Quality Assurance in Health Care

Dr. Kishor Adhikari

Assoc. Professor, SOPH, CMC
 What is Quality?
• "Degree to which a set of inherent
characteristic fulfills requirements"
• “Quality is a set of attributes of a service”
• Quality is “conformance to the norms of Input,
Process and Output”
• Quality is “conformance to the requirements
and Customer Satisfaction”
 What is ……Contd.
• Consistent delivery of a product or service according
to expected standards.
• Health care involves three main groups of people:
customers (patients), employees (service providers)
and the managers that interact in the provision of
healthcare.
• The customers (clients) satisfaction was made the
focus of all operations with managers and employees
working together as a team of decision-makers and
providers.
 What is quality…Contd.
• Quality is subjective in nature
• Different meaning to different people
• Context dictated by situation
– Need
– Resources
– Availability
– Purchasing Power
– Individual Perception
– Expectation
 Definition of Quality
• “Quality is defined as „the degree to which a set of
inherent characteristics fulfills requirements‟.
ISO 9000

• It is both objective and subjective in nature.

• “Quality of care is the level of attainment of health
systems‟ intrinsic goals for health improvement and
responsiveness to legitimate expectations of the
population.”
• WHO
 Contd.

A general definition of quality normally includes the following:

 
i) Achievement of a predetermined standard or target

ii) Involvement of clients’ requirement in determination of such a target or

standard

iii)Consideration of available resources financially and others in

determination of such a target or standard

iv) Recognition that there is always room for improvement and that targets
and standards must be reviewed.
 Myths on Quality
• Luxury
• Costly: Not affordable
• Intangible: Not measurable
• Problems: due to workers
• Originates from Quality department
 Quality of care is:
• Doing the right things (what)
• To the right people (to whom)
• At the right time (when)
• And doing things right first time
 Why Quality?
• Uniformity in process: Standards and Norms (to
reduce error, reduce waste, reduce cost)
• Performance measurement
• Increases the health status
• Poor quality can harm
• Social and economic benefits
• Accreditation
– Legal issues: consumer protection
– Increased motivation, this is what satisfies people
– Right things to do (Hippocratic oath)
 Quality in Health care
• No single definition of health service quality applies in all situations.

• The degree of quality is the extent to which the care provided is

expected to achieve the most favorable balance of risks and benefits.
- Avedis Donabedian, 1980

 
• ...proper performance (according to standards) of interventions that
are known to be safe, that are affordable to the society in question,
and that have the ability to produce an impact on mortality,
morbidity, disability, and malnutrition.
- M.I. Roemer and C. Montoya Aguilar, WHO, 1988
 Contd.

• The degree to which health care for

individuals and populations increase the
likelihood of the desired health outcomes
and are consistent with current professional
knowledge (1996, Institute Of Medicine )
 Contd.

• Assurance is defined as “maintaining and formally accounting for the

quality and appropriateness of care”

• All the arrangements and activities that are meant to safeguard,

maintain, and promote the quality of care. ( Dr. Donabedian )

• Systematic process for closing the gap between actual performance

and the desirable outcomes. . . (Drs. Ruelas and Frenk)

• It is a process of measuring quality, analyzing the deficiencies

discovered, and taking action to improve performance followed by
measuring quality again to determine whether improvement has been
achieved ..
(Dr. Heather Palmer)
 Contd.
• A systematic managerial transformation designed to address the needs and
opportunities of all organizations as they try to cope with increasing change,
complexity and tension within their environments (Dr. Donald Berwick )

• In essence, quality assurance is that set of activities that are carried out to set
standards and to monitor and improve performance so that the care
provided is as effective and as safe as possible

• Introduced into modern medicine by a British nurse, Florence Nightingale,

who assessed the quality of care in military hospitals during the Crimean
War.

