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Chapter 12

Management in
Health Care
By: Mohammed Hussien (MPH/HSM)
Wollo University

Learning objectives

After completion of this chapter, students will be
able to:

Discuss quality in the context of healthcare

Discuss the dimensions of quality health

Describe the components of quality
management in healthcare

Identify quality measurement
models/approaches in healthcare

Discuss quality management cycle

Definitions and the concept of

Quality means different things to different people

quality has different meanings for different health
care players

From the provider‘s perspective, quality might
mean providing the best possible care available to
the patient

Quality from the perspective of the administrator
is to provide effective care in a cost-conscious

From the patient's perspective, quality is getting
my care when and where I need it and from
whomever I choose to cure my condition
in the

1990)  An organization's processes and activities are designed and implemented in order to continuously meet the organization's customers' needs and expectations (Al-Assaf. 1996) 4 . 1982)  The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (IOM .Definitions…  The application of medical science and technology in a way that maximizes its benefits to health without correspondingly increasing its risks (Donabedian.

Important concepts in the definitions  Quality of healthcare is about   Achieving positive health outcomes  Limiting the negative consequences of health care  Complying with scientific recommendations  Addressing beneficiaries’ needs and expectations Modification on IOM’s definition:  ‘The degree to which health services for individuals and populations increase the likelihood of desired health outcomes while keeping risks minimal and are consistent with current professional knowledge and5 .

4. 10. 7. Acceptability Satisfaction Responsiveness to patient preferences Technical performance Management of the interpersonal relationship 6 . 6. 3. 5. 11. Effectiveness Efficiency Access Safety Equity Appropriateness Timeliness 8.Dimensions of quality health care • Several authors and organizations have defined quality by describing the concept according to a set of dimensions 1. 9. 12. 2.

or conversely to minimize the input for a given level of output 7 .Dimensions of quality….  Effectiveness refers to the extent to which the intervention in question produces the intended effects  Efficiency refers to how well resources are used in achieving a given result  the extent to which objectives are achieved by minimizing the use of resources  The goal is to maximize the output for a given input.

at the time it is needed  How easily people obtain services depends on:  Cost of service  the provider’s location  days and times when care is available  how well cultural characteristics and expectations of the patient match with those of the provider 8 .  Access refers to the “degree to which individuals and groups are able to obtain needed services”  whether a health service or treatment is available to the person needing it.Dimensions of quality….

  Safety refers to the reduction of risk  patient safety is “freedom from accidental injury due to medical care. and socioeconomic status. geographic location.  with medical error being defined as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim Equity implies considerations of fairness  providing care that does not vary in quality because of personal characteristics such as gender.Dimensions of quality…. or medical errors”.  Services are provided to all people who require 9 them (according to their need) . ethnicity.

 Appropriateness – how the treatment corresponds to the needs of the patient  Timeliness – receiving treatment within a reasonable time frame  Acceptability .care meets the expectations of the people who use the services  Responsiveness to patients or patientcentredness – consideration of individual patients’ and society’s preferences and values  Satisfaction – how the treatment and the improvement in the patient’s health meets her/his expectations 10 .Dimensions of quality….

Dimensions of quality…. therapy appropriateness. and skill in performing procedures Interpersonal relationship refers to how well the clinician relates to the patient which is important  to fully address the patient’s concerns  to elicit a more complete and accurate medical history  in motivating the patient to follow a 11 prescription .   Technical Performance  Quality of technical performance refers to how well current scientific medical knowledge and technology are applied in a given situation  timeliness and accuracy of the diagnosis.

control or coordinate quality  In healthcare it involves the process of:  defining what constitutes best healthcare  investing for its achievement  continuously measuring progress with the purpose of improving processes and outcomes 12 .Quality Management  Quality management includes all the activities that organizations use to direct.

Quality Management…   Management of quality includes coordination and facilitation of all activities related to:  Quality Assurance (QA)  Quality Control (QC) and  Quality Improvement (QI) It involves processes pertaining to the coordination of activities related to all or any one of the above three as well as the administration and resource allocation of these processes 13 .

organization of committees and councils.Quality Management …  Administration may include training. education. resource acquisition and allocation. building of infrastructure. and so on  Quality management is the umbrella encompassing all processes and activities related to quality  Other terms used in the field include such terms as continuous quality improvement and total Quality Management (TQM) 14 .

Quality Management …  Quality Assurance (QA)   includes the process of planning for quality. communicating standards to users. using appropriate indicators. and determining whether there is variation from the expected outcome and whether there is a need for improvement 15 . setting standards of quality. and developing indicators for performance monitoring Monitoring/Quality Control (QC)  Quality control involves monitoring these standards. the development of objectives and goals for quality.

Quality Management …  Quality Improvement (QI)  QI efforts and processes complement QA and QC and sometimes overtake them  QI is defined as an organized. analyze them. and narrow or close them 16 . prioritize and select appropriate gaps to study. structured process that selectively identifies improvement teams to achieve improvements in products or services (Al-Assaf 1997)  It includes all actions to identify gaps (opportunities for improvement).

