma for
whom appropriate medications are ordered.
- Number of times adolescents are provided
guidance on smoking avoidance.
3/ 27/ 2008 Dr. A. Saddique 261
Outcomes Outcomes
· The results of physician and other · The results of physician and other
provider activities.
· Examples: · Examples:
- Number of patients successfully treated.
- Test results within a range indicating - Test results within a range indicating
effective functioning.
- Number of avoidable complications and Number of avoidable complications and
deaths.
3/ 27/ 2008 Dr. A. Saddique 262
Outcomes Outcomes
· Patient definitions of desired results · Patient definitions of desired results.
· Use of the best currently available medical
knowledge.
· Most experts believe that outcomes are the best · Most experts believe that outcomes are the best
measures. However, outcomes are difficult to
interpret because they can be significantly affected
by patient characteristics such as: y p
- Age. Age can affect health care outcomes.
- Health status. Healthier people are likely to have
better health care outcomes.
- Socioeconomic characteristics. Better diets and
healthier environments relate to better health care
outcomes.
3/ 27/ 2008 Dr. A. Saddique 263
Difficulties with Rates
· Well-established standards of care exist · Well established standards of care exist
for some areas of health care treatment
and services. It is thus possible, in p ,
these areas, to say that a rate is "high"
or "low" or that a quality problem does
d or does not exist.
· Example: Standards exist for the
i b d i i appropriate types, number, and timing
of vaccinations for children. Thus, rates
are easily determined and compared are easily determined and compared
3/ 27/ 2008 Dr. A. Saddique 264
Quality Improvement
· Performance measurement provides · Performance measurement provides
one of the tools needed for effective
quality improvement initiatives. You quality improvement initiatives. You
can use performance measurement to
establish the initial or baseline level of
f d performance and to re-measure
performance after the quality
improvement intervention has begun improvement intervention has begun.
3/ 27/ 2008 Dr. A. Saddique 265
Th P f I t P Th P f I t P
GET and MAINTAIN STAKEHOLDER AGREEMENT
The Performance Improvement Process The Performance Improvement Process
CONSIDER
INSTITUTIONAL
DEFINE
DESIRED
PERFORMANCE
CONTEXT
MISSION
GOALS
FIND ROOT
CAUSES
Why does the
performance
SELECT
INTERVENTIONS
What can be done
to close the
GAP GAP
IMPLEMENT
INTERVENTIONS
GOALS
STRATEGIES
CULTURE
DESCRIBE
ACTUAL
performance
gap exist?
to close the
performance gap?
CLIENT and
COMMUNITY
PERSPECTIVES
ACTUAL
PERFORMANCE
MONITOR AND EVALUATE PERFORMANCE
3/ 27/ 2008 Dr. A. Saddique 266
MONITOR AND EVALUATE PERFORMANCE
Hierarchy of Quality Measurements Hierarchy of Quality Measurements
Ef f i ci ency
Qual i t y
Pat i ent Saf et y
3/ 27/ 2008 Dr. A. Saddique 267
The Need for Quality The Need for Quality
Quality is needed to provide the · Quality is needed to provide the
following:
- Environment for work excellence - Environment for work excellence
- Means to evaluate performance
- Means to decrease Cost
- Means to improve performance
3/ 27/ 2008 Dr. A. Saddique 268
Quality Provides: Quality Provides:
Environment for work excellence · Environment for work excellence
- To establish quality program it requires a set
of standards for care. These standards are of standards for care. These standards are
the basis for accreditation of the healthcare
organization.
S ki d d f ll ff - Sets working standards for all staff
irrespective of their background and
expertise. p
- Allows staff contribution in decision making
3/ 27/ 2008 Dr. A. Saddique 269
Quality Provides: Quality Provides:
Means to evaluate performance · Means to evaluate performance
- Quality provides tools to evaluate
performance of the different services as well performance of the different services as well
as staff performance.
- Also it provide the ground for overall
h l h i i l healthcare organizational assessment.
3/ 27/ 2008 Dr. A. Saddique 270
Quality Provides: Quality Provides:
Means to decrease Cost · Means to decrease Cost
- Cost containment is essential especially in a
continuously increasing healthcare cost. continuously increasing healthcare cost.
Quality management can provide means to
decrease waste and maximize the utilization
of the resources of the resources.
3/ 27/ 2008 Dr. A. Saddique 271
Approach Approach
d i i Measure determination
- Expert panels for specific measures p p p
- Evidence in peer-reviewed journals
- Use of consensus measures - Use of consensus measures
- Adoption of other robust outcome reports
3/ 27/ 2008 Dr. A. Saddique 272
Approach pp
C f f Current focus of measurement
- Clinical evidence-based measures
V l M ‚ Volume Measures
‚ Process Measures
- Adoption of technology - Adoption of technology
- Adoption of staffing standards
3/ 27/ 2008 Dr. A. Saddique 273
Challenges Associated with Using Reports Challenges Associated with Using Reports
of Quality
· Consumers—reports may be too technical—too
many caveats y
· Healthcare Providers—reports may not be detailed
enough to replicate
· Purchasers—reports may not be focused at
appropriate unit of analysis
· Government reports may not include information · Government—reports may not include information
necessary for making policy decisions
3/ 27/ 2008 Dr. A. Saddique 274
Recommendations
· Push for “consensus” driven measurement when · Push for consensus driven measurement when
possible
· Push measure developers to build in Push measure developers to build in
specifications and user guides
· Promote open systems—including risk p y g
adjustment
· Accept notion that reports can differ in
ifi it f diff t di specificity for different audiences
3/ 27/ 2008 Dr. A. Saddique 275
Policy Agenda
A d f d t ti f · Assess need for mandatory reporting of
healthcare information in specific quality areas
A t t f d l i t l i · Assess state vs. federal vs. private role in
assuring quality in healthcare
· Assess need for a policy agenda in support of · Assess need for a policy agenda in support of
public reporting
3/ 27/ 2008 Dr. A. Saddique 276
S f P f Steps of Performance
Improvements Improvements
3/ 27/ 2008 Dr. A. Saddique 277
T l A li i Tools Application
Dr. A. Saddique 278
APPLICATION OF CQI APPLICATION OF C.Q.I
“Guiding Cycle”
· FOCUS
‚ FIND ‚ FIND
‚ ORGANISE
‚ CLARIFY
‚ UNDERSTAND
‚ SELECT
Dr. A. Saddique 279
3/ 27/ 2008 Dr. A. Saddique 280
Obst acl es ar e t hose f r i ght f ul t hi ngs y ou
see w hen y ou f ai l t o f ocus on y our goal s.
FOCUS FOCUS
· Find a process to improve Find a process to improve
· Organize a team that knows the
process
· Clarify knowledge of the process Clarify knowledge of the process
· Understand causes of process
variation
· Select the process improvement
Dr. A. Saddique 281
· Select the process improvement
PTEAM Approach PTEAM Approach
Pl ·Plot
·Theorize ·Theorize
·Examine Examine
·Analyze y
·Modify
3/ 27/ 2008 Dr. A. Saddique 282
Surgery Process Chart:
Elec
Adm
OP workup
OP visit
Investigation
Anaes
Consultn
Day
Surg
Booking
Surg
Admit
Fit
Prep &
Premed
S
Postop
Preop
Reassess
Unfit
IP
Workup
Surgery
Recovery
End
Discharge
Disch Planning
OP Follow-Up
Dr. A. Saddique 283
Quality Improvement Techniques
Cause Cause--effect / Ishikawa Diagram / Fishbone: effect / Ishikawa Diagram / Fishbone:
EFFECT
M M
M
- Describes the process by its causative
M
P
- Describes the process by its causative
relationships.
- Adopts premise that work processes are complex
causal systems consisting of 4ms and a P -
machines, materials, methods, measurements,
people.
284
- A completed good diagram is well balanced.
Cause Effect Diagram Cause Effect Diagram
Policy & Procedure
Supply
Delay
Waiting time
too long
Short
too long
Schedule
Down
Slow
Computer
Staff
Down
Sickness
Dr. A. Saddique 285
Line Graph Line Graph
2000
1400
1600
1800
2000
UCL
800
1000
1200
1400
UCL
LCL
x
-
200
400
600
800
Procedures
0
200
Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec
Dr. A. Saddique 286
QI is a Science: Statistical Approach
Dimensions of Data
SHAPE
R
E
A
D
CENTER
S
P
SEQUENCE
Dr. A. Saddique 287
QI is a Science: Statistical Approach
O ll I t St t Overall Improvement Strategy
Remove special causes
Process change
Process change
Outcome
Unstable process
Stable process Stable process
Stable process
Dr. A. Saddique 288
Unstable process
Special causes present
Average is too high
p
Common cause
variation is high
Average is too high
p
Common cause
variation reduced
Average too high
Stable process
Common cause
variation low
Average reduced
Quality Improvement Quality Improvement
Techniques
Process Description Process Description
STATISTICAL STATISTICAL
TOOLS
Dr. A. Saddique 289
C Q I PRINCIPLES C.Q.I. PRINCIPLES
· Evaluate processes, not individuals
· Drive fear as a motivate from the · Drive fear as a motivate from the
workplace
· Build quality into the processes · Build quality into the processes
· Benchmark for continuous improvement
· Objectively derived data determine · Objectively derived data determine
decisions
· Focus on customer needs · Focus on customer needs
· Build strong customer-supplier relations
Dr. A. Saddique 290
05/04/97
IMPLEMENTATION OF CQI IMPLEMENTATION OF CQI
F CQI i l t ti d For CQI implementation we need
to implement organization wide
Total Quality Management
program. p g
BUT
CQI is the beating heart of TQM CQI is the beating heart of TQM
Dr. A. Saddique 291
05/04/97
APPLICATIONOF CQI APPLICATION OF C.Q.I
“Guiding Cycle”
· PDCA
‚ PLAN
‚ DO
‚ CHECK
‚ ACT ‚ ACT
Dr. A. Saddique 292
PDCA PDCA
· PDCA · PDCA
- PLAN THE STRATEGY FOR THE CHANGE
DO THE CHANGES EFFECTIVE SET DATE - DO THE CHANGES EFFECTIVE SET DATE
- CHECK THE RESULTS OF THE CHANGE
- ACT THE PROGRAM (REPEAT TO - ACT THE PROGRAM (REPEAT TO
EVALUATE THE PROCESS CHANGES
QUARTERLY)
Dr. A. Saddique 293
Find a Process to Improve
O i T Th K h P Organize a Team That Knows the Process
Clarify current knowledge of the process
Understand the causes of process variation
S l h i Select the process improvement
PDCA Cycle
PLAN
ACT
* Improvement
* Data collection
* To hold gain
* Continue
Data collection
* Improvement
* Data collection
* Data for Process
improvement
C t i
Improvement
Dr. A. Saddique 294
DO
CHECK
* Data analysis
- Customer view
- Worker view
PDSA Cycle: Implementation
PLAN
• Hypothesis: What do you expect to accomplish?
• Action Plan: Who? Does What? When?
• With what tools and training? • With what tools and training?
• What are the data collection procedures?
DO
• How will the change be implemented?
DO
• What are the results?
g p
• What are the process indicators?
STUDY
W th ?
• What happened?
• What are we learning?
• Was there success?
• What will we do with the results?
• What else needs to be done?
ACT
Dr. A. Saddique
295
• Are there more change ideas?
• What do we do to hold the gains ?
STEPS OF CQI APPLICATION STEPS OF CQI APPLICATION
· Priorities Opportunities for change
· Forming the team to evaluate the
process p
· Setting the team to work
OGenerating the necessary charts OGenerating the necessary charts
OEvaluating the extent of the
problem problem
OP-TEAM approach to problem
l i
Dr. A. Saddique 296
solving
Quality Improvement Quality Improvement
¤ What is QI? QI is a Science!! What is QI? QI is a Science!!
_Scientific Method
_Systematic Methods _Systematic Methods
_Continuous Data
_Testing
_ACT _ C
¤ Gain knowledge about effectiveness
and its deployment
Dr. A. Saddique 297
and its deployment
Summaryy
· Quality can be measured
· Methods of measurement should be publicly
available to allow for replication and
improvement
· Public reporting will differ across user types
and is different from “internal quality
improvement”
· Consensus is good—but will it drive change?
· Policy makers are involved—whether or not
h b they want to be….
3/ 27/ 2008 Dr. A. Saddique 298
FINALLY FINALLY
REMEMBER THAT THE REMEMBER THAT, THE
1000 MILE TRIP 1000 MILE TRIP
STARTS WITH ONE
STEP
3/ 27/ 2008 Dr. A. Saddique 299
3/ 27/ 2008 Dr. A. Saddique 300
3/ 27/ 2008 Dr. A. Saddique 301
· Variation in hospitalization rates - the
“decision to treat” b l decision to treat --Wennberg et. al
· High rates of care judged inappropriate
or equivocal or equivocal --RAND: Brook, Chassin, Leape et. al (primun
non nocere)
· Variation in the process of care -- the Variation in the process of care the
“manner of treatment” --O’Connor et. al
· Variation in “expert” opinion -- perceived Variation in expert opinion perceived
treatment outcomes -- Eddy
3/ 27/ 2008 Dr. A. Saddique 302
· Overuse (eg. Antibiotics, C-Section) ( g , )
· Underuse (eg. Mammography, Beta-
Blockers) Blockers)
· Misuse (eg. Medical errors)
The issue is unnecessary variation The issue is unnecessary variation
i.e., appropriateness of care
3/ 27/ 2008 Dr. A. Saddique 303
· Standards Implementation
Q li M · Quality Management
· Computers & Information Technology
· Evidence Based Guidelines
· Local Knowledge Based Pathways g
· Science of Improvement
3/ 27/ 2008 Dr. A. Saddique 304
¤ What is QI? QI is a Science!!
_Scientific Method
_Systematic Methods _Systematic Methods
_Continuous Data
_Testing
_ACT _ACT
¤ Gain knowledge about effectiveness
and its deployment
3/ 27/ 2008 Dr. A. Saddique 305
and its deployment
· Improvement in Healthcare Improvement in Healthcare
* Not all change is improvement but all
improvement is change p g
* Not all improvement is quality
improvement
· QI has a defined methodology
· Defined statistical approach pp
· Defined set of tools
· QI is a Discipline
3/ 27/ 2008 Dr. A. Saddique 306
QI is a Discipline
Improvement in Healthcare p
Expert knowledge
Content knowledge
System Thinking
Statistical Variation
Scientific Method
Psychology of Change
Traditional Improvement Continuous Quality
Improvement
3/ 27/ 2008 Dr. A. Saddique 307
Improvement
Paul Batalden MD
S hi ki · System thinking
· Knowledge of variation
· Knowledge for improvement
· Psychology of change y gy g
3/ 27/ 2008 Dr. A. Saddique 308
Deming
· Appreciation for care taking place
· Flexible improvement model · Flexible improvement model
· Sequential building of knowledge
- Testing changes on a small scale
- Deployment of improvements to similar sites
ff d ff f d · Efficient and effective use of data
- Interpretation of variation
· Strive for usefulness not perfection
· Part of everyday work, embedded
3/ 27/ 2008 Dr. A. Saddique 309
· Focus on systems (Systems theory)
· Develop ideas for change and test
th (S i tifi th d) them (Scientific method)
· Understand the variation of data
measured continuously over time (SPC) measured continuously over time (SPC)
· Understand reasons and motivation of
people to act on data
· Use a balanced set of measures (Value
compass)
3/ 27/ 2008 Dr. A. Saddique 310
Lessons about Variation
· Once we begin to measure important g p
quality characteristics and outcomes, we
notice variation.
· We question measurements that display
no variation.
3/ 27/ 2008 Dr. A. Saddique 311
· Often, single data points alone are
uninformative, but data displayed over
time can provide information for
i t improvement.
· The primary purpose of understanding
variation is to enable prediction variation is to enable prediction.
· Interaction among process variables
produces sources of variation: materials produces sources of variation: materials,
methods, procedures, people,
equipment, information, measurement,
3/ 27/ 2008 Dr. A. Saddique 312
q p , , ,
and environment.
SHAPE
R
E
A
D
CENTER
S
P
SEQUENCE
3/ 27/ 2008 Dr. A. Saddique 313
©1990 Paul E. Plsek & Associates - Used with permission
· Understand the Process · Understand the Process
* Process flow charts
* Cause and effect diagrams * Cause and effect diagrams
* Pareto charts
Test of Change · Test of Change
* Run charts
* Control charts * Control charts
3/ 27/ 2008 Dr. A. Saddique 314
Traditional health services research tools · Traditional health services research tools
· Organization change tools
· Epidemiology methods
· Outcomes assessment (Value Compass)
· General financial accounting
· Activity based cost accounting y g
3/ 27/ 2008 Dr. A. Saddique 315
· QI science is a major business strategy Q j gy
for leading corporations such as General
Electric (Six Sigma), Toyota, Motorola,
Hewlett Packard and medical groups
such as Mayo Clinic.
· Baldrige Award for the Healthcare Sector.
3/ 27/ 2008 Dr. A. Saddique 316
· QI science in healthcare is worldwide Q
· National forum has 2000+ attendees
each year from around the world
· The European forum has almost 1000
attendees from around the world
· There are peer reviewed journals devoted
exclusively to improvement research and
efforts efforts
3/ 27/ 2008 Dr. A. Saddique 317
Why do we do what we do? · Why do we do what we do?
· How do we know what we do works?
· How can we improve what we do?
3/ 27/ 2008 Dr. A. Saddique 318
Model for Improvement
What are we trying to accomplish?
How will we know that a change
Is an improvement?
What changes can we make that
Will result in an improvement?
Plan Act
Check Do
3/ 27/ 2008 Dr. A. Saddique 319
Small rapid cycles of change
·Basics for Improvements
_Aim
_Measure
_Understand Process
_Change Ideas
Plan
Check Do
Act
_Plan & Questions (Hypotheses)
_Predictions (Expected results) _Predictions (Expected results)
_Do (Methods of Who, What, When, Where)
3/ 27/ 2008
Dr. A. Saddique
320
Focus on processes of care
Functional
Access Assess Dx Rx Follow-up
to improve outcome
Clinical Satisfaction
Costs
Patient
with need
Patient
with need
met
Feedback
3/ 27/ 2008 Dr. A. Saddique 321
F ti l Functional
Health Status
General and Disease-specific
• Physical function
• Mental function
• Pain/Symptom Relief
• Quality of life
Satisfaction Clinical
Outcomes
• Quality of life
• Recommendation
Outcomes
• Mortality
• Complications
Recommendation
Patient
Staff
Referring Physician
• Access, Retention & Loyalty
Costs
• Direct Medical
• Mutual Respect & Trust
•Got what I want and need when I
wanted it and needed it
3/ 27/ 2008 Dr. A. Saddique 322
• Direct Medical
• Indirect Social
• Market Share & Volume
UNDERSTAND PROCESS: What is the current
process or baseline state of affairs?
Satisfaction
Clinical
Outcomes
Access
System
Assessment Dx Rx
Functional
Health Status
•Physical function
•Mental function
Process-Outcome Model of Care
Costs
Outcomes
• Mortality
• Complications
• Cost
• Market Share
Follow-up
Patient with
d f
QI Tools
need for:
QI Tools
Team Work: Who should work on this improvement?
Multidisciplinary Team
Flowchart Flowchart
Pareto Charts
Focus Groups
3/ 27/ 2008 Dr. A. Saddique 323
Baseline Data
Benchmark Data
III. CHANGE IDEAS: What changes
can we make that will result in an improvement? can we make that will result in an improvement?
Wh t id d h f h i h t’
G t Ch Id
Outcome Measures
What ideas do we have for changing what’s
done (process) to get better results?
Generate Change Ideas:
S i f i
Clinical
Access
System
Assessment Dx Rx
Functional
Health Status
Outcome Measures
(What we are trying to improve).
Process-Outcome Model of Care
Satisfaction
Costs
Clinical
Outcomes
System
Follow-up
Patient with
Priorities:
Patient with
need for:
1.
Priorities:
PDCA Projects
Pre 
Assessment  Diagnosis  Treatment  Discharge & 
F/U 
 