• She introduced the first standards in nursing care; these resulted in dramatic
reductions of mortality rates in hospitals.
 Quality in Healthcare
• The Professional Perspective
The proper performance (according to standards) of
interventions that are- safe, Affect mortality, morbidity,
disability, and malnutrition. (Roemer and Aguilar, WHO,
1988)
• The Managerial Perspective
Doing the right thing right, right away, right time (Deming)
• The Client’s Perspective
The ability and capacity of healthcare to satisfy the
client’s needs
 DIMENSIONS OF QUALITY

• Quality is a comprehensive and multifaceted

concept.
• These dimensions of quality are a useful
framework that helps health teams to define
and analyze their problems and to measure
the extent to which they are meeting program
standards
 Dimensions of Quality

1. Access and affordability

2. Appropriateness
3. Techinical competence and skills
4. Effectiveness and Efficiency
5. Equity & Eqality
6. Responsiveness
7. Safety and reliability
8. Timeliness and Continuity
9. Amenities
 Quality Measures at different points in the health
system (Donabedian’s)/ Principles of Quality
management
 

i. Structural Quality Measures (Structure)

• Availability and quality of resources,

management systems and policy guidelines.
• Number of qualified staff, appropriate training
programs, available capital facilities (e.g.
functioning X-Ray equipment, number of road
worthy vehicles, amenities, etc.)
ii. Process Quality Measures (Process)

• The care given, imparting information and clinical

decision making are the actual processes of health care
delivery
• Collection of this data depends on the existence of
proper monitoring system.
• Process measures include waiting time, correct
diagnosis, proper examination of patients, etc.
 Contd.
iii. Outcome Quality Measures (Outcome)

• It is the overall end result of health care delivered; the outputs

and health status.

• Outcome measures include such as mortality, morbidity,

patient satisfaction, coverage, attendance levels etc.

• If we want to improve health outcomes, we must understand

the processes and structures that contribute to achieving the
outcome.
 Principles of Quality Assurance

a. Oriented toward meeting the needs and expectations of the

patient and the community.

b. Quality assurance focuses on systems .

c. Quality assurance uses data to analyze service delivery

processes.

d. Quality assurance encourages a team approach to problem

solving and quality improvement
e. Effective communication to improve service delivery
 The Quality Assurance Process

• The QA process is based on QAPs experience

working with health services in developing
countries.

• However, it also integrates lessons learned

from earlier quality assurance methodologies.
 Quality Assurance Process

1) Planning for quality assurance

2) Developing guidelines and setting standards
3) Communicating standards and specifications
4) Monitoring quality
5) Identifying problems and selecting opportunities for improvement
6) Defining the problem operationally
7) Choosing a team
8) Analyzing and studying the problem to identify its root causes
9) Developing solutions and actions for improvement
10) Implementing and evaluating quality improvement efforts
 
 TOOLS FOR QUALITY ASSURANCE – Quantitative and Qualitative

• Checklists can be prepared for various parameters based on Inputs/Structure,

Process/Services and Outcome (Health benefits/client satisfaction) indicators

• Qualitative methods such as indepth interviews, focus group discussions can be used
to assess quality of services provided, training and proficiency of health workers etc

• Both methods can be used in combination as tools for quality assurance

FACILITY CHECKLIST (Input)

• Clinic Timings properly displayed

• Availability of Service Provider
• Presence of adequate and sheltered waiting area
• Availabilty of drinking water and running water
• Availability of Screen in examination room
• Availability of Electricity
 QUALITY ASSURANCE TOOLS
• Process Quality Assessment Checklist- OPD Services provided by MO PHC

Curative Services
i.History Taking- MO asked chief complaints, History of present illness taken, Past
history taken
ii. Clinical Examination- Vital signs assessed, Systemic examination conducted
iii.Prescription writing- Provisional diagnosis written

Counselling and follow up Services- Prescription explained to patient, Health Education

given, Patient’s queries answered

• Eg Client Satisfaction- Can be assured using Quantitative Methods- Checklists and

Qualitative methods- In depth interviews or Focus Group Discussion
i. Using health facility regularly, Felt that clinic hours are adequate, Health
personnel gave sufficient time to listen and treat etc.

• eg. Interviewing mother of under five children for assurance of quality of services
provided on VHND
 Key Activities in the Development of a Quality Assurance
Program

i. Foster commitment to quality

ii. Conduct a preliminary review of QA-related activities
iii. Develop the purpose and vision for the QA effort
iv. Determine level and scope of initial QA activities
v. Assign responsibility for QA
vi. Allocate resources for QA
vii. Develop a written QA plan
viii. Strengthen QA skills and critical management systems
ix. Disseminate QA activities
x. Manage change
 Total quality management

• Total quality management (TQM), as defined by ISO 2002,

Management approach for an organization, centred on quality based on
participation of all its members and aiming at long term success through
customer satisfaction and benefits to all members of organization and
to society.

