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BY/ Dr. Osama Fahim
A comprehensive guide, to healthcare quality professionals. Who are preparing to undertake the CPHQ exam. This guide is based on the CPHQ exam guidelines and my personal experience. Divided into Four Parts: Leadership, Improvement, Information and patient Safety
By Dr. Osama Fahim
Copyright 2010 @ Cairo to ALP
The first edition of this book Was completed in 2010
All rights are reserved To the publisher and author
For comments or more books by the author Email: Osama.email@example.com
Contents CPHQ: Practice to be the best 1. Introduction and Test Taking Tips: What is Quality and why What is CPHQ and why to certify Test taking strategy
2. Foundation, Techniques and Tools: Process analysis tools (e.g., fishbone, Pareto chart, run chart, scatter gram, control chart) Statistical techniques to describe data (e.g., mean, standard deviation) Statistical process control (e.g., common and special cause variation, random variation, trends) Statistical techniques to evaluate data (e.g., t-test, regression) Communication
3. Using Data for Improvement: Confidentiality of performance improvement activities, records, and reports Information for committee meetings (e.g., agendas, reports, minutes) Customer needs/expectations (e.g., surveys, focus groups, teams) Data inventory listing activities (i.e., what is available from which sources?)
Data collection methodology and Analysis Computerized systems for data collection and analysis Epidemiological theory in data collection and analysis Comparative data, benchmarking , outcomes Incident/occurrence reports Decision making
4. Strategy and Leadership: leadership values and commitment the organization’s quality culture organization-wide strategic planning Identify internal / external customer/supplier relationships organizational vision and mission statement goals and objectives performance measures (e.g., balanced scorecards, dashboards, core measures) lines of authority/accountability performance improvement models (e.g., FOCUS, PDCA, Six Sigma) national/international excellence/quality models accreditation process financial benefits of a quality program performance improvement oversight group (e.g., Quality Council, Steering Council, QM Committee) performance improvement team or teams and team structure (e.g., cross functional, self-directed)
Quality champions (e.g., process owners, quality, and patient safety) performance measures/indicators written plan for a risk management program survey processes (i.e., accreditation, licensure, Certification) cost analysis and departments budget
5. Continuous Improvement: process improvement activities and Teams performance improvement action plans and projects process and outcome measures evidence-based practice guidelines external quality awards (e.g., Malcolm Baldrige, Magnet) credentialing and privileging process medication usage review medical record review infection control processes peer review service specific review (pathology,radiology, pharmacy, nursing) patient advocacy (e.g., patient rights, ethics) risk management: prevention and identification mortality review failure mode and effects analysis quality department Education and Training
Integration between: performance improvement incorporated into the employee performance appraisal system findings from performance improvement incorporated into the credentialing/appointment/privilege delineation process data analysis results incorporated into the performance improvement process outcome of risk management assessment incorporated into the performance improvement process outcome of utilization management assessment incorporated into the performance improvement process quality findings incorporated into governance and management activities (e.g., bylaws, administrative policies, and procedures) accreditation and regulatory recommendations incorporated into the organization
Evaluation of: measures, teams, projects, Surveys, Accreditation performance/productivity reports patient/member/customer satisfaction practitioner profiling complaint analysis
6. Change Management and Innovation: Organization quality and safety culture ISO, Lean and Six sigma
Interpersonal relationship Integrate quality concepts within the organization organizational values and commitment among staff
7. Patient Safety: Patient safety culture – goals and program Technology and patient safety program Risk management Incident report Infection control program Sentinel/unexpected event Root cause analysis
If, it is quite difficult to find quality in your workplace, it is rather easier to start doing something that will be recognized.
When I started to do this book, I was faced by two things to make it simple or to make it comprehensive. But I decided to make it by both ways. Comprehensive yet simple and I hope that you will find it like that. When we speak about healthcare quality we have to distinguish it from quality in other sectors as in manufacturing or other service providing organizations.
Lastly I would wish for all of you to get the results that we were looking for and that this guide will do that for you.
Yours sincerely, Osama fahim
Chapter I Introduction and Test Taking Tips
What is Quality? The tale of the five blind men’s first encounter with an elephant depicts how each man describes an elephant based upon which part of the elephant's anatomy he happen to touch. A similar problem occurs when trying to define quality. How each person describes the 'elephant' is substantially different.