 
       
2.
3.
 
 
   
    
 
3/ 27/ 2008 Dr. A. Saddique 324
 
 
PLAN
• Hypothesis: What do you expect to accomplish?
• Action Plan: Who? Does What? When?
• With what tools and training? • With what tools and training?
• What are the data collection procedures?
DO
• How will the change be implemented?
DO
• What are the results?
• How will the change be implemented?
• What are the process indicators?
Check
What are the results?
• What happened?
• What are we learning?
Check
• Was there success?
• What will we do with the results?
• What else needs to be done?
ACT
3/ 27/ 2008 Dr. A. Saddique 325
• Are there more change ideas?
• What do we do to hold the gains ?
Rudimentary Rigorous
Problem Solving now needs
an Implementation Plan
Publishable
Research
Knowledge
y g
Knowledge
3/ 27/ 2008 Dr. A. Saddique 326
· Computer assisted management of
antibiotics NEJM 1998 J
· Decreasing CABG mortality-New
England Cardiovascular Group JAMA g p J
1996
· Radical Retropubic Prostatectomy J. of ad ca et opub c ostatecto y J o
Urology 1995
3/ 27/ 2008 Dr. A. Saddique 327
Observed Mortality Rate by Surgeon for Observed Mortality Rate by Surgeon for
All CABG (22 month period)
8
9
10
5
6
7
8
R
a
t
e

