Quality in health

care
 Why do we need quality
improvement?
• Quality improvement aims to design systems
capable of:
– identifying
– preventing ERRORS

– mitigating
• Examples (non-medical):
– seatbelt alarms in cars
– heat-sensitive fire sprinkler systems
 What are the principles/objectives of
quality improvement
• Institute of Medicine (IOM) report, USA, in 2001
defined 6 aims of health care (Acronym: STEEEP)
What are the principles/objectives
of quality improvement
 What are the principles/objectives of
quality improvement
• The IOM 6 aims of health care (STEEEP):
1.Safe: avoid patients’ injuries
2. Timely: reduce waits and delays in care
3. Effective: provide care based on scientific
knowledge likely to benefit patients
4. Efficient: avoid waste in equipment, supplies, ideas,
and energy
5. Equitable: provide care that does not vary in quality
because of personal characteristics such as gender,
ethnicity, geographic location, and socioeconomic
status
6. Patient-centered: provide care that is respectful
of and responsive to individual patient preferences,
needs, and values.
These principles/objectives remind us of
certain ethical principles
 What are the principles/objectives
of quality improvement
Non-maleficence

Autonomy
Dignity
Honesty
Non-maleficence

Beneficence
Justice
 Quality assessment projects
Examples:
•Clinical audits
•Quality improvement projects (e.g. PDSA)
Clinical
Audit
• Deming’s PDSA cycle
How do audit and PDSA differ?
 How can we assess the quality
of health care?
• Many measures exist but the traditional
measures of quality are:
– Structure
– Process
– Outcome
– Balance
 Measures of Quality

• Structure: the physical equipment, resources, or

facilities (e.g., number of ICU beds in a hospital).
• Process: how the system works (e.g. how often
nurses use bar coding to identify patients prior to
administering medication).
 Measures of Quality

• Outcomes: the final product or end result in patient care (e.g.

infection rate in patients admitted to the hospital).
• Balancing measures assesses if changes made to improve one
part of the system cause an unanticipated decrease in
performance in another part (e.g. did an initiative aimed at
increasing the efficiency of discharging patients from the
hospital lead to more patients being sent home without
appropriate follow-up instructions).
 Measures of Quality

• Existing measures address some domains

more extensively than others:
– The vast majority of measures: effectiveness &
safety
– a smaller number: timeliness & patient-
centeredness
– very few: the efficiency & equity of care
 Which measure to use?

- Outcomes are often difficult to assess in

quality improvement. Therefore, process
measures are often used as a surrogate for
outcomes.

- For example, it may be difficult to accurately

track all HAI (outcomes measure), so rates of
compliance with hand washing are monitored
instead (process measure).
 Aiding tools

Charts
•Flow charts
•Pareto charts
•Run charts
 • Flowchart: is a
visual illustration of
all the steps or
parts of a process
in patient care.
• Flowcharts help health-care providers
understand a clinical process so that they:
– identify steps that do not add value to the process
– determine areas of delay in care
– discover failure points in the system
• Then they use that knowledge to design new
ways to improve services.
• Pareto chart: 80/20 rule
• Run charts: help determine whether an
intervention in patient care resulted in true
improvement over time or only a random
fluctuation.
 Question 1
• You are trying to develop a new system to more closely
monitor blood glucose levels of admitted diabetic patients.
Your team will conduct a PDSA cycle. Which of the following
statements is correct regarding the PDSA cycle?
A. The PDSA cycle begins with full scale implementation
B. The PDSA cycle consists of small, rapid test of new initiatives
C. Changes from PDSA are based on expert intuition, and do not
require data collection or interpretation
D. PDSA is a means of analyzing past errors to design system-
based interventions
E. The PDSA cycle requires a randomized control trial
 Question 2
An ICU team is attempting to decrease their rate of ventilator-
acquired pneumonia. A new protocol is made that includes
several new activities as head of bed elevation, daily oral care,
daily assessment of readiness to extubate and having access to
infectious disease specialists for consultation. Which one of the
following represents an outcome measure of quality?
A. Measure the compliance rate in following the guidelines for head of bed
elevation over a 3-month period
B. Determine the number of infectious disease specialists available for
consultation during a 3-month period.
C. Monitor the number of patients who self-extubate prematurely over a 3
months period
D. Monitor the number of ventilator-acquired pneumonia cases over 3 months
 Question 3
• A geriatric team aims to decrease the number of
patient falls in their nursing home.
• A new system of identifying patients at high-risk for
falling & providing these patients with fall
prevention interventions is implemented.
• Following this intervention, the rate of patient falls
per month is followed for 12 months on a run chart.
No baseline data were collected. Which of the
following best describes the results of the run
chart?
A. The intervention led to a significant decrease in patient
falls
B. The intervention led to a significant increase in patient
falls
C. The intervention resulted in no change in patient falls
D. The impact of the intervention is subjective
E. The impact of the intervention is inconclusive
 Question 4
• An 85-year-old woman is transferred to an acute
rehabilitation facility following hip replacement surgery.
• She was started on DVT prophylaxis medication after
surgery and should continue the medication after discharge.
• The intern and nurse discharging the patient failed to convey
this new medication to the rehabilitation team.
• The patient is not continued on her anticoagulation
medication and sustains a DVT leading to a fatal pulmonary
embolus 3 weeks after transfer.
 Question 4
Which of the following actions will facilitate quality improvement
& the prevention of a similar error in the future?
A. Determine which staff member(s) failed to order the medication
B. Develop a process to increase the use of medication
reconciliation
C. Send a memo to all staff about the importance of DVT
prophylaxis
D. Educate patients about the dangers of DVT following hip surgery
E. Conduct monthly audits to monitor medication errors at
transitions of care
 Question 5
• Which of the following best describes structure
measure?
A. ask whether changes made to improve one part of the
system cause an unanticipated decrease in
performance in another part
B. Evaluate how the system works
C. represent the final product or end result in patient care
D. relate to the physical equipment, resources, or
facilities
 Sources
Kaplan’s Behavioral and Social Sciences book
2018: Principles of quality improvement
Pp: 162- 166 and questions in pages 172– 176.