Lecture 1

Healthcare Quality Concepts:

What is Quality?
* Doing the RIGHT things – standards- right, the first time
and every time.

* Is fitness for use “Juran”: a service which is free from

deficiencies and meets customer needs.

* Meet the desired health outcomes using the best practice.

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Aspects of quality (MAP):
- Measurable : Compliance with/ adherence to standards.

- Appreciative : According to the judgment of peer

review bodies

- Perceptive : As perceived by the recipient of care

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CUSTOMER
* Who is the customer?
-A customer is anyone who receives our service
-The customer is anyone who is dependent on “me” as a
supplier.

* What are the types of customers?

- "External customers" include all those who are
outside the organization receiving services from the
organization or vendors.
- "Internal customers" are those performing work, but
dependent on others performing work, within the
organization.

Types of Customers
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External customers Internal customers
•Patients/families •Admitting/reception/front office staff
•Physicians •Administrative staff
•Purchasers: •Administrative services staff
•Insurance companies and health •Ancillary staff/technicians
plans •Care coordination/social services
•Employers staff
•Government agencies •Communications staff
•Regulators and accrediting agencies •Human resource staff
•Vendors/suppliers (goods and •Facilities staff
services) •Finance staff
•Other providers •Medical/clinical record staff
•Educational institutions •Nurses, aides, medical assistants
•Performance improvement, QM
•Pharmacists
•Physicians, med. directors,

Customer-Supplier relationship (Triple role)

Each person in the organization is a part of one or more

processes. The worker is a:
Customer of all those supplying inputs;
Processor, performing managerial, technical, or
administrative tasks using the inputs;
Supplier to customers by delivering products or services
(outputs).

Healthcare practitioners are also:

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* Suppliers, providing degrees of expertise, experience,
commitment, empowerment, satisfaction, time
* Processors of care certainly
* Customers, dependent on others in each process.

The patient has a triple role as:

 Customer: ask for and receive services, with needs
and expectations.

 Processor : perform tasks such as taking

medications, learning diet and exercises, self-care skills,
diabetic management, etc.) patient is unique processor

 Supplier: of characteristics such as age, sex,

socioeconomic status, and perceptions of care, in addition
to clinical history and symptoms,etc

 Key Dimensions Of Quality:

Appropriateness The degree to which the care and services

‫مالئمة لحاجة المريض‬ provided are relevant to an individual's clinical
needs, given the current state of knowledge.
"Correct," suitable resource utilization as judged
by peers;
Doing the right things in accordance with the
purpose.

Availability The degree to which appropriate care and

services are accessible and obtainable to meet an
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individual's needs.

Competenc The degree to which the practitioner adheres to

y professional and/or organizational standards of
care and practice.

Continuity The coordination of needed healthcare services

for a patient or specified population among all
practitioners and across all involved
organizations over time.

The delivery of needed healthcare as a coherent

unbroken succession of services.

Effectivene The degree to which care is provided in the

ss correct manner, given the current state of
knowledge, to achieve the desired or projected
outcome(s) for the individual"

Efficacy The potential capacity, or capability of the care

to produce the desired effect or outcome, as
‫تقديم الخدمة‬ already shown, e.g., through scientific research
‫المثالية حسب‬ (evidence-based) findings;
guidelines The power of a procedure or treatment to
improve health status.

Efficiency The relationship between the outcomes (results

of care) and the resources used to deliver care.
"The relationship of outputs (services produced)
to inputs (resources used to produce the
services)"

Prevention/  The degree to which interventions, including

Early the identification of risk factors, promote health
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Detection and prevent disease. ( instruct to early detect as
breast cancer )

Respect The degree to which those providing services do

and Caring so with sensitivity for the individual's needs,
expectations, and individual differences.
The degree to which the individual or a designee
is involved in his or her own care and service
decisions.

Safety The degree to which the healthcare intervention

minimizes risks of adverse outcome for both
patient and provider; ( eg prevent falls )

Timeliness The degree to which care is provided to the

individual at the most beneficial or necessary
time.
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?What is Total Quality Management
* It is the involvement of the entire organization in a process of
customer-driven ( to satisfy customer needs ) quality improvement
to provide value.

* Benefits from TQM:

- increase customer satisfaction
- increase top down and bottom up emphasis on quality
- increase profits
- increase market share
- decrease costs

Difference between traditional monitoring

and evaluation and TQM ( EXAM )

traditional monitoring and TQM
evaluation – quality assurance
Focus on clinical aspects of Focus on clinical and non-
care only. clinical aspects

QA activities are departmental. QA activities are cross-

departmental acc. to patient
flow.

Errors are due to individual Errors are due to system failure

performance. (85%).

Actions are initiated when a Continuous improvement

problem is identified. process.
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:Advantages of TQM

TQM ……PROACTIVE……continuous development

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Change in emphasis:
* In the Past; the focus was on:
.WHAT of care Patientcare given -
WHO of care Patient care giver -

* Now ; we added these focuses to the previous ones:

- HOW of care Patient care processes
- RESULT of care Patient care outcome

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Continuous quality improvement (CQI)
 It is a management process or approach to the continuous
improvement of processes of providing healthcare services to
meet the needs of the customers.
 What do we need to make CQI?
1- Leadership commitment : provide resources + participate in
decision making + take buy-in ‫االقناع‬
2- Organizational Culture : staff participation – team work -
communication
3- Customer focus : private communication – survey – focus
groups.
4- Continuous learning

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Concept of Value:
VALUE= (quality of care + outcome ) / Cost
optimum cost ‫الموارد المثلي‬

The goal from a value-based healthcare system is…………….