%
2
3
4
5
M
o
r
t
a
l
i
t
y

0
1
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
3/ 27/ 2008 Dr. A. Saddique 328
Surgeon
O’Connor et al JAMA 266:803, 1991
· Standardized post-op management Standardized post op management
· Implemented an extubation protocol
· Changed perfusion technique · Changed perfusion technique
· Decreased number of pre-op coag tests
Ch d t f h l ti tibi ti · Changed type of prophylactic antibiotic
· Changed myocardial preservation
h i techniques
3/ 27/ 2008 Dr. A. Saddique 329
· Standardized post-op care and transfers Standardized post op care and transfers
· Critical pathways in care units
· Same day admission program · Same day admission program
· Multidisciplinary work groups to
reexamine clinical processes reexamine clinical processes
· Redesigned existing operating rooms
R l d b i OR · Relocated bypass pump in OR
3/ 27/ 2008 Dr. A. Saddique 330
· Dedicated operating room staff for Dedicated operating room staff for
cardiac surgery program
· Surgeon as a permanent first assistant Surgeon as a permanent first assistant
· One perfusionist rather than two
· Cross training of support staff · Cross training of support staff
· Enhanced internal review of all deaths
A f · Assessment of surgeon resource
utilization
3/ 27/ 2008 Dr. A. Saddique 331
Expected and Observed Mortality for
All Patients Undergoing CABG
9
10
Expected Mortality Observed Mortality
Preintervention
n=6638
Intervention
n=1969
Postintervention
n=6488
5
6
7
8
9
n 6638 n 1969 n 6488
2
3
4
5
0
1
3/ 27/ 2008 Dr. A. Saddique 332
Quarter
O’Connor et al JAMA 275:841, 1996
Example of Performance
Improvement p
3/ 27/ 2008 Dr. A. Saddique 333
· Intensified patient education Intensified patient education
· Outpatient treatment of rejection
· Outpatient treatment of infection · Outpatient treatment of infection
· Reduced # of lab tests
Li it d th f P t l t iti · Limited the use of Parenteral nutrition
· Switch from IV cyclosporine to PO
3/ 27/ 2008 Dr. A. Saddique 334
70%
80%
90%
40%
50%
60%
70%
Before
After
10%
20%
30%
40%
Benchmark
0%
10%
2 Year Survial
Rate
Rejection Steroid Resistant
Rejection
3/ 27/ 2008 Dr. A. Saddique 335
j
21
20
25
14
15
Before
Af
5
10
After
0
Length of Stay
3/ 27/ 2008 Dr. A. Saddique 336
(P <0.001)
95
100
e
80
85
90
Before
f
k
y

