Department of Health Systems and Policy

Institute of Public Health

CMHS
University of Gondar

Quality Management
 Outline
• Introduction
• Conceptualizing and defining quality
• Quality Management
• Quality planning, quality improvement and quality assurance
• Measuring quality
 CROSSING THE QUALITY CHASM
“Between the health care we
have and the health care we can
have lies not only a gap but a
chasm…”
- IOM
2001
 THE “KNOW – DO GAP”
The gap
between what
we can do and
what we
actually do
 What Causes the Quality Chasm?
Why are we not able to consistently deliver health interventions that we
know to be effective?
• Scarce resources?
• Lack of knowledge/skills?
• Lack of accountability?
• Health system complexity
 DEFINING QUALITY (AHCRQ)
• Doing the right thing
• At the right time
• In the right way
• To achieve the best possible
results
- US Agency for Health Care Research and Quality
 DEFINING QUALITY (IOM)

Quality is the extent to which health services:

• Improve desired health outcomes
• Are based on clinical evidence
• Are provided in a technically and culturally
competent manner, with good communication and
shared decision making
- US Institute of Medicine
 DEFINING QUALITY (IOM,
2001)
Six domains of health care quality:
1. Safe
2. Effective
3. Patient-centered
4. Timely
5. Efficient
6. Equitable
 DEFINING QUALITY (PATIENTS/CLIENTS)
• Patients/clients may not always define quality
in the same way as clinicians and policy makers
• Priorities often include:
– Technical competence
– Respectful treatment
– Availability of medications
 Is quality also an end in itself?

• The health system is a core social institution

• An important means by which individuals interact with their
government
• Should be an institution where inequities are redressed
• Health system performance is positively correlated with trust in
government
(Rockers et al., 2012)
 Quality is a Means to an End
Service Delivery
Access
Improved Health Coverage Health Workforce
Equity
Responsiveness Information

Risk Protection Products, vaccines, technology

Quality
Financing
Safety

Efficiency Leadership/Governance
Quality Management: “The Juran
Triad”

Quality Improvement
 Quality Management

Quality Planning:

• Establishes strategic and tactical goals needed to attain results

• Sets specifications (“standards”) for processes and outcomes

Quality Control:
• Measures actual performance through reporting and inspection (compared to standards), and takes action
to correct.
• Goal is stability and consistency with standards
Quality Improvement:
• Activities to foster change to achieve new levels of performance
• Focuses on effective design, management, organization and delivery
of health services
 Quality Assurance Vs Quality Improvement
Quality Assurance:
• Measures performance vs. standards at a point in time
• “Snapshot” or retroactive, focuses on individuals, Ex. SS, Acc., audits, inspections
• Standards and measures developed for quality assurance, however, can inform the
quality improvement process
Quality Improvement:
• Scientific methods to continuously improve processes to meet or exceed standards
• Measures change over time
• Proactive approach to improve processes and systems
 COMPARE AND CONTRAST

Criteria Quality Assurance Quality Improvement

Source of Ideas experts, best practice concepts from experts, best
practice, ideas from front-line
staff
Type of Measurement input, process process, outcome
Process of Measurement periodic, usually external continuous, internal

Ownership leadership/management front-line staff

Sustainability external checks (accreditation) self-regulation through high-
level continuous measurement

Future state static evolving

QUALITY PLANNING, QUALITY CONTROL AND CONTINUOUS QUALITY IMPROVEMENT

Policy, resources, coordination, accountability,

Quality Planning execution design

Quality Control (QA) CQI

Standards/ 1. Aims: what are the “gaps”
Guidelines/ in performance and outcomes
protocols 2. Measures: tools to measure
Professional and feedback processes and
oversight IMPROVED outcomes
Accreditation
OUTCOMES 3. Changes: QI change
activities for leadership, admin
Performance
and frontline to close the “gap”
review
 MEASURING QUALITY
Donabedian’s Framework:
• Structure: The context in which care is delivered,
including infrastructure, staffing, financing and equipment
• Process: Transactions between patients and
providers (what is done and how it is done)
• Outcome: Effects of health care on the health status of
patients and populations
LINKING DEFINITIONS AND INDICATORS
Category Sub-Category Description and Indicators
Structural Infrastructure Availability and condition of facilities,
equipment, drugs and supplies
Supply chains
Delivery Responsiveness Wait time, privacy, friendliness,
communication, dignity
Effort Length of consultation time, # of
explanations given, physical examination
Patient satisfaction Patients’ satisfaction with last consultation
Technical Competence Professional knowledge and skills
Clinical practice Presence/absence of critical elements of care,
following standards & guidelines, correct
prescribing behavior
THE ROLE(S) OF QUALITY IN HEALTH

Utilization ✗ Qualit = Health

y

Margaret Kruk
2013
 In Summary

• Health systems deliver suboptimal quality in rich and poor countries alike
• Evidence from LMIC shows particularly poor performance in patient safety,
effectiveness and patient-centeredness
• Quality management comprises quality planning, quality control/assurance
and quality improvement.
THANK YOU!!