Quality Management in Health Care

Objectives of the course

• By the end of this class, students will
 Be able to define quality in the context of healthcare
 Understand the components of quality in healthcare
 Be introduced to different models of quality management in
healthcare
 Understand the basic steps to measure and improve quality in
healthcare
 Be introduced to efforts to improve quality in the Ethiopian
health sector

1
Outline of presentation
• Defining quality
• Components of Quality in Healthcare
• Managing quality in healthcare
• Continuous Quality Improvement (CQI)
• Quality Measurement
• Quality improvement
• Infrastructure for quality management
• QM in the Ethiopian health sector

2
Definition of Quality in healthcare

• Quality in the health sector is becoming a major

concern for patients, public health officials, funding
agencies and governments.

• However, the concept is among those lacking

standard definition and description.

• What constitutes quality in healthcare?

3
 Definition cont…
• What constitutes quality in healthcare?
 Different for different groups of
stakeholders/actors
healthcare providers
healthcare financers/donors
Patients
Others
 Wide range of different views exist even within
a specific group of stakeholders
 Definitions depend on what people value more

4
 Definition cont…
• Focus of stakeholders

• Patients
• Focus on physician-patient interaction,
physical environment, time, distance

• Health workers
• Appropriateness of provided care
• Provision of appropriate care
• Fulfillment of required equipments and
medical supplies

5
Focus of stakeholders cont…

• Funding agents
• Emphasize the importance of efficiency and
accessibility of care

• Relatively common to different groups

• Appropriateness of provided care
• Provision of appropriate technical care

6
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 and beneficiaries’
expectations.”

7
 Components of healthcare Quality

• According to Donabedian, quality of healthcare

has seven pillars/components

 Efficacy  Acceptability
 Effectiveness  Legitimacy
 Efficiency  Equity
 Optimality

8
 Components cont…

1. Efficacy:
 Is the ability of the science and technology of
healthcare to achieve desired outcomes under
best circumstances.
 What constitutes “best circumstances” is always
difficult to define and controlling other factors is
always challenging
 Therefore, a more realistic definition could
substitute “specified circumstances” for “best
circumstances”

9
 Components cont…

2. Effectiveness:
 Is the degree to which attainable outcomes are
attained in reality.
 It is the comparison between what is achieved
in reality with what is potentially achievable
with the ‘best’ care provided

10
 A hypothetical cancer treatment example
achievement with current care ( X  Y )
100 effectiveness 
90 potentially achievablewith ideal care ( X  Y  Z )
80
70 Course of
60 illness with
Quality of life

no treatment
50
40 Course of
30 Y Z illness with
X QALYs QALYs
QALYs current
20 treatment
10
0 Course of
illness with
Year 1

Year 2

Year 3

Year 4

Year 5

Year 6

Year 7

Year 8

Year 9

Year 10

Year 11

Year 12
best care

Time 11
 Components cont…
3. Efficiency
 The ability to achieve attainable outcomes of care
at a lower cost.
 Improving efficiency means decreasing the cost of
care without compromising achievement of
maximum attainable results
 This can be done by:
 Improving the technology of healthcare
(producing more efficient drugs, diagnostic
algorisms, etc)
 Improving the process of healthcare to avoid
medical errors (harmful, useless or less effective
decisions)
 Appropriate use of resources for healthcare
12
 Components cont…

4. Optimality
 The balancing of improvements in health
against the cost and other negative
consequences of such improvements
 Optimizing benefits

13
 Components cont…
5. Acceptability
 Is the level of conformity to the wishes, desires
and expectations of patients

 Usually related to what beneficiaries of healthcare

value more including
 Accessibility of services
 Empathetic provider – patient interaction
 Time, expense, physical comfort to receive
services
 Patient preferences regarding the effects, risks
and costs of care

14
 Components cont…

6. Legitimacy
 Is the conformity of healthcare to social
preferences as expressed in ethical principles,
values, norms, laws and regulations

 Is the equivalent of acceptability as applied to

the society

15
 Components cont…
7. Equity
 Conformity to a principle that determines what
is just and fair in the distribution of healthcare
and its benefits among members of the
population

 Do interventions facilitate the fair distribution

of health services and benefits out of health
care fairly among different segments of the
population?