S
c
o
r
e
70
75
After
K
a
r
n
o
f
s
k
60
65
3 mo 6 mo 1 yr 2 yr
K
3/ 27/ 2008 Dr. A. Saddique 337
3 mo 6 mo 1 yr 2 yr
(P 0.01)
$140 000
$119,000
$104,000
$100 000
$120,000
$140,000
$60,000
$80,000
$100,000
Before
After
$24,000
$35,000
$18,000
$26,000
$20,000
$40,000
,
$0
Pharmacy Lab Total
3/ 27/ 2008 Dr. A. Saddique 338
(P<0.025)
(P<0.025)
I’ve got two jobs, doing my job seeing the
patient and helping to make my job in the
system I work in better…improving the system
h l as a whole.
It’s that second role “citizenship in improvement” It s that second role citizenship in improvement
that is the real new challenge for doctors.
……..Don Berwick, M.D.
3/ 27/ 2008 Dr. A. Saddique 339
“The Price of Autonomy The Price of Autonomy
is Accountability”
3/ 27/ 2008 Dr. A. Saddique 340
· Knowledge
· Skill
· Professionalism
· Communication
· System practice System practice
· Improvement & continual learning
3/ 27/ 2008 Dr. A. Saddique 341
·Own and be responsible for ·Own and be responsible for
our own data and outcomes
·Systematically improve the
processes of care to improve p p
outcomes
3/ 27/ 2008 Dr. A. Saddique 342
· Model for improvement (QI Framework) p (Q )
· Focus on Process of Care
· Involve everyone (Systems Thinking)
· Collaborative practice (Teamwork)
· Balanced set of measures (Value Compass)
· Do cycles of change to gain knowledge
(Scientific Method)
Real time science (QI is a Science) · Real time science (QI is a Science)
3/ 27/ 2008 Dr. A. Saddique 343
3/ 27/ 2008 Dr. A. Saddique 344
3/ 27/ 2008 Dr. A. Saddique 345
Facilitation of Teams
“None of us is as smart as all of us”
Dr Abdulaziz Saddique Dr. Abdulaziz Saddique
Six Sigma Master Black Belt
346
Teamw or k i s t he abi l i t y t o w or k t oget her
3/ 27/ 2008 Dr. A. Saddique 347
y g
t ow ar ds a common v i si on. I t i s a f uel t hat al l ow s
common peopl e t o at t ai n uncommon r esul t s.
What is a Team ? What is a Team ?
“A high –performing task group whose
members are interdependent and share members are interdependent and share
common performance objectives . ”
A team is…
f l h ll ti l k … a group of people who collectively work
towards the accomplishment of team goals.
3/ 27/ 2008
Dr. A. Saddique
348
What is Team Building? g
“The process of deliberately creating an The process of deliberately creating an
effective team”
A-team approach is important and beneficial to quality
improvement processes
3/ 27/ 2008 Dr. A. Saddique 349
QUALI TY MANAGEMENT I N ACTI ON
Cust omer sat i sf act i on
Empowe Empowe
r ment
Mi ssi on
,Vi si on, Val ues
Cor e hospi t al
Educat i on
Manage By Fact
Cor e hospi t al
pr ocesses
Team
wor k
3/ 27/ 2008 Dr. A. Saddique 350
C l d lti f t d bl i h lth Complex and multi-faceted problems in health care.
Integration of divergent points of view.
Collaboration & cooperation to achieve rapid
progress/success .
Knowledge process.
Open atmosphere to enhance creativity Open atmosphere to enhance creativity.
Greater number of ideas.
Greater acceptance of solutions.
Hi h i l t ti t i bl i Higher implementation rate ,overcoming problems in
relationships, commitment and lack of clarity.
Mutual support
3/ 27/ 2008 Dr. A. Saddique 351
A positive Team experience can contribute to the sense of
empowerment and a satisfying Work climate .
“Essentials ‘’ For a performance
Improvement Team :
Recognized and supported by leadership .
Limited in scope to a “workable’’ problem Limited in scope to a workable problem
, opportunity for improvement .
Focused on a process or processes Focused on a process or processes .
Include all the people involved in the process
(es) under consideration (es) under consideration .
Be “ driven by data ” .
3/ 27/ 2008 Dr. A. Saddique 352
Be clear in role and expectations .
T f Q lit T Types of Quality Teams:
Task Teams .
P j t T Project Teams .
Functional Teams
Self Directed Team
3/ 27/ 2008 Dr. A. Saddique 353
Teamwork requires leadership with vision
of a clear goal, a flow of strong
communication and the inspiration and
drive to get the job done.
3/ 27/ 2008 Dr. A. Saddique 354
Factors Influencing team Effectiveness Factors Influencing team Effectiveness
Individual concern
The Task
Team skills
3/ 27/ 2008 Dr. A. Saddique 355
The Team
=Team Member
=Team Leader
=Team Member
TEAM
=Team Leader
T f ilit t
3/ 27/ 2008 Dr. A. Saddique 356
=Team facilitator
Team Team
Faci l i t at or Faci l i t at or
Team Member Team Member
Team Team
l eader l eader
Encour age and Encour age and shar i ng shar i ng Di r ect t he Di r ect t he Encour age and Encour age and
suppor t gr oup suppor t gr oup
pr ocesses pr ocesses
shar i ng shar i ng
i nf or mat i on and i nf or mat i on and
ex per t i se ex per t i se
Di r ect t he Di r ect t he
Team Team
Key Funct i on Key Funct i on
““ How How ’’ ’’ deci si ons deci si ons ““What What ’’ ’’ deci si ons deci si ons That deci si ons That deci si ons How How deci si ons deci si ons
ar e made ar e made
What What deci si ons deci si ons
ar e made ar e made
That deci si ons That deci si ons
ar e made . ar e made .
What deci si on What deci si on
ar e made ar e made
Key Focus Key Focus
Gui des dur i ng Team Gui des dur i ng Team
meet i ng. meet i ng.
Hel ps t he Team Hel ps t he Team
st ay on t r ack st ay on t r ack
Fol l ow gr ound Fol l ow gr ound
r ul es r ul es
Act i vel y i nvol ved Act i vel y i nvol ved
i n Team act i vi t i es i n Team act i vi t i es
Leads Team Leads Team
meet i ng meet i ng
Moves t he Moves t he
Team t ow ar ds Team t ow ar ds yy
&mai nt ai ns &mai nt ai ns
ef f ect i v e gr oup ef f ect i v e gr oup
dy nami cs. dy nami cs.
Focuses t he Team Focuses t he Team
&&deci si on mak i ng deci si on mak i ng
and suppor t s and suppor t s
pr obl em pr obl em
sol vi ng / goal sol vi ng / goal
at t ai nment at t ai nment
Communi cat es Communi cat es
Key Key
Responsi bi l i t y Responsi bi l i t y
Focuses t he Team Focuses t he Team
on dat a dr i v en & on dat a dr i v en &
t r ai n t hem on t r ai n t hem on
qual i t y t ool s qual i t y t ool s
Communi cat es Communi cat es
Team act i vi t i es Team act i vi t i es
3/ 27/ 2008 Dr. A. Saddique 357
Stages of TeamDevelopment Stages of Team Development
Forming
Closing
Storming Performing
Norming
3/ 27/ 2008 Dr. A. Saddique 358
g
Stages Of Team Development
Occurs when the team gets together
(uneasiness& excitement )
Forming
(uneasiness& excitement )
Storming Occurs when the team hits its first Storming Occurs when the team hits its first
disagreement or conflict
F li f li f
Norming
Feeling of relief
Team knows how to handle similar
storms that might arise in the
Performing
storms that might arise in the
future
Feels great !
3/ 27/ 2008 Dr. A. Saddique 359
Working well together
Stage 1: Forming Stage 1: Forming
· Excitement
· Anticipation
· Optimism
· Anxiety
· Formal Formal
· Attempts to define
task task
· Complaints
3/ 27/ 2008 Dr. A. Saddique 360
Stage 1: Forming Stage 1: Forming
· Polite, fairly formal
Task orientated · Task orientated
· Figuring out what is acceptable
group behaviour group behaviour
· How to deal with group
problems p
· Discuss issue not relevant to
task
· Complain about organisation &
behaviours
3/ 27/ 2008 Dr. A. Saddique 361
Stage 1: Forming Stage 1: Forming
· Clarify mission/project · Clarify mission/project
· Introduction & specifying activities
bl h d l f · Establish ground rules for team
behaviour
· Provide training
3/ 27/ 2008 Dr. A. Saddique 362
“Ground Rules”
A code of conduct for all teams
O Leave your egos and titles at the door . O Leave your egos and titles at the door .
O Respect each Team member .
O Share responsibility . p y
O Critique only ideas ; not people
O Keep an open mind .
O Focus on one issue at a time.
O Question and participate .
O Engage in only one conversation at a time. No side conversations
OAttend all Team meetings .
3/ 27/ 2008 Dr. A. Saddique 363
O Listen constructively .
Stage 2: Storming Stage 2: Storming
· Resistance · Resistance
· Varying attitudes
b h - about the team
- team members
h f - chance of success
3/ 27/ 2008 Dr. A. Saddique 364
Stage 2: Storming Stage 2: Storming
· Argue
D f i · Defensiveness
· Competition
hd l · Withdrawal
· Questioning purpose
· Unrealistic goal setting
· Concern about excessive
k work
3/ 27/ 2008 Dr. A. Saddique 365
Stage 2: Storming Stage 2: Storming
· Conflict management
technique
· Clarification of
concepts, tools, roles
etc.
3/ 27/ 2008 Dr. A. Saddique 366
Stage 3: Norming Stage 3: Norming
· Relief
· “Playful” interactions y
· Commitment to working out
differences
· Clarify criteria for achieving success
· Take intelligent & effective action
3/ 27/ 2008 Dr. A. Saddique 367
Stage 3: Norming Stage 3: Norming
· Creativity
Fl ibili · Flexibility
· Effectively
3/ 27/ 2008 Dr. A. Saddique 368
Stage 3: Norming Stage 3: Norming
· Develop understanding among Develop understanding among
members
· Problem solving Problem solving
· Structured methods of operating
3/ 27/ 2008 Dr. A. Saddique 369
Stage 4: Performing Stage 4: Performing
· Satisfaction
· Trust
3/ 27/ 2008 Dr. A. Saddique 370
Stage 4: Performing Stage 4: Performing
· High energy
A i k · Attention to task
· Shared values
· Openness
· Confrontation
· Trust
· Enjoyment Enjoyment
3/ 27/ 2008 Dr. A. Saddique 371
Stage 4: Performing Stage 4: Performing
· Training in QA concept &
tools to enhance
f performance
3/ 27/ 2008 Dr. A. Saddique 372
Stage 5: Closing Stage 5: Closing
· If successful : joy, pride, elation & loss
· If unsuccessful: frustration, anger
3/ 27/ 2008 Dr. A. Saddique 373
Stage 5: Closing Stage 5: Closing
· If successful: appreciation, avoidance of
final close-out activities
· If unsuccessful:
denial, blame, dissociation
3/ 27/ 2008 Dr. A. Saddique 374
Stage 5: Closing Stage 5: Closing
· Discuss next steps · Discuss next steps
· Evaluate
· Presentations
3/ 27/ 2008 Dr. A. Saddique 375
• What do you think should be done to prepare?
• Before the Meeting
WHO –WHO
–WHAT
–WHY WHY
–WHERE
– OTHER
3/ 27/ 2008 Dr. A. Saddique 376
First Meetingg
• Introductions
• Goals and time lines
G id li /G d l • Guidelines/Ground rules
Ongoing Ongoing
• Guidelines
• Listen Listen
• Encourage
• Protect
• Positive
3/ 27/ 2008 Dr. A. Saddique 377
Effective Discussion Effective Discussion
• Clarify
• Equal participation
• Listen
• Summarize
C t i • Contain
• Time management
• Evaluate • Evaluate
3/ 27/ 2008 Dr. A. Saddique 378
Th O b i P ti i t The Overbearing Participant
•Remind everyone about equality
•Ask for cooperation and patience •Ask for cooperation and patience
•Stay focused on the tools and the
process p ocess
•If all else fails, discuss with the
person outside of the meeting.
3/ 27/ 2008 Dr. A. Saddique 379
The shy
••Brainstorm
••Ask simple, no risk questions
••Use verbal/nonverbal signals to draw the
person in person in.
3/ 27/ 2008 Dr. A. Saddique 380
The talker The talker
••Use the tools•
•Go round the room for response s
••Ask for his/her help to get others
to participate outside meeting
3/ 27/ 2008 Dr. A. Saddique 381
The Arguer g
Relax-----do not argue back •
•Ask questions to reflect the issue
back to the group•
•Clarify the issue and areas of
agreement•• agreement••
Let the team members debate the
issue. issue.
3/ 27/ 2008 Dr. A. Saddique 382
The attacker or the ignorer
••Cover this in the ground rules ••Cover this in the ground rules
••All ideas will be given respect
and equal consideration q
3/ 27/ 2008 Dr. A. Saddique 383
••Take Action minutes
••The minutes document
what will be done who will do what will be done, who will do
it, and when they will do it.
•Circulate the minutes the NEXT DAY Circulate the minutes the NEXT DAY
3/ 27/ 2008 Dr. A. Saddique 384
Conflict
· The value of conflict
· Understanding your responses to
conflict
· Conflict intervention
3/ 27/ 2008 Dr. A. Saddique 385
Conflict Conflict
· The value of conflict
- Energy gy
- Creativity
- Depth p
- Effective solution
“Too much agreement is a risk for a team”
3/ 27/ 2008 Dr. A. Saddique 386
g
Conflict Conflict
· IGNORED
· MANAGED
- Productivity drops
- Unpleasant
B kd
- Changes occur
- Feelings aired
- Breakdown
- Stress
- Less information
- Clarification
- Understanding
Less information
- More time lost
- More involvement
- Increased motivation
and creativity and creativity
- Increased
alternatives
3/ 27/ 2008 Dr. A. Saddique 387
Conflict Conflict
Conflict results from disagreement about g
the following:
- Facts
- Methods
- Goals
- Values
3/ 27/ 2008 Dr. A. Saddique 388
Understanding & Belief g
About Conflict
fl l d b l bl · Conflict is natural and can be valuable
· Conflict can be a source of energy
C fli i l f l diff · Conflict is a result of real differences
· Differences in perspectives are often
necessary for breakthrough thinking necessary for breakthrough thinking
· One’s view and habits in handling
conflict are important determinants of p
the outcomes of a conflict
· Mastering skills in managing conflict
k l f i takes lots of practice
3/ 27/ 2008 Dr. A. Saddique 389
Response to Conflict Response to Conflict
Ask yourself 2 questions: y q
- How important to you is the opinion, goal, or
perspective under discussion?
- How important to you is it to maintain good
relationship with the people with whom you
are in conflict?
Then use one of the following responses:
• Avoid (prevention) Avoid (prevention)
• Smooth (minimise & sacrifice)
• Force (win-lose)
C i
3/ 27/ 2008 Dr. A. Saddique 390
• Compromise (lose-lose)
• Solve the problem (win-win)
Dealing with Conflicts Dealing with Conflicts
h bl · Anticipate & prevent whenever possible
· Think of each problem as a group
problem problem
· Neither over-react not under-react.
· A leader’s range of responses includes: · A leader s range of responses includes:
- do nothing (non-intervention)
- off-line conversation (minimal intervention)
- impersonal group time (low intervention)
- off-line confrontation (medium intervention)
i f t ti (hi h i t ti ) - in-group confrontation (high intervention)
- expulsion from the group (rarely use)
3/ 27/ 2008 Dr. A. Saddique 391
Tactics for Conflict Intervention
· Select neutral territory
M k th tti i i f l · Make sure the setting is informal
· Make sure all appropriate people are
present present
· Set an agenda and ground-rules; stick to
them
· Manage the time carefully
· Use active listening and constructive g
feedback skills throughout the
intervention
S t i t i
3/ 27/ 2008 Dr. A. Saddique 392
Groupthink Groupthink
· What is it?
· How to recognise it?
3/ 27/ 2008 Dr. A. Saddique 393
Groupthink (cont ) Groupthink (cont.)
· What are the conditions for
groupthink? groupthink?
- “Sameness”
- Isolation Isolation
- Domineering
- Closed-minded
3/ 27/ 2008 Dr. A. Saddique 394
Groupthink (cont ) Groupthink (cont.)
· How to prevent groupthink?
- Use scientific method Use scientific method
- Norm of brainstorming
- External eye External eye
- Criteria to evaluate options
- Risk assessment Risk assessment
- Alternatives
3/ 27/ 2008 Dr. A. Saddique 395
Effective and Ineffective Team
characteristics
I nef f ect i v e I nef f ect i v e Ef f ect i v e Ef f ect i v e I nef f ect i v e I nef f ect i v e Ef f ect i v e Ef f ect i v e
