QUALITY

 Quality is doing the right thing, right the

first time and every time.

 There is no second time in dealing with

human lives
QUALITY
Quality is efficiency and effectiveness

Efficiency
level of performance that describes a process that uses
the lowest amount of inputs to create the greatest
amount of outputs.

Effectiveness is meeting the expectations of customers

and other stakeholders
QUALITY MEANS
that the nurses and other allied
health workers are efficient and
effective
WE NEED TO DO
BETTER THAN BEFORE
The 4 Cs
• Customer
• Cost
• Competition
• Crises
 THE COST OF QUALITY
IS THE COST OF NOT DOING
THE RIGHT THING RIGHT THE
FIRST TIME
WHY QUALITY?
QUALITY IS NECESSARY
FOR THE ORGANIZATION’S
SURVIVAL.
KAIZEN
a Japanese business philosophy of continuous improvement of working
practices, personal efficiency, etc.
HOW TO MAKE THINGS BETTER
We make work / processes –
 Simpler
 Shorter
 Easier
 Cleaner
 Faster
THE STRONG
WOODCUTTER
How to do Quality Improvement?

1. DO MEASUREMENTS
What is not measured cannot be managed
& controlled.

2. CREATE STANDARDS
Variation is the enemy of quality

3. USE QUALITY TOOLS

CONCEPT OF CONTINOUS
QUALITY IMPROVEMENT (CQI)
An approach to quality management that
builds upon traditional quality assurance
methods by emphasizing the organization and
systems: focuses on “process” rather than the
individual; recognizes both internal and
external “customers”; promotes the need for
objective data to analyze and improve
processes.
 THE 5 DEMING PRINCIPLES THAT HELP
HEALTHCARE PROCESS
1. Quality improvement is the science of process
management.
2. If you cannot measure it…. you cannot improve it.
3. Managed care means managing the processes of care, not
managing physicians and nurses.
4. The right data in the right format at the right time in the
right hands.
5. Engaging the ‘smart cogs” of healthcare.
QUALITY IMPROVEMENT FRAMEWORKS
Quality Improvement is a formal approach to the
analysis of performance and systematic efforts to
improve it.

PDSA
DMAI
QUALITY IMPROVEMENT
FRAMEWORKS (PDSA)

Desired
Outcome

Opportunities
to Improve
QUALITY IMPROVEMENT
FRAMEWORKS (DMAI)
Presentation of some CQIs:
POKA YOKE
FOOL PROOFING THE PROCESSES:
• Quality from the source
• Do not accept defect
• Do not pass on defect
CONCEPT OF PERFORMANCE
IMPROVEMENT
•Performance Improvement (PI) is a method
for analyzing performance problems and
setting up systems to ensure good
performance. PI is applied most effectively to
groups of workers within the same
organization or performing similar jobs.
PERFROMANCE IMPROVEMENT
FRAMEWORK
QUALITY PROBLEMS IN HEALTHCARE
• Incorrect dosages of drugs to patients
• Wrong drug given
• Improper administration of drug
• Number of toxic reactions observed to drugs given
• Number of incomplete medical records
• Number of unnecessary surgical procedures
performed
• Number of surgical complications
• Number of transfusion reactions
(DEMING , 1982)
Study Suggests Medical Errors Now
Third Leading Cause of Death in the
U.S. - John Hopkins Study, May 3, 2016

According to Journal of the American

Medical Association (JAMA) 2000
• 12,000 die from unnecessary surgery
• 7,000 die from medication errors in hospitals
• 20,000 die from other errors in hospitals
• 80,000 die from hospital-acquired infections
• 106,000 die from the negative side effects of drugs taken as prescribed
TYPE OF ADVERSE EVENTS
Suicide of patient or w/in 72 hrs of discharge
Surgery on wrong patient or body site

Medication error leading to death

Rape/assault/homicide in an inpatient setting

Incompatible blood transfusion

Maternal death

Infant abduction/wrong family discharge

Retained instrument after surgery

 TYPES OF ISSUES IDENTIFIED BY
INCIDENT MONITORING
Falls

Injuries other than falls (e.g. burns, pressure injuries, self-harm)

Medication errors

Clinical process problems (wrong diagnosis, poor care, inappropriate tx

Equipment problems (misuse, failure, malfunction)

Documentation problems (inadequate, incorrect, incomplete, unclear)

Hazardous environment (contamination, inadequate sterilization)

 TYPES OF ISSUES IDENTIFIED BY
INCIDENT MONITORING
Inadequate resources (staff absent, inexperienced, poor orientation)

Logistic problems (problems with admission, treatment, transport)

Administrative problems (inadequate supervision, poor mgmt
decision)
Infusion problems (omission, wrong rate)
Infrastructure problems (power failure, insufficient beds)

Nutrition problems (fed when fasting, wrong food, food

contaminated)
Blood product problems (underdose, overdose, storage problem)