The term 'quality' is often used in a vague, blurred way. There are as many definitions of quality as there are quality consultants, but the common element of the business definitions is that the quality of a product or service refers to the perception of the degree to which the product or service meets the customer's expectations. Quality has no specific meaning unless related to a specific
function and/or object. Quality is a perceptual, conditional and somewhat subjective attribute. The business meanings of quality have developed over time. Various interpretations are given below: 1. ISO 9000: "Degree to which a set of inherent characteristics fulfills requirements." The standard defines requirement as need or expectation. 2. Six Sigma: "Number of defects per million opportunities." 3. Subir Chowdhury: "Quality combines people power and process power." 4. Philip B. Crosby: "Conformance to requirements." The requirements may not fully represent customer expectations; Crosby treats this as a separate problem. 5. Joseph M. Juran: "Fitness for use." Fitness is defined by the customer. 6. Noriaki Kano and others, present a two-dimensional model of quality: "must-be quality" and "attractive quality." The former is near to "fitness for use" and the latter is what the customer would love, but has not yet thought about. Supporters characterize this model more succinctly as: "Products and services that meet or exceed customers' expectations." 7. Robert Pirsig: "The result of care."
To make customer happier and increase profits
Purpose of six sigma :
8. Genichi Taguchi, with two definitions: a. "Uniformity around a target value." The idea is to lower the standard deviation in outcomes, and to keep the range of outcomes to a certain number of standard deviations, with rare exceptions. b. "The loss a product imposes on society after it is shipped." This definition of quality is based on a more comprehensive view of the production system.
9. American Society for Quality: "A subjective term for which each person has his or her own definition. In technical usage, quality can have two meanings: a. The characteristics of a product or service that bear on its ability to satisfy stated or implied needs; b. A product or service free of deficiencies." 10. Peter Drucker: "Quality in a product or service is not what the supplier puts in. It is what the customer gets out and is willing to pay for." 11. W. Edwards Deming: concentrating on "the efficient production of the quality that the market expects," and he linked quality and management: "Costs go down and productivity goes up as improvement of quality is accomplished by better management of design, engineering, testing and by improvement of processes." 12. Gerald M. Weinberg: "Value to some person".
Philip Crosby’s definition is easily toppled: if requirements are wrong, then failure is guaranteed. His focus is the domain of QA where, without a specification, quality cannot be measured and thus controlled. You cannot have zero defects if you do not have a standard against which to measure defectiveness. This reflects the early days, where quality was clearly about product. Quality control, and later QA, was our domain - we didn’t care about customers; the research and design department was responsible for designing the job and sales and marketing for selling it. But those halcyon days of definitive specifications and jobs for life are long gone.
Though Juran takes a step further down the value chain, to the use of the product or service (at which point customers had forced their way into the frame), he still presupposes that we can fully understand how the product will be used, which is a great challenge (and not always possible). As Deming himself said, some things are ‘unknown and unknowable’. ISO 8402 recognises this uncertainty with its ‘implied need’. It uses the word ‘entity’ as opposed to the ‘product or service’ definition of its earlier (1986) version, indicating a broadening uncertainty. Nonetheless, it suffers again from a simplistic, single-minded focus - all we need to do is to figure out what is wanted and then deliver it. The quality models are a step further into broader business. Here, although processes are important, quality is much more about people: customers are there, but so too are stakeholders - employees, partners, suppliers, shareholders and society. Perhaps wisely, the models avoid nailing down a specific definition of quality, leaving us without a definition that encompasses a broader business view. ISO9000:2000 steps in this direction also, talking about ‘customer and other interested parties’, but leaves the definition of quality at a rather generalised ‘degree to which a set of inherent characteristics fulfils requirements’. If someone talks about 'working on quality', they may simply mean activities designed to improve the organization and its services. Quality is essentially about learning what you are doing well and doing it better. It also means finding out what you may need to change to make sure you meet the needs of your service users. Quality is about:
knowing what you want to do and how you want to do it learning from what you do using what you learn to develop your organization and its services seeking to achieve continuous improvement Satisfying your stakeholders - those different people and groups with an interest in your organization.
Quality in business, engineering and manufacturing has a pragmatic interpretation as the non-inferiority or superiority of something. Quality is a perceptual, conditional and somewhat subjective attribute and may be understood differently by different people. Consumers may focus on the specification quality of a product/service, or how it compares to competitors in the marketplace. Producers might measure the conformance quality, or degree to which the product/service was produced correctly. The CQI defines quality in terms of innovation and care:
No doubt that everyone will benefit from applying quality: 1- The organization: a. Better product or service b. Improve process c. Reduce scrap and cost of production d. Customer satisfaction e. Increase profit 2- The Employees: a. Increase satisfaction b. Increase production
3- The society: a. Better product and service 4- The Customers: a. Increase satisfaction b. Decrease price for service or product
Brief History of Quality
The history of quality management, from mere 'inspection' to Total Quality Management, and its modern 'branded interpretations such as 'Six Sigma', has led to the development of essential processes, ideas, theories and tools that are central to organizational development, change management, and the performance improvements that are generally desired for individuals, teams and organizations.
Levels of Quality