• Quality standards of an organization be maintained in all aspects and

requires ensuring that things are done right the first time and that
defects and waste are eliminated from operations.

• Places strong focus on process measurement and controls as means of

continuous improvement.

• It encompasses quality assurance, quality control and quality

improvement within its purview.
 Quality Assurance in Context of Nepal
• In Nepal importance of QA in health care was felt in 1990s
and Nepal Medical Standard of Contraceptive was prepared
in 1991.
• In 1993 with restructuring of MoH a QA cell was established
under the Health institutions and Manpower Division, DOHS.
• In the same year a quality care management center was
established under the Family Health Division, DOHS.
• Quality assurance programs are also carried out by the
National Public Health Laboratory, Department of Drug
Administration and by National Health programs such as TB
Control, Leprosy Control etc.
 Standard Guidelines for Different Types of Health Services and Health Institutions

• Those private health institutions and health organization

who had registered and got permission to open
according to the recent policies and rules beside that,
those health organization have to fulfill pre requisition
and standard decided by MOH and take approval letter.
• After these formalities they are allow for running and
implementing the program.
• Standards and pre-requisition have to be managed and
maintained according to the nature and level of health
organization and institution.
 Roles and Functions of QA Section

• Develop/design national QA system both for public and private

sector health programs and institutions.
• Draft necessary regulatory framework and get it promulgated
and develop related rules for its implementation.
• Monitor /supervise the quality of health care services provided
by both public and private sectors and provide feedback
accordingly.
• Facilitate program divisions and health institutions in
developing and health institutions in developing standards,
guidelines and service protocols for specific health services
including social inclusion and health care waste management.
• Coordinate with NHTC and other concerned agencies for
conducting orientation / training on QA.
 Roles and Functions of QA Section…Contd.

• Coordinate with NHEICC and other concerned agencies for

conducting awareness program on consumer’s right and
responsibilities to quality health services.
• Conduct / support studies and research activities to improve
quality health service.
• Coordinate and liaise with private health sector service and health
human resources training institutions.
• Monitor quality of care and human resources of both public and
private sector institutions.
• Liaise with QA Steering Committee at MoHP and QA Working
Committee at district level.
• Collect QA activity reports conducted by program divisions, health
institutions and other agencies review and analyze QA reports and
provide feedback to concerned agencies.
 Quality assurance in federal healthcare
system
• In newly restructured MoHP organogram, it has five
divisions: The Policy, Planning & Monitoring Division; the
Health Coordination Division; the Quality Assurance &
Regulation Division; the Population Management Division
and the Administration Division.
• In addition, the six professional councils: Nepal Medical
Council, Nepal Nursing Council, Nepal Ayurvedic Medical
Council, Nepal Health Professional Council, Nepal
Pharmacy Council and Nepal Health Research Council)
accredits health-related schools and training centers and
regulate care providers.
Major Progress against NHSS Outcome targets

• Outcome 2: Improved Quality of Care at Point-of-delivery

• In line with the new organogram of MoHP in the federal context, the
“Quality Assessment and Regulation Divisions” has been established.
• Public Health Service Act 2018 has been enacted, which lays the
foundation for meaningful quality improvements in health.
• A Health Institution Quality Assurance Authority Act was drafted which
provisions the establishment of an autonomous body for accreditation
of private (including NGO) health institutions. The Public Health Act
2018 provisions institutional arrangements for accreditation.
• The Basic Health Care Package has been defined.
• A High-Level Steering Committee on Antimicrobial Resistance has been
formed with representation from other sectors.
 QA in Public Health Laboratory
• There are currently diagnostic health laboratories in 8 central hospitals, 5 regional
hospitals, 3 sub- regional hospitals, 10 zonal hospitals, 62 district hospitals, 16
other district level hospitals, 198 PHCCs, 150 health posts and more than 1,700
private health institutions.
• Almost all of these laboratories need to improve their quality assurance practices,
human resources, competency, service range and physical infrastructure.
• NPHL monitors these laboratories through its external quality assurance of lab
services and the quality control testing of samples and periodic supervision of
both government and nongovernment laboratories.
• It conducts the National External Quality Assurance Scheme (NEQAS) programme
to monitor testing quality.
• It sends samples (including biochemical tests, malaria slides, Gram stain,
Peripheral Blood Smear, haemoglobin, TC, DC, RBC Count andTransfusion
Transmissible Infection (TTI) screening, to the laboratories and Blood Transfusion
Service Centres.
• NPHL/NBBTS provides feedback based on the results. This also helps to enhance
the testing capability of lab personnel.
 QA in National Tuberculosis Programme (NTP)