16
 Components cont…
• Other components – mentioned by other authors
and organizations
 Almost all are overlapping with Donabedian’s
seven pillars
 Safety
 Appropriateness
 Timeliness
 Responsiveness
 Satisfaction
 Health improvement
 Continuity of care
 Technical competence
 Availability

17
 Improving all the components of
quality requires:
• Research to improve knowledge
• Education to transfer knowledge
• Policy making to create enabling environment for
implementation
• Resource allocation to finance effective
interventions
• Health facilities practices to ensure compliance
• Patient/client behavior to ensure adherence

18
 Quality Management

• Quality management includes all the activities that

organizations use to direct, 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

19
 Quality Management Cont…
• There are different models of QM in healthcare
• Licensing
• Certification
• Accreditation
• Continuous quality improvement
• Most of the time, countries implement a
combination of these models.
• No single model can effectively improve healthcare
quality, a combination of models is usually
important.

20
Licensing
• Is a process by which a governmental authority
grants permission to an individual practitioner or
health care organization to operate or engage in an
occupation or profession.

• Licensure reflects fulfillment of minimum

requirements

• No individual or organization can be engaged in

service provision without a license.

21
 Certification
• Is a process by which an authorized body, either a
government or non-governmental organization,
evaluates and recognizes either an individual or an
organization as meeting pre-determined
requirements.
• Certification reflects the capability of an individual to
provide services additional to minimum
requirements.
• Certification provides added credential to an entity’s
qualification.
• Examples.
 Certification of a GP to perform C/S in Ethiopia
 Certification of a general hospital to provide some
specialized services

22
 Accreditation

• Is a formal process by which a recognized body

usually a non-governmental organization, assesses
and recognizes that a health care organization meets
applicable pre-determined and published standards.

• Participation is voluntary but advantageous

• Assessment involves self assessment and external

assessment by a team of peers

23
Continuous Quality Improvement (CQI)
• An equivalent in the healthcare for Total Quality
Management (TQM) in the industry

• CQI is an ongoing, organization wide framework in

which HSOs and their employees are committed to
and involved in monitoring and evaluating all
aspects of the HSO’s activities and outputs in order
to continuously improve them. (American Hospital
Association)

24
 CQI cont…
• It is a continuous process with a goal of doing the
right things right the first time, every time.
 Doing the right things: investing resources on
activities proven to achieve desired benefits
 Doing things right: implementing designed
interventions in a way that is acceptable to
beneficiaries, at the lowest cost possible and in
line with current professional knowledge.
 Doing things right the first time, every time:
achieving these as an institutional culture.

25
 Principles of CQI
• Client Focus: Focus first and foremost on meeting
the needs and expectations of clients/patients.
• Teamwork: Work is accomplished through
processes in which different people are responsible
for different activities.
• Achieve continual improvement through small,
incremental changes.
• Actions need to be based upon accurate and
measured data
• Infrastructure enhances systematic
implementation of improvement activities.
• Most problems are found in processes, not in
people  focus on processes

26
 CQI cont…

• CQI includes two important components

and a supporting infrastructure

o Quality Measurement

o Quality Improvement

27
27
 Components of CQI
(the HIVQUAL model)

• Quality Measurement

• Quality Improvement

• Infrastructure for QM

Infrastructure

28
 Quality Measurement
• The initial step required to initiate quality
improvement processes in any kind of institution
• Advantages of Quality Measurement
 Primary use
 Identifying opportunities for improvement

 Other advantages
 Encourages improved documentation system
 Builds skills for analysis and interpretation of
data
 Facilitates informed decision making in other
areas

29
 Quality Measurement cont…
• Donabedian’s framework for measurement of
healthcare quality
 Structure
 Process
 Outcome

• Most of the time confused as components of quality

• S-P-O are areas of measures on which information

can be gathered and potentially inferred about the
quality of healthcare.