Compl ai nt s ,conf usi on . Compl ai nt s ,conf usi on . I nnovat i ve and cr eat i ve . I nnovat i ve and cr eat i ve .
““II ’’l l hav e t o cl ear i t l l hav e t o cl ear i t ’’ ’’
at t i t ude . at t i t ude .
Commi t ment . Commi t ment .
I sol at i on of member s . I sol at i on of member s . Member s hi ghl y Member s hi ghl y
i nt er dependent . i nt er dependent .
Conf l i ct av oi dance . Conf l i ct av oi dance . Resol v e conf l i ct s w i t hi n Resol v e conf l i ct s w i t hi n
gr oup . gr oup . g p g p
Lack of t r ust . Lack of t r ust . Hi gh l ev el s of t r ust . Hi gh l ev el s of t r ust .
Low ent husi asm . Low ent husi asm . Hi gh ent husi asm Hi gh ent husi asm
3/ 27/ 2008 Dr. A. Saddique 396
gg
,i nt er est . ,i nt er est .
Definition :
I f h i i f ti th Is a process of sharing information or the
process of generating and transmitting
meanings meanings.
Communication process involves a source
(encoder), message ,channel and receiver
(decoder)
3/ 27/ 2008 Dr. A. Saddique 397
(decoder) .
Communication skills are the building blocks of
professional relation ships: nurse-client ,
nurse-nurse , and nurse-physician. (and other nurse nurse , and nurse physician. (and other
heath team members )
3/ 27/ 2008 Dr. A. Saddique 398
Verbal
Forms of
communication communication
N b l
Verbal communication :
Nonverbal
Verbal communication :
is an exchange of information using words and
include both the spoken and the written words. for
l ( di i th i t example( recording in the nursing progress notes
,speaking to the client )
3/ 27/ 2008 Dr. A. Saddique 399
Non verbal communication
is exchange of information with out
th f d it i h t i t id the use of words, it is what is not said.
3/ 27/ 2008 Dr. A. Saddique 400
Sender
Massage Massage
Method
Receiver
3/ 27/ 2008 Dr. A. Saddique 401
Common Methods of Communication Common Methods of Communication
A H lth C P f i l A H lth C P f i l Among Health Care Professionals Among Health Care Professionals
Comput er message Comput er message Audio t aped Audio t aped Writ t en Writ t en Telephone Telephone
t i t i
Face t o face Face t o face
t i t i
Met hods Met hods
message message massage massage conversat ion conversat ion meet ing meet ing
Message can be Message can be
d l d d l d
Can be Can be
h d h d
Can be Can be
h d h d
Message can Message can
b d l d b d l d
I mmediat e I mmediat e
d l f h d l f h
advant age advant age
delivered delivered
immediat ely even t o immediat ely even t o
t hose at a great t hose at a great
dist ance. dist ance.
Part ies need not be Part ies need not be
exchanged at exchanged at
t imes t imes
convenient for convenient for
people people
involved . involved .
exchanged exchanged
at t imes at t imes
convenient convenient
for t he for t he
people people
be delivered be delivered
immediat ely immediat ely
and can be and can be
clarified . clarified .
Tow part ies Tow part ies
delivery of t he delivery of t he
massage massage
Receiver Receiver
quest ions can quest ions can
Part ies need not be Part ies need not be
present in same present in same
place. place.
Tow way Tow way
communicat ion is communicat ion is
involved . involved .
Record is Record is
available. available.
Time efficient Time efficient
if informat ion if informat ion
people people
involved. involved.
Record is Record is
available. available.
Time Time
Tow part ies Tow part ies
need not t o need not t o
be present in be present in
same place. same place.
quest ions can quest ions can
be raised and be raised and
answered answered
possible via Email possible via Email
Record is available Record is available
Many people can Many people can
part icipat e in part icipat e in
communicat ed communicat ed
is complet e. is complet e.
efficient if efficient if
massage is massage is
underst ood underst ood
3/ 27/ 2008 Dr. A. Saddique 402
exchange exchange
Common Methods of Communication Common Methods of Communication
Among Health Care Professionals Among Health Care Professionals Among Health Care Professionals Among Health Care Professionals
Comput er Comput er
message message
Audi o Audi o
t aped t aped
Wr i t t en Wr i t t en
massage massage
Tel ephone Tel ephone
conv er sat i on conv er sat i on
Face t o f ace Face t o f ace
meet i ng meet i ng
Met hods Met hods
message message
NO non ver bal NO non ver bal Message Message
bb
Message Message
l l l l
No non v er bal No non v er bal Bot h t he Bot h t he
i i i i
Di sadvant a Di sadvant a
message can message can
be be
communi cat ed communi cat ed
..
Pr i v acy Pr i v acy
can not be can not be
v al i dat ed v al i dat ed
w i t h t he w i t h t he
sender sender
usual l y usual l y
can not can not
v al i dat ed v al i dat ed
w i t h t he w i t h t he
sender sender
message . message .
No per manent No per manent
r ecor d. r ecor d.
communi cat i communi cat i
ng and ng and
r ecei v i ng r ecei v i ng
peopl e must peopl e must
be av ai l abl e be av ai l abl e
ge ge
Pr i v acy Pr i v acy
concer ns concer ns
r emai n an r emai n an
i ssue i ssue
sender sender be av ai l abl e be av ai l abl e
at t he same at t he same
t i me and i n t i me and i n
same pl ace same pl ace
No No
per manent per manent
r ecor d f or r ecor d f or
l at er use . l at er use .
3/ 27/ 2008 Dr. A. Saddique 403
The Communication Plan
Who is the Audience?
What needs to be communicated and when ?
What channels and methods of communication What channels and methods of communication
will be used ?
Who will be the source of the communication ?
How will the communication be sequenced and How will the communication be sequenced and
coordinated ?
Ho ill the feedback be obtained ?
3/ 27/ 2008 Dr. A. Saddique 404
How will the feedback be obtained ?
Methods for communication
Employee Handbook \ Manuals.
T i i \ W k h Training \ Workshops.
Formal conferences, meeting, seminars.
Supervision program.
Monitoring program. g p g
Newsletters.
Informal Talks Informal Talks.
Job Aids.
3/ 27/ 2008 Dr. A. Saddique 405
Barriers to Communication
R i B i
W d h t
Audience may not
Sender Bar r i er s
Recei ver Bar ri er s
Words, phrases or terms are
not clear
Time is inappropriate
Audience may not
understand the
purpose of the
Time is inappropriate
Information does not match
audience in terms of
information
Fear of changing the
audience status
audience in terms of
complexity .
Information was not
audience status
Belief that the
information is because
Information was not
appropriate for target
audience
information is because
of their poor job
performance.
3/ 27/ 2008 Dr. A. Saddique 406
Method of communication
was not appropriate
The need for different
groups to cooperate
Summaryy
• Understanding team and team building is essential in
lit i t quality improvement.
• Appreciation of effective team work would enhance the
team productivity, not only in performing the tasks but y y g
also getting the task done in a harmonious and
enjoyable environment
• Conflict in a team can be healthy. Appreciating the
value of conflict and how to recognize it would
h th t bilit t t t i ll d it enhance the team ability to strategically managed it.
3/ 27/ 2008 Dr. A. Saddique 407
QUALITY IMPROVEMENT TOOLS
A Dash through the charts g
3/ 27/ 2008 Dr. A. Saddique 408
Quality tools facilitate the work of teams
and individuals in quality improvement and individuals in quality improvement
1. To identify problems
2. To analyze problems
3. To develop, test and implement
solutions of those problems
3/ 27/ 2008 Dr. A. Saddique 409
Examples of Ops Statements Examples of Ops Statements
R d d d t (ADE ) i iti l R d d d t (ADE ) i iti l 44 Reduce adverse drug events (ADEs) in critical Reduce adverse drug events (ADEs) in critical
care by care by 75 75 percent percent within within 1 1 year year
44 Reduce waiting time to see a physician to less Reduce waiting time to see a physician to less 44 Reduce waiting time to see a physician to less Reduce waiting time to see a physician to less
than than 15 15 minutes within minutes within 9 9 months months
44 Reduce incidence of ventilator Reduce incidence of ventilator--associated associated
pneumonia by pneumonia by 25 25 percent. percent.
3/ 27/ 2008 Dr. A. Saddique 410
Charts & Diagrams Charts & Diagrams
44 Bar Chart s Bar Chart s
44 Cause and Effect Diagram Cause and Effect Diagram 44 Cause and Effect Diagram Cause and Effect Diagram
44 Check Sheet Check Sheet
44 Cont rol Chart s Cont rol Chart s
D i i M t i D i i M t i 44 Decision Mat rix Decision Mat rix
44 Flowchart Flowchart
44 Gant t Chart Gant t Chart
44 Hist ogram Hist ogram
44 Paret o Diagram Paret o Diagram
44 PDSA Cycle PDSA Cycle 44 PDSA Cycle PDSA Cycle
44 Pie Chart Pie Chart
44 Run Chart Run Chart
Scat t er Diagram Scat t er Diagram
3/ 27/ 2008 Dr. A. Saddique 411
44 Scat t er Diagram Scat t er Diagram
44 Vot ing Vot ing
Tools For Planning Tools For Planning
3/ 27/ 2008 Dr. A. Saddique 412
1- Gantt Chart
3/ 27/ 2008 Dr. A. Saddique 413
2- Critical Paths
A comprehensive ,flexible framework used to guide a p , g
single patient care process
3/ 27/ 2008 Dr. A. Saddique 414
Tools For Teams Tools For Teams
3/ 27/ 2008 Dr. A. Saddique 415
1- Brain stormingg
It is a way for a group to generate as many ideas
ibl i h t ti (id ti as possible in a very short time (idea-generating
technique)
3/ 27/ 2008 Dr. A. Saddique 416
Brainstorming Brainstorming
• A brainstorm starts with a clear question, and ends with a raw list of
ideas.
Brainstorms help answer specific question such as: Brainstorms help answer specific question such as:
• What opportunities face us this year?
Wh t f t t i i f i d t t X? • What factors are constraining performance in department X?
• What could be causing problem Y?
• What can we do to solve problem Z? p
3/ 27/ 2008 Dr. A. Saddique 417
Uses of Brainstorming: Uses of Brainstorming:
1. To generate ideas and insights
2. To draw out the experiences of each
participant
3 Wh ti id h b 3. When creative ideas have been
suppressed in the group
3/ 27/ 2008 Dr. A. Saddique 418
22-- Affinity Analysis Affinity Analysis
The affinity diagram was developed to discover meaningful
groups of ideas within a raw list. It is used to refine a brainstorm
3/ 27/ 2008 Dr. A. Saddique 419
Use affinity analysis when:
1. The problem or area for improvement is
large and complex
2. The group feels overwhelmed by the
complexity and size of the problem
3. You need a lot of ideas in a short time
3/ 27/ 2008 Dr. A. Saddique 420
3 prioritization tools 3- prioritization tools
Prioritization Tools: Prioritization Tools:
• Voting • Voting
• Prioritization (criteria) matrix
3/ 27/ 2008 Dr. A. Saddique 421
Prioritization tools
Voting Voting
When to use:
1. When you need a quick and efficient way to make
a decision a decision
2. There are quiet and dominant group members
3/ 27/ 2008 Dr. A. Saddique 422
Types of voting:
* Straight voting
* Multi voting Multi voting
* Weighed voting
3/ 27/ 2008 Dr. A. Saddique 423
Straight Voting
3/ 27/ 2008 Dr. A. Saddique 424
Multivoting Multivoting
• Multivoting : is a technique for narrowing a broad list
of ideas down to those that are most important .
• It allows for each member to participate equally in • It allows for each member to participate equally in
the decision making process.
3/ 27/ 2008 Dr. A. Saddique 425
Multivoting
3/ 27/ 2008 Dr. A. Saddique 426
Weighted Voting
3/ 27/ 2008 Dr. A. Saddique 427
Prioritization tools Prioritization tools
Prioritization (criteria) matrix
When to use:
Prioritization (criteria) matrix
1. The group agrees that a solution is needed but
disagrees about where to start disagrees about where to start
2. Resources for testing and implementation are
scarce.
3 A t li k b t it t d t 3. A strong link between areas necessitates a need to
sequence options
3/ 27/ 2008 Dr. A. Saddique 428
Decision Matrix Decision Matrix
3/ 27/ 2008 Dr. A. Saddique 429
4- Flowchart
A flowchart is a graphic representation of how a
process works.
St i h ith b li h d th fl f Steps in a process are shown with symbolic shapes, and the flow of
the process is indicated with arrows connecting the symbols.
It should always reflect the actual process not the It should always reflect the actual process, not the
ideal process.
3/ 27/ 2008 Dr. A. Saddique 430
Flowcharting a process often brings to light:
1 redundancies 1. redundancies
2. Delays.
3. indirect paths that would otherwise remain 3. indirect paths that would otherwise remain
unnoticed or ignored.
3/ 27/ 2008 Dr. A. Saddique 431
When to use:
1. Understand processes.
2. Consider ways to simplify processes.
3 R i t i 3. Recognize unnecessary steps in a process.
4. Determine areas for monitoring or data
collection
5. Identify who will be involved in or affected by the
improvement process.
6 Formulate questions for further research 6. Formulate questions for further research.
3/ 27/ 2008 Dr. A. Saddique 432
hi h l l fl h t high level flow chart
3/ 27/ 2008 Dr. A. Saddique 433
Detailed flow chart
•A detailed flowchart provides an information
about activities at each step in a sub-process about activities at each step in a sub process.
3/ 27/ 2008 Dr. A. Saddique 434
start
EMRGENCY ADMISSION FLOW CHART
Detailed flow chart
ER MD decides to admit
ER Writes
order
order
Clerk calls admitting department
ER Nurse calls Unit Nurse
Room available ?
NO
3/ 27/ 2008 Dr. A. Saddique 435
yes
A
admit
Unit Nurse calls
ER N
Nursing
order
ER Nurse
S i l ?
yes
Special case?
ER Nurse and
assistant transport
NO
ER clerk calls
transport
T t i Transport arrives
and takes patient
Patient arrives
on Unit
end
3/ 27/ 2008 Dr. A. Saddique 436
end
Flowchart Flowchart
3/ 27/ 2008 Dr. A. Saddique 437
MATRIX FLOW CHART
which organize the flowchart by columns, with each
column representing a person or department involved in
a process a process.
3/ 27/ 2008 Dr. A. Saddique 438
Rul es t o be f ol l owed Rul es t o be f ol l owed
* For improvement purposes, flow chart
* Team work
* Determine the objectives
For improvement purposes, flow chart
Team work
* Involved members who are in direct contact with the process
* must reflect the current process
* Divide complicated process
* must reflect the current process
* Avoid complicated details
* Periodic updating
3/ 27/ 2008 Dr. A. Saddique 439
Tools For Data collection
3/ 27/ 2008 Dr. A. Saddique 440
Check Sheet Check Sheet
3/ 27/ 2008 Dr. A. Saddique 441
Tools For Data Analysis Tools For Data Analysis
3/ 27/ 2008 Dr. A. Saddique 442
Run Chart Run Chart
3/ 27/ 2008 Dr. A. Saddique 443
Control Chart
3/ 27/ 2008 Dr. A. Saddique 444
“In Control” Control Chart In Control Control Chart
3/ 27/ 2008 Dr. A. Saddique 445
Points out of Control Points out of Control
3/ 27/ 2008 Dr. A. Saddique 446
Bar Charts Bar Charts
3/ 27/ 2008 Dr. A. Saddique 447
Histogram Histogram
3/ 27/ 2008 Dr. A. Saddique 448
Scatter Diagram
3/ 27/ 2008 Dr. A. Saddique 449
Pie Chart Pie Chart
3/ 27/ 2008 Dr. A. Saddique 450
Tools For Understanding Root
Causes Of performance
3/ 27/ 2008 Dr. A. Saddique 451
Cause Cause--Effect Analysis Effect Analysis