Oxygen problems (omission, overdose,underdose, failure of supply)

TYPES OF
MEDICATION
ERRORS
TAXONOMY OF MEDICATION ERRORS
LEARNING FROM ERRORS

Healthcare professionals need to

understand how and why systems
break down and why mistakes
happen, so they can act to prevent
and learn from them.
Using QI method to improve the care

The implementation of most quality

improvement methods involves teams of
people who work together using an
agreed upon process to fix or prevent
particular problem.
BARRIERS TO QUALITY
•CAWS – Cannot Argue With Success

•PITM – Prove It To Me

•NIH – Not Invented Here

•WADB – We’ve Always Done (this) Before

Quality is never an accident;
it is always a result of high
intention, sincere effort,
intelligent direction and
skillful execution; it represents
the wise choice of many
alternatives.
William A. Foster
PATIENT SAFETY AND
THE JUST CULTURE
The single greatest impediment to error
prevention in the medical industry is, “that we
punish people for making mistakes.”

Dr. Lucian Leape Professor

“BLAME CULTURE”
• The way we have traditionally managed failures
and mistakes in health care has been based on the
person approach–we single out the individuals
directly involved in the patient care at the time of
the incident and hold them accountable.

• This act of “blaming” in health care has been a

common way for resolving problems. We refer to
this as the “blame culture.
 “People make errors, which lead to accidents.
Accidents lead to deaths. The standard solution is
to blame the people involved. If we find out who
made the errors and punish them, we solve the
problem, right? Wrong.
“
The problem is seldom the fault of an individual;
it is the fault of the system. Change the people
without changing the system and the problems
will continue.”
Don Norman
Balancing Accountability and No-Blame
Finding the Balance
NO
BLAME

ACCOUNTABILITY
TAKE OWNERSHIP
Be involved and perform quality work
and quality care.

SURVIVAL OF YOUR COMPANY IS YOUR

WORK SURVIVAL
THE CUSTOMER
DEFINITION:
Is the user of one’s work output
Customer is a generic term

For airline – passengers

For lawyers – clients
For hospitals - patients
THE CUSTOMER
TYPES OF CUSTOMERS

INTERNAL CUSTOMER

EXTERNAL CUSTOMER
LEVELS OF CUSTOMER SERVICE
 SATISFYING

 DELIGHTING

 SURPRISING
TEAMWORK IN HEALTHCARE
THE NURSE AS FIRST LEVEL OF HOSPITAL DEFENSE
THE NURSE AS LAST LEVEL OF HOSPITAL DEFENSE
 The Eleven Deadly Sins of
Customer Service in Hospitals
HOW A TYPICAL COMPANY LOOKS LIKE

President

Vice
President

MGR MGR
HOW A WORLD CLASS COMPANY LOOKS LIKE

Customer

President

Vice
President

MGR MGR
Managing Change for Improvement

• Change occurs as a process, not as an event. Organizational

change does not happen instantaneously. Individuals do not
change simply because they received an email or attended a
training program. When we experience change, we move
from what we had known and done, through a period of
transition to arrive at a desired new way of behaving and
doing our job.
Managing Change for Improvement

• Change as a process is a central component of

successful change and successful change
management. By breaking change down into
distinct phases, you can better customize and tailor
your approach to ensure individuals successfully
adopt the change to how they work.
Change Process Framework
Change Process Framework
The Current State
The Current State is how things are done today. It
defines who we are. It may not be working great, but
it is familiar and comfortable because we know what
to expect. The Current State is where we have been
successful and where we know how we will be
measured and evaluated. Above all else, the Current
State is known.
Change Process Framework
The Transition State
The Transition State is messy and disorganized. It is
unpredictable and constantly in flux. The Transition
State is often emotionally charged - with emotions
ranging from despair to anxiety to anger to fear to
relief. During the Transition State, productivity
predictably declines. The Transition State requires us
to accept new perspectives and learn new ways of
behaving, while still keeping up our day-to-day
efforts. The Transition State is challenging.
Change Process Framework
The Future State
The Future State is where we are trying to get to. It is
often not fully defined, and can actually shift while
we are trudging through the Transition State. The
Future State is supposed to be better than the
Current State in terms of performance. The Future
State can often be worrisome. The Future State may
not match our personal and professional goals, and
there is a chance that we may not be successful in
the Future State. Above all else, the Future State is
unknown
Strategies to Implement
Change Management

Coaching and Mentoring

COACHING
Coaching typically refers to methods of helping
others to improve, develop, learn new skills, find
personal success, achieve aims and to manage
life change and personal challenges.
MENTORING
A relationship in which a more experienced or more
knowledgeable person helps to guide a less
experienced or less knowledgeable person.
The mentor may be older or younger than the person
being mentored, but she or he must have a certain
area of expertise.
The Flight of Rebirth