30
 Quality Measurement cont…

• Structure
 Is the setup in which care is being provided

 Includes:
People
Resources
Knowledge and technology

31
Quality Measurement cont…
• Using structural measures as quality measures
takes the assumption:
“If appropriate resources are available, the
likelihood of their appropriate use and then
achieving attainable outcomes is high.”

• E.g. To measure the quality of HIV care, one can

use “Percentage of hospitals with medical doctors
trained on HIV care” as an indicator.

32
 Quality Measurement cont…
• Process
• Is the set of interrelated activities that
constitute what healthcare is.

Assumption
“if healthcare is provided in compliance with
scientific recommendations, potentially
attainable outcomes will be achieved.”

33
 Quality Measurement cont…
• Outcome
• Is the change observed on beneficiaries of
healthcare (individuals or population) that is
attributable to healthcare.

• May include intermediate or longer term outcomes

• Includes:
• Change in physical, mental and social health
status
• Knowledge and attitude of beneficiaries
• Behavior/Practice of beneficiaries

• Challenge: attribution

34
Logical model of healthcare quality

35
 Quality Measurement cont…
• How to use S-P-O
• Selection of measures depends on who will use the
information
• The three categories of measures are not
alternatives from which someone need to choose
one.
• Recommended to mix measures
• While selecting measures of quality, consider:
• Evidences of importance
• The degree of control at the specific level of care
• Data integrity and other attributes of a good quality
indicator (sensitivity, specificity, validity, reliability,
measurability, understandability, comparability, …)

36
Quality Measurement cont…
• 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

37
 Components of CQI
(the HIVQUAL Model)

• Quality Measurement

• Quality Improvement

• Infrastructure for QM

Infrastructure

38
 Quality Improvement

• Is 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

39
Deming’s Cycle

Act Plan

Study Do

40
 A P
S D

Plan
• Based on findings of Quality
Measurement
• Investigate the root causes of
performance gap Plan
• Come up with a prioritized list of
feasible solutions
• Set objectives for improvement
• Plan implementation (who, what,
where, when)

41
A P
S D

Do
• Carry out the plan – small scale

• Document problems and

unexpected observations
Do
• Begin analysis of the data

42
A P
S D

Study
• Why:
 All improvements need
changes but not all changes
result in improvement
• Analyze data completely
Study
• Compare findings with
expectations and previous
findings
• Draw conclusions on what to
expand and what to further
improve

43
A
S
P
D Act
• Expand changes that brought
improvements

• Modify changes that need Act

modifications to bring more
improvements

• Find out other solutions for

areas with no improvement

• Start the next cycle

44
• Work for small Act Plan
incremental changes with:
 More frequent short Study Do
cycles
 Acceptable level of D S
P A
accuracy
TA A P
 Consistent methods of
DA S D
measurement to allow D S
comparison P A
A
• “The perfect is the enemy S P
D
of the good!!” (anonymous)
A P
S D

45
 Commonly used quality improvement actions
• Quality improvement actions should be developed by
considering:
 Nature of the problem to be addressed
 Previous documentation of effectiveness
 Feasibility of the intervention designed
 Potential sustainability of improvements
 Conformity with national and international efforts

46
Quality improvement actions cont…
• Examples of actions to improve quality of
healthcare:
 Training on specific topics
 Development of standards, guidelines and job
aids
 Electronic diagnostic support
 Physician reminders
 Process redesign
 Change in technology
 Reallocation of resources (human, financial,
material)
 Patient education programs
47
 Quality Improvement Tools
• Tools for prioritization of problems
• Simple voting
• Multi voting
• Weighted voting
• Tools for cause effect analysis
• Fishbone
• The Five Why’s
• Tools for analysis of potential factors facilitating or
hindering implementation of change
• Force field analysis