Generates and sorts hypotheses Generates and sorts hypotheses
about possible causes of a problem
3/ 27/ 2008 Dr. A. Saddique 452
Cause Cause--and and-- effect effect analysis analysis
44 When to use: When to use:
•• At the beginning of the analysis stage At the beginning of the analysis stage
•• To broaden thinking about the possible To broaden thinking about the possible
reasons for a problem reasons for a problem
•• To develop hypotheses about the causes of To develop hypotheses about the causes of
the situation the situation
3/ 27/ 2008 Dr. A. Saddique 453
Cause and Effect Diagram
Fishbone Diagram Fishbone Diagram
3/ 27/ 2008 Dr. A. Saddique 454
fishbone diagram
methods manpower
problem
machine
material
3/ 27/ 2008 Dr. A. Saddique 455
Cause-and-Effect Diagram “ fishbone diagrams “ "
Causes in a cause & effect diagram are frequently arranged into four major
manpower
How do people influence….?
methods
How do methods & policies affect…?
categories. While these categories can be anything, you will often see:
policies
people
4 M
d i i t ti
4 Ms
(Manufacturing)
administration
and service
Problem
statement
3/ 27/ 2008 Dr. A. Saddique 456
machines
How does equipments affect…?
materials
How do equipment & supply affect …?
equipment
procedures
How does procedures steps affect ?
Cause & effect diagrams can also be drawn as tree Cause & effect diagrams can also be drawn as tree
diagrams
From a single outcome or trunk, branches extend g ,
that represent major categories of inputs which then
lead to smaller and smaller branches of causes
The tree structure has an advantage over the
fishbone-style. With the tree structure, all items on
the same causal level are aligned vertically the same causal level are aligned vertically
3/ 27/ 2008 Dr. A. Saddique 457
Cause and effect analysis
Tree diagram Tree diagram
Why?
Why?
Why?
Why?
Wh ?
Why?
Why?
Why?
3/ 27/ 2008 Dr. A. Saddique 458
problem
Cause and Effect Diagram: Cause and Effect Diagram:
Fishbone
3/ 27/ 2008 Dr. A. Saddique 459
Pareto Diagram – Data Table
3/ 27/ 2008 Dr. A. Saddique 460
Pareto Diagram Pareto Diagram
3/ 27/ 2008 Dr. A. Saddique 461
PDSA Cycle PDSA Cycle
3/ 27/ 2008 Dr. A. Saddique 462
TQM Si Si TQM-Six Sigma
Turningg
Strategy into Results
Abdulaziz Saddique, CPHQ, Six Sigma Master Black Belt
TQM-Six Sigma TQM Six Sigma
Turning
Strategy into Results Strategy into Results
Introducing the trainers
&&
program program
464
Hi st or y of qual i t y
Systematical search to
1
9
2
0