Transparency!
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 Patient choose best practices
 Encourage competition

Services Vs Products:
1.Services are intangible ‫ غير ملموسة‬, cannot be measured

2.Services are heterogeneous ‫ال يمكن تحديد نقطة بداية ونهاية محددة‬.

3.Production of a service is inseparable from its consumption.

4.Services are perishable ‫ ; فانية‬cannot be stored or resold.

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IOM reports:
** 1999: To Err is Human
- “At least 44,000 and perhaps as many as 98,000 Americans die in
hospitals each year as a result of medical errors”
- 275 lives lost daily from preventable medical errors
- This means there is one death in every 343 to 764 admissions. In
comparison, aviation averages one death for every 8 million
flights.

** 2001: Crossing the quality chasm‫فجوة‬

Stated that the six key areas to monitor quality in healthcare are:

STEEEP ( EXAM )
Safe care Avoiding injuries to patients

Timely care Reducing wait for both recipients and providers of care.

Effective care
Providing care based on scientific knowledge for better
outcomes.

Efficient care
Avoiding waste

Equitable care Ensuring that the quality of care does not vary because
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of characteristics such as gender, ethnicity,
socioeconomic status, or geographic location.

Patient-centered care Providing respectful and responsive care that ensures

that patient values guide clinical decisions

Juran trilogy or QM cycle: ( EXAM )

- Quality Planning:

- Quality Control:
data collection – initial analysis – compare actual
performance by my targeted goals
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- Quality Improvement:
intensive analysis – RCA – correct mistakes by making
action plans
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Donabedian paradigm (Systems approach)-
causal relationship:

Structure Process Outcome

- Is the evidence of the
organization’s capacity to
provide care
E.g.:
•Staff no.
•Staff qualifications
•Organizational chart
•Resources(equipment,budget….
.)
Are the procedures/ Are the results of care
sequence of steps to E.g..:
provide care •Clinical(complication
E.g..: rate, mortality rate..)
•Services (registration, •Functional( long term
lab,pharmacy…) health status..)
•Clinical processes(ttt, •Percieved( pt
assessment, satisfaction, peer
medication…) acceptability)
•Administartion and
management
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Redesigning the organization:
 Reengineering (fundamental change):
It is a sustained approach to change how work is done through
redesigning the entire business to gain competitive advantage and
create Future market growth.
(‫) اهدها وابنيها من األول‬

Downsizing:
is contracting or decreasing business activities to reduce costs-
NO future growth.

Restructuring = right sizing:

refers to improving a process through correcting past mistakes
and identifying opportunities for growth.

Paradigm shift:
is the change in the way of thinking and beliefs to make a radical
change.

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Integrated delivery system
An integrated delivery system (IDS) is a network of health care
providers and organizations which provides or arranges to provide
a coordinated continuum of services to a defined population and is
willing to be held clinically and fiscally accountable for the clinical
outcomes and health status of the population served.

Objectives of integrated delivery systems:

1- Quality Improvement and Cost Reduction:
• Reducing administrative/overhead costs
•Sharing risk
•Outcomes management and continuous quality improvement
•Reducing inappropriate and unnecessary resource use
•Efficient use of capital and technology
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2- Patient satisfaction:
•Seamless continuum of care.
•Focus on the health of patients.

3- Community Benefit:
• Improvement of community health status
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 Healthcare delivery settings
1.Emergency care

2.Acute/inpatient/hospital care

3.Ambulatory care

4.Home care

5.Hospice care

6.Transitional subacute care

7.Long term care LTC

8.Behavioral health

9.Retail health clinics

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Insurance coverage Types of Reimbursment systems:
- Fee for service(indemnity):

- discounted FFS:

- Prospective Payment system:

* DRGs :
* Case rate :
* Capitation: Prepayment with fixed number of dollars per member
per month PMPM,regardless the amount of care the patient
receives.
* perdiem:
* capped rate:

Advantages of prospective payment systems:

Encourages the organizations for balanced use of resources for
the patient across the continuum of care.

Efficient hospital stays, with discharge as soon as medically

possible.
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Diagnosis-related group (DRG)
Diagnosis-related group (DRG) is a system to classify hospital
cases into one of originally 467 groups. DRGs are assigned by a
"grouper" program based on ICD (International Classification of
Diseases) diagnoses, procedures, age, sex, discharge status, and
the presence of complications or co-morbidities.
o DRGs are a patient classification scheme which provides a
method of comparing the type of inpatients a hospital treat (case
mix) to the cost incurred by the hospital. For each DRG, a fair
payment is determined.
oDRGs help 3rd party payers to compare between hospitals.
oWhen a patient is admitted to the hospital, the reimbursement
from Medicare is based on the patient's DRG, regardless of what
the real cost of the hospital stay was, or what the hospital bills
Medicare for. The assumption is made that patients that fit the
same profile will need approximately the same care and services.
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International classification of diseases (ICD)
The International Statistical Classification of Diseases and Related
Health Problems (most commonly known by the abbreviation ICD)
is a medical classification that provides codes to classify diseases
and a wide variety of signs, symptoms, abnormal findings,
complaints, social circumstances, and external causes of injury or
disease. Under this system, every health condition can be
assigned to a unique category and given a code, up to six
characters long.

Complication  ( EXAM )
are concurrent diseases, accidents or adverse reactions that
aggravate the original disease. It is NOT present on admission.
Eg: A patient was admitted with acute atrial fibrillation and
developed a decubitus ulcer during the hospitalization.

Co-morbidity 
are secondary diseases to the patient’s primary diagnosis which
affects his treatment and LOS. It is PRESENT on
admission(POA).
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