Figure: Quality Management Cycle 17 .

as mentioned above. is a process of reducing variation from a desired standard  Therefore. quality improvement is the process and sub-processes of identifying opportunities for improvement. and communicating standards-are all quality assurance steps  Step four.Quality improvement steps  According to the USAID quality cycle shown above. the first three steps of the cycle-planning. defining it from an operational 18 standpoint and acting on it . is also called quality control  The next six steps are quality improvement steps  Quality improvement. selecting an opportunity for improvement. setting standards. monitoring.

using appropriate indicators. and setting and communicating of standards  Quality control involves monitoring these standards.  Following analysis. and determining whether there is variation from the expected outcome and whether there is a need for improvement  Quality improvement identifies opportunities for improvement and prioritizes them.In summary  Quality management includes quality assurance. and the design of an 19 intervention. a solution is implemented to improve . quality control and 'quality improvement  Quality assurance includes the process of planning for quality.

this can be determined only by monitoring the quality process continuously  Monitoring is based on specific and measured indicators related to standards  It is a process of measuring variance from standards and initiating processes to reduce this variance  Without quality control it is impossible to determine whether the standards are met and whether there is an opportunity to improve or not 20 .In summary …  The solution may or may not meet the set standards.

Key success factors in quality improvement  The following principles are considered as key success factors towards quality improvement  Leadership  Commitment  Customer focus  Continuous process-oriented and outcomedriven improvements  Employee empowerment  Proactive improvements  Data-driven decision-making  Interdisciplinary team-work  Education. retraining and recognition 21 .

incremental improvements in the standards also are important  If high or even perfect compliance with a specific standard has been documented. upgrading this standard is the next step to take  Otherwise.Continuous Quality Improvement  Improvements are not onetime activities  When a team has worked on a process and improvement has been accomplished. it should not abandon this process and move on to the next one  Monitoring should continue. the organization will stay in the status quo and further improvement will not occur 22 . and improvements should be initiated every time they are needed  Once compliance has been achieved.

Continuous Quality Improvement… QI includes two important components and a supporting infrastructure   Quality Measurement  Quality Improvement  Infrastructure for QM Infrastructure 23 .

24 .Quality Measurement  The initial step required to initiate quality improvement processes in any kind of institution  Donabedian’s framework for measurement of healthcare quality   Structure  Process  Outcome S-P-O are areas of measures on which information can be gathered and potentially inferred about the quality of healthcare.

training. and overall organization  Evaluations of quality that rely on such structural elements assume that well-qualified people working in well-appointed and well-organized settings will provide high-quality care  However. equipment. To measure the quality of HIV care. although good structure makes good quality more likely to ensue. one can use “Percentage of hospitals with medical doctors trained on 25 HIV care” as an indicator .Quality Measurement…  Structure  Structure is the setup in which care is being provided  include the education. and certification of professionals who provide care and the adequacy of the facility’s staffing. it does not guarantee it  E.g.

which refers to how well actions were carried out and how timely they were  Assumption: “if healthcare is provided in compliance with scientific recommendations. and skill. which refers to whether the right actions were taken. which refers to what takes place during the delivery of care. also can be the basis for evaluating quality of care  The quality of the process in turn can vary on two aspects: appropriateness. potentially attainable outcomes will be achieved” 26 .Quality Measurement…  Process  Process.

Quality Measurement…  Outcome  the costs of care and patients’ health outcome  outcomes typically refer to health status-related indicators .the change observed on beneficiaries of healthcare that is attributable to healthcare  may include intermediate or longer term outcomes  change in health status  change in health behavior  client satisfaction  Challenge: attribution  many factors that determine clinical outcomes —including genetic and environmental factors 27 .

Quality Measurement…   Steps to measure quality  Identify priority areas for improvement  Select quality of care indicators related to priority areas of improvement  Collect data  Analyze data Expected results  Opportunities for quality improvement identified 28 .

Quality Improvement  the step during which series of actions will be taken to:  Plan and implement potential solutions to address underlying root causes of problems  Study if changes bring improvement  Expand those changes that are found effective and modify those found ineffective Act Plan Deming’s Cycle Study Do 29 .

what.Quality Improvement…  PLAN • Based on findings of Quality Measurement • Investigate the root causes of performance gap • Come up with a prioritized list of feasible solutions • Set objectives for improvement • Plan implementation (who. where. when)  DO • Carry out the plan – small scale • Document problems and unexpected observations 30 • Begin analysis of the data .

Quality Improvement…  STUDY  Analyze data completely  Compare findings with expectations and previous findings  Draw conclusions on what to expand and what to further improve  ACT  Expand changes that brought improvements  Modify changes that need modifications to bring more improvements  Find out other solutions for areas with no improvement  Start the next cycle 31 .

guidelines and job aids • Electronic diagnostic support • Physician reminders • Process redesign • Change in technology • Reallocation of resources (human. financial.Quality Improvement…  Examples of actions to improve quality of healthcare: • Training on specific topics • Development of standards. material) • Patient education programs 32 .

always.Infrastructure  Quality management needs to be institutionalized if improvements have to be made continually  QM is not a onetime activity. there are rooms for improvement  It should include the human and material resources that are required to:  Plan for CQI processes  Measure quality of care  Test and implement quality improvement actions  Monitor and evaluate if the quality management program is working 33 .

expertise is available within and commitment is fully integrated and maintained  A quality environment or culture is achieved when quality activities become day-to-day activities 34 .A quality culture  Establishing a quality culture is the next milestone  Institutionalization is achieved when appropriate healthcare quality activities are carried out effectively. and on a routine basis throughout a system or an organization  It is a state of achievement whereby healthcare quality is practiced and maintained without additional outside resources  In such a state. efficiently.

and outcome 35 . and makes it part of his or her responsibility and not the responsibility of a department or another individual  In such a culture.A quality culture…  Such activities are not separate from the normal activities carried out daily by the system and its personnel  It is a state in which each employee is aware of the quality concept. each individual is responsible for his or her task’s own quality structure. believes in it. practices its principles. process.

Thank ! ! u o y .