Taylor
SQC
Systematical search to
more effective work
methods
Statistics, learning from
data
1
9
4
0






SQC
Shewhart
data
Focus on processes
Added value for clients
Experimenting




1
9
6
0




Drucker
Experimenting
Decentralized approach
Aggressive defect






1
9
8
0

TQM
ISO
gg
reduction
Management involvement
Quality in development
stage









2
0
0
Six Sigma
ISO
g
Taskforce fully dedicated
to improvement (Belts)
Structured and integrated
465
0


g
Structured and integrated
methodology fact based
Do I really have to change? Do I really have to change?
· Change is inevitable
· The rate of Technological Change is continuously
increasingg
· No organization has a guarantee that it will survive
466
Strategy for Growth
Globalization
• WTO
• IMF
• WHO
• World Bank
• Economic
developments
ff t ll
Governance Citizens / Industry
effects all
• Laws
• Rules
• Regulations
G id li
Local Governance
• Guidelines
• Implementation
• Performing
467
Performing
• Execution
How does TQM-Six Sigma assist How does TQM Six Sigma assist
management to achieve
d t d l l f unprecedented levels of
performance? p
TQM-Six Sigma is a combination of proven
th d l i d t l th t ll i methodologies and tools that allow senior
management to “see” what cannot be seen
ith th with other processes
468
TQM Si Si ! TQM-Six Sigma!
Before we start Before we start….
Wh i t ? Who is my customer?
469
Voice of the Customer Voice of the Customer
470
What i s Cust omer Sat i sf act i on?
•Meeting expected quality
requirements
•Meeting/exceeding performance
requirements q
471
Types of Customers
There are two main types of customers
•Internal
•External
•Intermediate
•End-user
I t d ti •Impacted parties
472
Internal Customers
•An Internal Customer can be defined as anyone within
the organization who is affected by the product or the organization who is affected by the product or
service as it is being generated
•The Internal Customer is often forgotten in the effort
to produce a product or service for an external
customer
•The immediate goal should be to produce a product •The immediate goal should be to produce a product
or service as simply, efficiently, and conveniently as
possible for internal consumption. This requires:
•Proper training
•Proper equipment
•Specific instructions
•Example – IT department is customer of: Example IT department is customer of:
•Administration
•Budgeting
•Human Resources
P bli S i
473
•Public Services
•Management improvement
•Etc.
External Customers
D t b l t t f th i ti b t •Does not belong to any part of the organization, but
is affected by its presence
•Identifying the external customer can greatly impact
understanding the needs of the customer g
•Types of External customers
•End-users - those that purchase a product or
service for their own use
•Intermediate customers those that purchase •Intermediate customers - those that purchase
the product or service and then
resell, repackage, modify, or assemble the
product to the end-user of the product
•Impacted parties - those who do not purchase or
use the product, but would be impacted by it
•In education, this could be
parents communities colleges and parents, communities, colleges and
universities, Hospitals, etc.
474
Customer Feedback
Can be gathered in many different ways
•Complaint-based systems •Complaint-based systems
•Feedback to the customer should be immediate
•Corrective actions should be initiated when a problem is uncovered
•Viewed as a second chance to keep the customers business Viewed as a second chance to keep the customers business
•Customer surveys y
•Determine what quality is
•Find out what competitors are doing
•Identify factors to give a competitive edge
•Identify urgent problems
•Issued periodically
•Drives organization to action if an issue arises
475
Data Gathering Instruments
Surveys
Must be properly designed Must be properly designed
•Consistent set of standardized questions
•A sample is selected for use
•The survey can be administered by interviewers or self-administered
Focus Groups
Small group (3 to 12)
•Assembled to explore specific topics and questions Assembled to explore specific topics and questions
Face-to-Face Interviews
Individual interviews
C •Could take 30 - 60 minutes per interview
•Very time consuming
Test Markets Test Markets
Product or service issued to specific markets
•Feedback gathered after pre-established time period
•Results drive product or service plans
476
Product Cards
Return of card prompts a reaction by the company
•Could function as feedback forms
Customer Survey Pitfalls
•Improperly designed survey form
•Poorly defined survey issues oo y de ed su ey ssues
•Poor sampling techniques
•Ignoring responses
•Treating customer perceptions as objective measures
•Treating surveys as an event, not a process
•Asking nonspecific questions Asking nonspecific questions
•Using incorrect analysis methods
•Ignoring the results or using them incorrectly
•Failing to provide feedback when necessary
•Using too many questions (25-30 is typical)
•Using a temporary employee to conduct interviews
477
Using a temporary employee to conduct interviews
Customer Service Essentials
•Must be made personal ust be ade pe so a
•Employees must be empowered at all levels
•Determine who your customers are
•Know their needs and expectations •Know their needs and expectations
•Work toward satisfying those needs an expectations
478
Supplier Relations
•External: Trust, Communications, Mutual Benefits
•To Customers...To Suppliers pp
•Supplier seen as Part of Process - Interdependence
•Total Value vs. Piece Part Price
•Includes Services
•Engineering •Engineering
•Marketing
•Technical
•Finance
•Etc.
•Two-Way Loyalty
•Supplier as a Customer of Information
479
TQM-Six Sigma
Turning Turning
Strategy into Results
480
Cost of Quality
Internal Failure Prevention Costs
• Waste
• Re-work
• System Failure
• Education
• Quality Planning
• Process Control y
• Elimination of failures • Customer Service
• Customer care
• Operational Loss
External Failure
• IT Costs
• Audits
Inspection Costs
p
• Image Loss/Building
• Penalties
• Inspections
• Measurements & Reporting
481
Cost of poor Quality
The Cost of Poor Quality
Sigma Level Defects per Million Opportunities Cost of Poor Quality
2 398 3 ( C ) 2 398,537 (Noncompetitive Companies) Not applicable
3 66,807 25-40% of sales
4 6,210 (Industry Average) 15-25% of sales
5 233 5 15% of sales 5 233 5-15% of sales
6 3.4 (World Class) < 1% of sales
Each sigma shift provides a net income improvement which equals 10% of sales. g p p q
Six Sigma, by Harry and Schroeder, p. 17
482
Si x Si gma - I mpr ov e, Cr eat e and
Sust ai n
Six Sigma Triad
DMAI C
DMEDI
I mpr ov e ex i st i ng
pr ocesses,
pr oduct s,
i d
DMEDI
Cr eat e new
pr ocesses, pr oduct s
ser v i ces, and
pl ant s t o 6 Si gma
qual i t y
, ser vi ces, and
pl ant s t o 6 Si gma
qual i t y
Lev er age and sust ai n
t he gai ns achi ev ed by
cont i nuous
483
cont i nuous
i mpr ov ement and
dev el opment
Follow t he 6 Sigma Core Processes…
1.0
Def i ne
O t i t i
2.0
Measur e
P f
3.0
Anal y ze
O t i t
4.0
I mpr ov e
f
5.0
Cont r ol
DMAI C ( I mpr ov ement Pr ocess)
Oppor t uni t i es Per f or mance Oppor t uni t y
Per f or manc
e
Cont r ol
Per f or manc
e
DMEDI ( Cr eat i on Pr ocess)
1.0
Def i ne
2.0
Measur e
3.0
Ex pl or e
4.0
Dev el op
5.0
I mpl eme
nt
I mpr ov e
Pr ocess
PROCESS CONTROL
SYSTEM
Pr ocess Management ( Sust ai n t he Gai ns)
Pr ocess
Per f or manc
e
and
Pr ev ent &
Pr edi ct
Appl y
Cont r ol
&
Pr ocess
Measur eme
nt
Appl y
Apply
Anal y ze
Pr ocess
Per f or manc
e
SYSTEM
484
Pr edi ct
Fai l ur es
Six Sigma: The Why
Si x Si gma al w ay s st ar t s w i t h t he Cust omer and t he
St r at egi c Vi si on of t he or gani zat i on.
Si x Si gma f ocus i s on goal s and st r et ch t he goal s of
Mi ni st r y of Tr anspor t at i on w i t h r espect t o: Mi ni st r y of Tr anspor t at i on w i t h r espect t o:
× Cust omer Sat i sf act i on and per cei v ed Val ue
× St ock hol der / St ak ehol der ex pect at i ons × St ock hol der / St ak ehol der ex pect at i ons
× Fi nanci al per f or mance
× Bot t om l i ne r esul t s
Busi ness Uni t per f or mance × Busi ness Uni t per f or mance
× Empl oy ee sat i sf act i on and ut i l i zat i on
× Asset Management
485
Kano Model of Cust omer Sat i sf act i on
Del i ght e
r
Per f or manc
e c
t
i
o
n
e
S
a
t
i
s
f
a
c
Basi c
o
m
e
r

