Quality Improvements Steps: DR Bruno Bouchet Regional Quality of Care Director

Quality Improvements Steps
Dr Bruno Bouchet
Regional Quality of Care Director
OBJECTIVE
• To implement a logical sequence of

activities that will lead to improved
quality of care to patients, through
identification of issues, understanding of
their causes, and interventions to
address them.
QIP Planning Meeting

Ferghana, September 17, 2002
3 Main Quality Improvement Steps
1. Express the improvement objective or

quality issue to address
2. Get information
3. Implement interventions/changes

Quality Improvement Methods (1)
• Many “small” methods promoted by

various organizations
• Many acronyms: PI, FOCUS-PDCA,
COPE, etc.
• Lots of confusing jargon: team-based
problem solving, permanent process
improvement, reengineering, quality
design, rapid improvement cycle, etc.

Quality Improvement Methods (2)
• The name of the method does not really

matter as long as you follow a logical
sequence of steps.
• All methods have their own little sub-

steps and differences but follow the
same logic/sequence of 3 main steps:
express objective, get information,
implement intervention
First: Express your Improvement
Objective (1)
• Identify an opportunity for improvement
or a quality of care issue
• Criteria:
– Frequency (high volume)
– Seriousness (high risk)
– Difficulty to manage (problem-prone)
– Costly (high cost)

Express your Improvement
Objective (2)
Criteria: Examples:
1. Frequency (high 1. 25% of adult population has

volume) arterial hypertension
2. 80% of women with pregnancy-
induced hypertension develop
2. Seriousness (high risk)
eclampsia
3. 60% of patients with
3. Difficult to manage myocardial infraction die within
(problem-prone) the first 48 hours at the hospital
4. 50% of newborns are
4. Costly (high cost) hospitalized for 2 months for
neonatal infections, for an
average cost of $2000.
Objective (3)
• Sources of information:
– Routine Health Information System
– Health Statistics Reports
– Performance Monitoring Systems
– Supervision/Visits/Inspection System
– Health Surveys (DHS, etc.)
– Burden of Diseases Surveys
– Providers’ opinions
– Patients’ opinions
Objective (4)
• Examples of general quality
improvement objective statements:
– To improve the quality of care to adult patients
with arterial hypertension
– To improve the performance of the healthcare

system for women of reproductive age with
anemia
– To improve the quality of care to children

according to IMCI clinical care standards
Objective (5)
• Subsequent main steps:
– Define what is meant by system performance or
quality of care in each particular situation* (health
topic, level of the health system, stakeholders’
perspectives)
– Identify indicators that would reflect improved
quality of care or overall system performance
– Setup a Quality Performance Monitoring System
*When evidence-based clinical care standards are
not available, use common-sense standards for
the first improvement cycle

Second: Get Needed Information
(1)
• Identify the information you need:
– To know more about the topic for
improvement (knowledge of the content of
care)
– To know more about the magnitude and

types of quality issues
– To know more about the consequences of

poor performance/quality

Get Needed Information (2)
– To understand the causes of poor
performance and factors influencing quality
– To identify who is involved in the

healthcare system and processes to
improve
– To know the opinions of the stakeholders

on the topic for improvement

– To know more about the current organization of
healthcare services for the particular topic
– To understand the referral patterns between levels

of the system
– To identify the components that need to be part of

the healthcare system for a particular health
condition/issue

• Get the information you need:

– Review of existing data (many sources)
– Collection of more data (direct observation,
review of records, interviews, focus group
discussions, inspections)
– Through the Quality Performance
Monitoring System
– Transform data into meaningful information
(indicators, qualitative, costs, etc.)

Third: Implement
Interventions/Changes (1)
• Make sense of the information you got
• Use the information to suggest/identify
interventions
• Be creative
• Focus on interventions that
change/redesign some or all
components of the healthcare system
involved in the particular topic

Implement Interventions/Changes
(2)
Consider PDSA: A Scientific Rationale
Interventions
as ideas to
test, and PLAN the CHANGES
implement
them as an
TEST the IMPACT
operational ACT UPON the RESULTS
ofCHANGES
INTRODUCE THE CHANGES
research,
following the
STUDY the IMPACT of the
Shewhart CHANGES
cycle: Plan-
Do-Study-Act

Repeated PDSA to increase compliance with standards
3%
8% A P
S D Cycle 4: Assessment of
15% providers’ performance
25% Cycle 3: Pharmacist checks
relation treatment/diagnosis
A P
S D
Cycle 2: Define job-aids for IRA
30% Cycle 1: Remind IRA treatment standards
Indicator = proportion of antibiotics prescription that are not justified

Chart illustrating the effect of
changes on performance
Proportion of Non Justified Prescriptions over Time
35
30
25 Change 3
20
Change 1 Change 4
%
15
10 Change 2
5
0
1 2 3 4 5 6 7
Months
The Overall Management of a
Quality Improvement Project (1)
• Before the QI steps:

– Obtain consensus/agreement
– Discuss ideas
– Expose stakeholders to Quality
management concepts
– Planning meeting
– Setup different teams
– Inform everybody
• During the QI/Steps:
– Reconsider the team composition and
needs for new teams
– Maintain team cohesion
– Facilitate communication
– Sustain enthusiasm
– Encourage/Motivate
– Provide technical assistance
– Ensure quality of work processes
After the QI steps:
– Draw lessons and conclusions
– Celebrate/reward
– Document
– Present/Communicate
– Replicate, expand changes/results
– Institutionalize an improvement dynamic

Conclusion
• Pilot Quality Improvement Projects
in Ferghana have the potential to
significantly influence the design of
the health sector reform through
increasing our knowledge of more
effective clinical practices and better
organization of healthcare services


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Quality Improvements Steps

• To implement a logical sequence of

QIP Planning Meeting

1. Express the improvement objective or

QIP Planning Meeting

• Many “small” methods promoted by

QIP Planning Meeting

• The name of the method does not really

• All methods have their own little sub-

QIP Planning Meeting

1. Frequency (high 1. 25% of adult population has

– To improve the performance of the healthcare

– To improve the quality of care to children

QIP Planning Meeting

– To know more about the magnitude and

– To know more about the consequences of

QIP Planning Meeting

– To identify who is involved in the

– To know the opinions of the stakeholders

QIP Planning Meeting

– To understand the referral patterns between levels

– To identify the components that need to be part of

QIP Planning Meeting

• Get the information you need:

QIP Planning Meeting

QIP Planning Meeting

QIP Planning Meeting

30% Cycle 1: Remind IRA treatment standards

Indicator = proportion of antibiotics prescription that are not justified

• Before the QI steps:

QIP Planning Meeting

QIP Planning Meeting

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