48
 Tools cont…
• Voting
• Used when there is a need for quick decision
making
• Allows equal participation of quiet and dominant
group members during decision making

• Simple voting
• Each person in a group given one vote

49
 Tools cont…
• Multi-voting
• This method is useful when the group wants to
pick more than one item or the list of items is
very long and needs to be reduced to two or more
• Used to reduce the list of options
• Group members will be given more than one vote

• Weighted voting
• Allows group members not only to select but also
express the strength of their support to selected
options
• Group members will be given equal points to
distribute among options
50
 Tools cont…
• Fishbone
 A tool for cause effect analysis
 Teams brainstorm to identify causes of an observed
problem under major categories
 Examples of categories
 Clients, workers, supplies, environment and
procedures
 People, methods, materials, measurements
 Findings will be presented as a fishbone
 The head representing the problem under analysis
 The major branches represent categories of problems
 The minor branches represent specific problems

51
 Fishbone cont…

Cause Cause Cause

Category I Category II Category III

P1 P10 P12

P2 P9 P11

Problem
P7
P8
P5
P3 P4 P6

Cause Cause Cause

Category IV Category V Category VI

52
 Tools cont…
• The Five Why’s
• A problem analysis tool that helps teams
understand the chain of problem causation
• Group members ask a “Why?” question and
hypothesize causation until the root causes of a
problem are identified
• Root causes of problems are the most specific
problems that could easily lead to design of an
intervention.
• Problem trees constructed based on expert
opinions are only hypothesis; there is a need to
test interventions before scale up.
53
The five why cont…

54
 Tools cont…
• Force-Field Analysis
• A tool used to:
• Anticipate facilitators and barriers of change
ahead of time
• Analyze existing problems
• A well-done force-field analysis keeps quality
improvement teams realistic by enabling them to
view the possible facilitators and challenges to
implement a designed intervention.
• It also enables to estimate the strength of forces in
order to decide where to invest resources.

55
 Force field analysis cont…
Planned Improvement Action

Driving forces Restraining forces

Driving force Strength Restraining force Strength

56
 Components of CQI (the HIVQUAL Model)

• Quality Measurement

• Quality Improvement

• Infrastructure for QM

Infrastructure

57
Infrastructure
• Why?
• Quality management needs to be
institutionalized if improvements have to be
made continually.
• QM is not a onetime activity; always, 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
58
 Quality Management in the Ethiopian
Health Sector
• External Quality Control
• A newly established Health Regulatory Agency
(previously DACA)
• Responsible for registration and licensing of
health care providers

• Internal Quality Improvement Processes

• One of the major activities under the
Monitoring and Evaluation Sub-Process
• Expected at health facility level (Health Post,
Health Center, Hospital)

59
 CQI in the Ethiopian Health Sector

• Quality measurement based on two sets of quality

indicators
• National quality of care indicators
• Locally relevant quality of care indicators

• Quality improvement processes at health facility

level (Health Post, Health Center, Hospital)
• Use the S-P-D cycle - a simplified adaptation of
the Deming's Cycle

60
 PLAN
SEE Investigate
Use national and underlying root
local quality causes; identify
indicators to assess solution and
opportunities for action points to
improvement improve the
situation

DO
Implement
quality
improvement
plan
61
SEE

• Does the observed level of quality need

improvement?

• Which of the areas need improvement?

• Which of them need to be maintained and

benchmarked?

62
 PLAN
• Set priorities for improvement
• Identify root causes of the observed quality
problems
• List the possible solutions for the observed
problems
• Prepare an action plan for the most effective and
feasible solution
• Communicate improvement plan with the
Performance Monitoring Team and others relevant

63
 DO
• Putting planed activities in practice

• The involvement of departments/units during

Quality Measurement makes this step appropriate
and contributes for the effective implementation of
the plan.

• Then the cycle restarts.

64