S
Basi c
Abi l i t y t o Meet Cust omer ’ s Needs
C
u
s
t
o
486
Abi l i t y t o Meet Cust omer s Needs
Example - CTQ Tree – a ceramic tile company
Service in the showroom Good Basic
Range of tiles
Wide
Delighter
Costumer
satisfaction
Excellent Quality of production Performance
Punctual Quality of delivery Performance
G d C ft hi E i d
Retail/Showroom Attractive Basic
487
Good Craftsmanship Experienced
Delighter
Voice of t h e Cu s t om er
Mea s u r e
I m p r ove
An a lyze Defin e
Control
I n s t it u t ion a liza t ion
488
The DMAICModel
Operations Excellence Model
Now y ou need t o k now how w el l t he pr ocess Now y ou need t o k now how w el l t he pr ocess
i s meet i ng y our cust omer ’ s needs!
You measur e how w el l t he pr ocess i s meet i ng
y our cust omer ’ s needs usi ng t hr ee “ Pr ocess
Capabi l i t y” Met r i cs Capabi l i t y Met r i cs
489
Voice of The Process ( VOP)
Upper
Low er
Upper
Speci f i cat i o
n Li mi t
Speci f i cat i on
Li mi t
490
Voi ce of t he Pr ocess ( VOP)
Mean or Aver age Mean or Aver age
Pr ocess # 1 Pr ocess # 2
St andar d
Devi at i on
St andar d
Devi at i on
St andar d
Devi at i on
491
Understanding Process
Capability p y
LSL USL
Voi ce of t he Pr ocess
Def ect s
Voi ce of t he Cust omer
492
Capability Increases As Variation
Decreases Decreases
No Def ect s
LSL USL
Def ect s
493
Process thinking…..What is that?
SIPOC-model
Suppliers Customers Input Output Suppliers Customers Input Output
Process
Process Thinking: The thought that all the work has to
result in output, is a process. At the process level this
applies to any organization.
494
pp y g
Management & Belts
Engaging the Right People
· Leadership
D l Ch i · Deployment Champions
· Project Sponsors
Master Black Belts · Master Black Belts
· Black Belts
· Green Belts · Green Belts
· Yellow Belts
· Financial Representatives
495
Financial Representatives
Management & Belts
Management Management
Focus Focus
·· Business leaders who Business leaders who
LEAD the cultural LEAD the cultural
change, remove change, remove change, remove change, remove
barriers and establish barriers and establish
objectives to reach Six objectives to reach Six
Sigma levels of Sigma levels of
Belt s Belt s
ÞÞ Resources who work Resources who work
wit h cross wit h cross-- funct ional funct ional
Sigma levels of Sigma levels of
performance. performance.
wit h cross wit h cross-- funct ional funct ional
t eams using Six t eams using Six
Sigma t ools and Sigma t ools and
t t i t i t t i t i t act ics t o improve t act ics t o improve
cust omer sat isfact ion cust omer sat isfact ion
and reduce cost s. and reduce cost s.
Opt i ons Opt i ons
496
Opt i ons Opt i ons
497
What is TQM-Six Sigma from a
Senior Management perspective?
· It is a formal, structured Management Process
that integrates and controls processes and
resources to ensure that they are allocated and
focused on achieving unprecedented results
that are: that are:
- Seen as high value by the Customer, and
- Linked to Strategic Critical Success Factors, Linked to Strategic Critical Success Factors,
and
- Have a significant, quantifiable benefit that
498
increases Shareholder / Stakeholder value
TQM-Six Sigma
Links Critical Systems
Management
Integrate Integrate
And
Control
Operations
Culture
Control
499
Operations
Overview
How TQM-Six Sigma helps you? How TQM Six Sigma helps you?
· To address the Management System To address the Management System
- Management Excellence Model
· To address the Operations System To address the Operations System
- Operations Excellence Model
· To Address the Cultural System To Address the Cultural System
- Change Management Model
· To Integrate and Control the Transformation To Integrate and Control the Transformation
Process
- Management Review Model
500
Q S S TQM-Six Sigma
M t M d l Management Model
For
Per f or manc e Ex c el l enc e
501
Management Model for Performance Excellence
Culture
System
Customer Satisfaction /
Shareholder – Stakeholder Value
System
• Leadership
• Vision
Management
System
Results are
Produced SR
Vision
• Mission
• Strategy
• Strategic Critical
S F t
Something Magic
Happens
Integratio
n &
Controls
Success Factors
• Strategic
Initiatives
• Policy
Operations
System
y
• Operating Units
• Supporting Strategy
• Goals
502
• Action Plans
• Process Management
Management Model for Performance Excellence
Cultur
e
Customer Satisfaction /
Shareholder – Stakeholder Value
e
System
• Leadership
• Vision
Management
System
Results are
Produced
$$
Vision
• Mission
• Strategy
• Strategic Critical
S F t
Something Magic
Happens
Integratio
n &
Controls
Success Factors
• Strategic
Initiatives
• Policy
Operations
System
y
• Operating Units
• Supporting Strategy
• Goals
503
• Action Plans
• Process Management
MANAGEMENT EXCELLENCE MODEL
BASED ON ISO9001:2000 QUALITY MANAGEMENT SYSTEM
Management
System
Management
Review
M t
Internal / External Audits Identify
Performance Gaps
- Six Sigma Projects
- Corrective/Preventative
Action
Input
Management
Responsibility
Feedback
Priorities
Guidance
Customer
Customer
Measurement,
Analysis,
Improvement
Resource
Management
M &
Product
Realization
Performance
Results
Manage &
Accelerate
Change
504
Realization
Input
Output
MANAGEMENT EXCELLENCE MODEL MANAGEMENT EXCELLENCE MODEL
BASED ON ISO BASED ON ISO9001 9001::2000 2000 QUALITY MANAGEMENT SYSTEM QUALITY MANAGEMENT SYSTEM
Management
System
Management
R i
M t
Internal / External Audits Identify
Performance Gaps
- Six Sigma Projects
Input
Review
Management
Responsibility
Feedback
- Corrective/Preventative
Action
Priorities
Guidance
Customer
Customer
Measurement,
Analysis,
Improvement
Resource
Management
Manage &
Product
Realization
Performance
Results
Manage &
Accelerate
Change
505
Realization
Input
Output
Management Excellence Model
Two Major Focuses
· Increasing Customer Satisfaction by:
- Meeting and exceeding Customer Requirements
- Continuous Improvement
- Corrective Action
- Preventive Action
· Continual Improvement of the Quality Management System · Continual Improvement of the Quality Management System
- This latest version of the standard shifts emphasis from just
documenting internal procedures to implementing an effective Quality
Management System (QMS) to develop and manage a family of
i t t d integrated processes
‚ Management Processes
‚ Human Resources
‚ Product Realization
506
Product Realization
‚ Measurement, Analysis and Improvement
Management Ex cel l ence
f
Model
Eight Performance Management Values
· Customer Focus
· Leadership · Leadership
· Involvement of People
· Process Approach pp
· System Approach to Management
· Continual Improvement
F t l A h t D i i M ki · Factual Approach to Decision Making
· Mutually Beneficial Supplier Relationships
507
Management Excellence Model Management Excellence Model
Fi v e Gl obal Pr ocesses
1) Qual i t y Management Sy st em
2) Management Responsi bi l i t y
3) Resour ce Management
4) Pr oduct Real i zat i on
5) Measur ement , Anal y si s and
I mpr ov ement
508
I mpr ov ement
Management Excellence Model
Based on ISO9001:2000 Quality Management System y g y
- QUALITY POLICY / QUALITY OBJECTIVES
WHAT LEVEL OF QUALITY
QUALITY MANUAL
1
-- WHAT LEVEL OF QUALITY
YOU GET WHEN YOU DO
BUSINESS WITH US
- QUALITY SYSTEM FRAMEWORK
POLICY &
OBJECTIVES
2
-- WHO IS ACCOUNTABLE FOR EACH
ELEMENT
PROCEDURES (6)
BEST PRACTICES
STANDARD WORK
3
- WHO, WHAT, WHEN, WHERE
WORK INSTRUCTIONS
HOW
BEST PRACTICES
STANDARD WORK
4
QUALITY RECORDS (28)
DATA AND REPORTS
- HOW
EVIDENCE
509
- DATA AND REPORTS
- INTERNAL AUDITS
CORRECTIVE & PREVENTATIVE ACTION /
MANAGEMENT REVIEW LOOP
Management Excellence Model
· It is a basic Management System
- Focuses on Product / Services Processes
- It is not Rocket Science, it is Fundamental
Management
· It provides a Management Structure where
b l d b l - Management Responsibilities and Accountability are
clearly defined
- A trained, motivated work force is focused on
processes processes
- When problems are identified, effective Corrective
and Preventative Actions are taken
You are doing these things now, you would not
be successful if you were not doing these
things
510
things
Management Model for Performance Excellence
Cultur
e
Customer Satisfaction /
Shareholder – Stakeholder Value
e
System
• Leadership
• Vision
Management
System
Results are
Produced
$$
Vision
• Mission
• Strategy
• Strategic Critical
S F t
Something Magic
Happens
Integratio
n &
Controls
Success Factors
• Strategic
Initiatives
• Policy
Operations
System
y
• Operating Units
• Supporting Strategy
• Goals
511
• Action Plans
• Process Management
Saunders’ Management Model for Performance Excellence
Cultur
e
Customer Satisfaction /
Shareholder – Stakeholder Value
e
System
• Leadership
• Vision
Management
System
Results are
Produced
$$
Vision
• Mission
• Strategy
• Strategic Critical
S F t
Something Magic
Happens
Integratio
n &
Controls
Success Factors
• Strategic
Initiatives
• Policy
Operations
System
y
• Operating Units
• Supporting Strategy
• Goals
512
• Action Plans
• Process Management
How much improvement is “Good Enough”?
Lean Thinking, World Class Performance
· Process throughput is maximized
- Quality at Six Sigma Levels
· Cycle Time is minimized
- Efficiency Measurement
· All waste is eliminated
- Cost Reduction Measurement
To accomplish this level of performance, an
organization must be able to manage and
513
g g
accelerate change
Operations Excellence Model
Key Steps
• Stabilize Processes
• Establish the Processes’ Capability
• Verify Capability meets requirements
• Fail-proof the Process
• Implement Statistical Process Control
• Sustain the Gains through the
Integration and Controls Model
514
QAME’s Basic Facts Q
What gets Measured, gets Managed!
What gets Managed, gets Improved!
Without Measures you are flying Blind!
515
Operations Excellence Model
How do you start?
You have to “Listen to the Process” to
see how well it is performing see how well it is performing
516
Voice of the Process Voice of the Process
(VOP)
Mean or Average Mean or Average
Process # 1 Process # 2
Standard Deviation Standard Deviation Standard Deviation
517
A Fundamental Fact:
E t t f Every output comes from a process
and every process leads to an output.
Mean or Average Mean or Average
Process # 1 Process # 2
Standard Deviation Standard Deviation Standard Deviation
Processes can be described mathematically.
Six Sigma uses this fact to guide the identification
518
Six Sigma uses this fact to guide the identification
and elimination of defects.
Operations Excellence Model
N th t k h t th Now that you know what the process
is saying, so what?
You now have to “Listen to the Customer”
to see what their needs are
519
Voice of The Customer Voice of The Customer
(VOC)
U
Lower
Upper
Specificatio
n Limit
Lower
Specification
Limit
520
Understanding Process
Capability
LSL USL
Voice of the Process
Defects
Voice of the Customer
521
Capability Increases As Variation
DDecreases
The metrics Sigma, Cp & Cpk
increase as capability
increases.
No Defects
LSL USL LSL USL
Defects
522
Operations Excellence Model
Now you need to know how well the
process is meeting your customer’s needs!
You measure how well the process is p
meeting your customer’s needs using three
“Process Capability” Metrics Process Capability Metrics
523
· 4 Sigma is ~99.5% defect free but also means
– 7.5 minutes per day of unsafe drinking water
– 210 minutes per month without electricity
2 500 i t i l d k – 2,500 incorrect surgical procedures per week
– 20,000 lost pieces of mail per hour
– 100,000 wrong drug prescriptions each year g g p p y
· Airlines (measuring deaths per year) are at
7.2 Sigma
· with ~1 death per 1 million flyers
7.2 Sigma
· However, their baggage handling is at
3.4 Sigma
· 29,000 lost bags per 1 million bags handled
524
, g p g
4 Sigma is ~99.5% defect free but also means g
Would You Be as Tolerant Would You Be as Tolerant
if the Same Standards
A li d t B ki ? Applied to Banking?
f S 36 i i C If So, 36 Million Checks
Would Be Deposited into the
Wrong Accounts Every Day
525
Management Model for Performance Excellence
Culture
System
Customer Satisfaction /
Shareholder – Stakeholder Value
System
• Leadership
• Vision
Management
System
Results are
Produced
$$
Vision
• Mission
• Strategy
• Strategic Critical
S F t
Something Magic
Happens
Integratio
n &
Controls
Success Factors
• Strategic
Initiatives
• Policy
Operations
System
y
• Operating Units
• Supporting Strategy
• Goals
526
• Action Plans
• Process Management
Management Model for Performance Excellence
Culture
System
Customer Satisfaction /
Shareholder – Stakeholder Value
System
• Leadership
• Vision
Management
System
Results are
Produced
$$
Vision
• Mission
• Strategy
• Strategic Critical
S F t
Something Magic
Happens
Integratio
n &
Controls
Success Factors
• Strategic
Initiatives
• Policy
Operations
System
y
• Operating Units
• Supporting Strategy
• Goals
527
• Action Plans
• Process Management
H d TQM Si Si How does TQM-Six Sigma
integrate and control processes
and resources to achieve
unprecedented levels of unprecedented levels of
performance?
C t l d I t ti M d l Control and Integration Model
528
Control and Integration Model
•The Management Systems identifies “Unacceptable Levels of
Performance” (Gaps) in an organization’s performance based
on the requirements of various Standards and Regulations
•International and National Laws
•Best Practices
•ISO9001:2000
•Unacceptable Process Capability Metrics
•Etc
•TQM-Six Sigma provides Top Management with a
disciplined, problem solving structure that results in data
b d f d i i i h i h R C f h G i based, fact driven insights into the Root Causes of the Gaps in
their critical processes
•Define, Measure, Analyze, Improve, Control (DMAIC)
529
•Design for Six Sigma (DFSS)
Control and Integration Model Control and Integration Model
•Management Review is the forum where these
i f t id d b t t various factors are considered by top management
and
•Priorities are established Priorities are established
•Guidance Given
•Resources are allocated
•Progress is monitored
530
Integration and Controls
Management Review Model
• Review Customer Feedback on current performance Review Customer Feedback on current performance
• Incorporate Customer input on future needs
• Review current process capabilities and performance
based on internal measurements
• Identify highest priority improvements / changes
• Establish improvement method Establish improvement method
• Six Sigma
• Corrective Action
P t ti A ti • Preventative Action
• Other
• Allocate Resources
531
• Provide ongoing Guidance and Support
Management Model for Performance Excellence
Culture
System
Customer Satisfaction /
Shareholder – Stakeholder Value
System
• Leadership
• Vision
Management
System
Results are
Produced RS
Vision
• Mission
• Strategy
• Strategic Critical
S F t
Something Magic
Happens
Integratio
n &
Controls
Success Factors
• Strategic
Initiatives
• Policy
Operations
System
y
• Operating Units
• Supporting Strategy
• Goals
532
• Action Plans
• Process Management
Management Model for Performance Excellence
Culture
System
Customer Satisfaction /
Shareholder – Stakeholder Value
System
• Leadership
• Vision
Management
System
Results are
Produced RS
Vision
• Mission
• Strategy
• Strategic Critical
S F t
Something Magic
Happens
Integratio
n &
Controls
Success Factors
• Strategic
Initiatives
• Policy
Operations
System
y
• Operating Units
• Supporting Strategy
• Goals
533
• Action Plans
• Process Management
What is a Cultural System?
I t is based on organizat ional values:
- How we behave
- What we believe
- The rules we follow
- - I n t he rule book
- - The unwrit t en rules
534
TQM-Six Sigma Values g
TQM-Six Sigma is About Success
· Relentless quest for perfection to meet customer needs
· Rigorous alignment of actions with strategy
g
· Rigorous alignment of actions with strategy
· Measuring bottom-line impact
D t d i f t b d d i i ki · Data-driven, fact-based decision making
· Focusing your best people on your highest priorities
· Improving the processes
535
· Transforming how people work
TQM-Six Sigma Values
TQM-Six Sigma Leader’s Values
· Your personal and the organizational commitment and
involvement that engages and further develops your people
The strategy for prioritizing your organization’s opportunities
· The proven methodology and structure to manage your
projects and deliver breakthrough results projects and deliver breakthrough results
Used to Accelerate Discipline It is the
Improvement Through Your Organization
536
Change Management Model
Management Thinking and Behavior
FRONT LINE EMPLOYEES
Management Thinking and Behavior
I
P
CEO
MIDDLE
FRONT LINE EMPLOYEES
E
R
S
H
I
DEPARTMENT
HEADS
DEPARTMENT
MANAGERS
L
E
A
D
E
MIDDLE
MANAGERS
CEO
N
HEADS
L S
U
P
P
FRONT LINE EMPLOYEES
CEO
P
O
R
T
537
Cultural Systems y
Change Management Model
• Establish the “Current State” of the Culture • Establish the Current State of the Culture
• Envision the “Future State” of the Culture
• Identify the changes in Thinking and Behaviors needed in the
Future State
• Create and implement a “Change Management Plan”
to move from the “Current State” to the “Future State”
• Communicate
• How the Change will benefit the employees
• What Is In It For Me (WIIIFM) • What Is In It For Me (WIIIFM)
• The Compelling Need for the Change
• When and how the changes will take place
538
• Managers at all levels demonstrate the new Thinking and Behaviors
Summary
How TQM-Six Sigma helps you? How TQM Six Sigma helps you?
· To address the Management System
- Management Excellence Model
‚ Based on ISO9000:2000 Quality Management System (QMS)
· To address the Operations System
- Operations Excellence Model
‚ Based on Statistical Process Control (SPC)
· To Integrate and Control the Transformation Process
- Management Review Model
‚ Based on linking Customers needs to critical internal processes ‚ Based on linking Customers needs to critical internal processes
· To Address the Cultural System
- Change Management Model
B d bli hi f hi ki d b h i
539
‚ Based on establishing new ways of thinking and behaving
The Synergy between TQM and Six Sigma
TQM-Six Sigma combines the power of two extremely powerful
management structures g
• TQM focuses on optimizing the four critical Management
Systems
•Management g
•Operations
•Culture
•Integration and Controls Integration and Controls
•Six Sigma provides a disciplined, fact based structure to
accelerate and manage change in
•ProblemIdentification Process Problem Identification Process
•Problem Prioritization Process
•Problem Solution / Prevention Process
•Sustaining The Gains
540
•Sustaining The Gains
LETS GO TO
PRACTI CALI TI ES
Thanks for Your
Participation p
3/ 27/ 2008 Dr. A. Saddique 541
542
Val ue y our t i me …
I t i s a di mi ni shi ng r esour ce
Not hi ng happens unl ess f i r st a dr eam
Those w ho ar e v i ct or i ous pl an ef f ect i v el y and
h d i i l Th l i k t i t h t change deci si v el y . They ar e l i k e a gr eat r i v er , t hat
mai nt ai ns i t s cour se, but adj ust s i t s f l ow .
I f t her e i s a bet t er sol ut i on, f i nd i t .
Teamw or k i s t he abi l i t y t o w or k t oget her y g
t ow ar ds a common v i si on. I t i s a f uel t hat al l ow s
common peopl e t o at t ai n uncommon r esul t s.
A l i t t l e push i n t he r i ght di r ect i on
can mak e a bi g di f f er ence.
When one door cl oses, anot her opens. , p
Sei ze t he oppor t uni t y
w hi l e t he pat h r emai ns l i t .
Our t hought s and i magi nat i on ar e t he
onl y r eal l i mi t s t o our possi bi l i t i es.
The r ung of a l adder w as never meant e u g o a adde as e e ea t
t o r est upon, but onl y t o hol d y our f oot l ong
enough t o put t he ot her f oot hi gher .
Obst acl es ar e t hose f r i ght f ul t hi ngs y ou see
w hen y ou f ai l t o f ocus on y our goal s.
Success i n busi ness and
cust omer ser v i ce go hand i n hand.
I f i t i s t o be … i t i s up t o me.

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