• The external quality assurance (EQA) for sputum microscopy is

carried out provincial health directorates (previously regional health
directorates) at seven provinces and at the National TB centre in
Kathmandu.
• A lot quality assurance sampling/system (LQAS) has been
implemented throughout Nepal. At each microscopy centre,
examined slides for EQA are collected and selected according to the
LQAS. Previously NTP used to collect all positive and 10 percent
negative slides for EQA.
• In LQAS, slides are collected and selected using standard procedures
to give a statistically significant sample size. LQAS is a systematic
sampling technique that helps maintain good quality sputum results
between microscopy centres and quality control centres.
 The hindering factors

• Lack of policy, plan, and unclear strategy.

• Weak leadership
• Corruption and transparency issues
• Poor skill
• Lack/adequacy of resources
• No unity and integrity
• Lack of trust
• Misuse of authority
• Different perceptions with in leaders and workers.
 Performance Management
• The term performance management gained its
popularity in early 1980’s when total quality
management programs received utmost importance
for achievement of superior standards and quality
performance
• According to Armstrong and Baron (1998),
Performance Management is both a strategic and an
integrated approach to delivering successful results
in organizations by improving the performance and
developing the capabilities of teams and individuals.
 What are Performance Standards?

• Performance Standards are the benchmark

against which performance is measured.
Definition of performance management

• “It is a continuous process of identifying,

measuring and developing the performance of
individuals and teams and aligning
performance with the strategic goals of the
organization”.
• PM contains two major components:
– It’s a continuous process
– Alignment with strategic goals
 NATURE OF PERSONNEL MANAGEMENT

• Personnel management includes the function of

employment, development and compensation- These
functions are performed primarily by the personnel
management in consultation with other departments.
• Personnel management is an extension to general
management. It is concerned with promoting and
stimulating competent work force to make their fullest
contribution to the concern.
• Personnel management exist to advice and assist the line
managers in personnel matters. Therefore, personnel
department is a staff department of an organization.
• Personnel management lays emphasize on action rather
than making lengthy schedules, plans, work methods.
• The problems and grievances of people at work can be
solved more effectively through rationale personnel
policies.
• It is based on human orientation. It tries to help the
workers to develop their potential fully to the concern.
• It also motivates the employees through it’s effective
incentive plans so that the employees provide fullest
co-operation.
 OBJECTIVES OF PERFORMANCE
MANAGEMENT
• To enable the employees towards achievement of
superior standards of work performance.

• To help the employees in identifying the knowledge

and skills required for performing the job efficiently as
this would drive their focus towards performing the
right task in the right way.
• To Boost the performance of the employees by
encouraging employee empowerment, motivation and
implementation of an effective reward mechanism.
• Promoting a two way system of communication between
the supervisors and the employees for providing a
regular and a transparent feedback for improving
employee performance and continuous coaching.
• Identifying the barriers to effective performance and
resolving those barriers through constant monitoring,
coaching and development interventions.
• Creating a basis for several administrative decisions
strategic planning, succession planning, promotions and
performance based payment
Booz Allen's performance management model
 Performance efficiency Indicators:

• Measurements that define and assess the

performance of an organization, department,
employee, etc..
• Objectives to be targeted in order to add the
most value to a organization.
• Choosing the right performance indicators
relies upon a good understanding of what is
important to the organization.
 Two Types:

• Result oriented indicators:

– Focus on the key outputs of a process.
– Related to the critical success factors.
– Examples: customer complaints and return on
investment (ROI).
• Process oriented indicators:
– Focus on the inputs to a process.
– Examples: time to process customer order and
late deliveries.
Performance efficiency Indicators are Used to:

• Help organizations to understand their performance levels.

• Help setting realistic performance goals.
• Help aligning daily work to strategic goals.
• Help monitoring progress on a real-time basis.
• Help understanding the weaknesses and establishing
improvement priorities.
• Determine whether an improvement is being made and
maintained.
• Help benchmark internally and externally.
• Identify if staff are doing well and to help them if they are not.
• Provide a basis for recognizing team and individual performance.