Professional Documents
Culture Documents
Introduction to
Quality Management
Quality Management
Project managers should incorporate sound
quality management practices into their
work/project, etc.
• What is quality?
• Quality of life
• quality of the environment
• quality of service
• quality of product
• Hard to define
• Everyone wants quality work, performance, goods and services
Some Definitions
• Philip B. Crosby
• quality is defined as conformance to requirements, not as goodness
• W. Edwards Deming
• Quality means the effective production of the quality that the market expects,
it does not mean achieving perfection. He viewed quality
as a responsibility of management.
Some more definitions
• Farrell
• Quality means products, services, processes & conditions
that effectively, efficiently & consistently meet or exceed
the requirements & expectations of all customers
• Joseph Juran
• Quality is fitness for use. Freedom from deficiencies
(errors that require rework or cause product failure)
The project management institute
says quality is
• Any ideas?
Where do quality and project management merge?
• inspection
• quality control
• quality assurance
• quality system
Inspection
• process of measuring, examining, testing, gauging, or otherwise comparing
one or more units of product with the applicable requirements
• this is an acceptance function involving:
• receiving
• in process inspection & testing
• final inspection & testing
• control of nonconformances
• day to day monitoring
• etc
Quality control
QS > QA > QC
Quality
Assurance
Quality Assurance
- management goals
Safety requirements
Compliance with QA requirements
Efficiency
The QA program contains
2. Surveillance audit.
Auditors observe work as it is being
performed.
Types of audits
3. Performance evaluations.
A deficiency in characteristic,
documentation, or procedure that renders
the quality of an item or activity
unacceptable or indeterminate.
• size of organization
• complexity of product or service
• requirements of the quality standard selected
• commitment & effort generated by management
• extent of inspection & control procedures already in place
Who is involved in implementation?
• Everyone
• To be successful, everyone must be committed to
• implementation
• maintenance
• continual improvement
• of the quality system
Who is responsible for Quality?
• Everyone
• misconception that only manager or quality dept. responsible
• similar to health and safety
• quality dept will have specific duties
• identify and document quality issues
• some companies don’t want process or line stopped
• need to have power of corrective actions necessary
• authority must be given
But
• To find out if the substance has been added to dairy, authorities look
for telltale leather-curing residues. The protein extracted from cow
leather is not known to be dangerous to human health, but the curing
chemicals are, Leedham said.
Hydrolyzate of bovine leather
• The China Daily newspaper said the chemicals could be fatal for
children in high doses and put adults at risk for osteoporosis.
Quality Project Management
Part 2
What is ISO
The International Organization for
Standardization is a global organization
headquartered in Geneva, Switzerland.
2008
Peanut
Butter
2009
Spread of S. typhimurium in U.S. from Sept 1 2008 to Feb 8 2009
Salmonella in the peanuts
CDC traced the outbreak to one peanut
producing plant in Georgia owned by Peanut
Corporation of America.
The
company
Will
protect
me!!
Das Scandal
• Another case to look at is the 2015 Volkswagen scandal,
in which they engineered cars to give better (less)
emission readings for NOx when they car was being
tested for emissions. While driving emissions went
backup, allowing the car to perform better.
• WASHINGTON—The U.S. EPA accused Volkswagen AG
of deliberately dodging air-pollution rules on nearly half a
million cars sold since 2008.
• http://www.wsj.com/articles/auto-software-in-focus-after-
volkswagen-flap-1442945494
• German authorities have ordered a recall of all VW cars
fitted with the software, affecting all 8.5 million diesel
cars across the EU. The company says a fix could stretch
through 2016.
Policy Manual
Objectives
Procedures
Detailed
Instructions
Forms
Why Document?
Provides a basis for quality
• keep record of what you do so that it can be repeated.
• quality policies
• describe what is done by the company to ensure
quality
• provide an overview of your quality system
Quality Manual (cont.)
• manual defines what is done
• Procedure
• detail the actions to be performed
Procedure Structure (cont’d)
• References
• identify any documents which you have referred to in the
procedure
• Attachments
• list all forms, samples or similar attachments
Instructions
Instructions
If no formal written instructions exist - get some
• scope
• to what does the instruction apply
• definitions
Instruction Format
• Responsibilities
• instruction
• step-by step process put here
• References
• Attachments
Benefits of good instructions
Can be used as training aids.
12 - 15 employees at a time.
The amount of detail depends on the education
level of the workforce and complexity of the
product and processes.
Use Flow Charts
Flow charts can help in understanding process flow & decision making
• illustrated picture of the process
• shows activities
• shows the sequence
• a deployment flow chart is useful when documenting
procedures
• shows who is responsible for each task in the process
Deployment Flow Chart
How is it made?
1. Define the process boundaries (starting
point/stopping point).
2. Describe the process in operation.
3. Draw the People Coordinate.
4. List major steps in the process.
5. Draw the flow chart, using symbols
6. Study the flow chart.
A simple deployment flow chart
Another deployment flow chart
Yes No
Conduct a
Report End of
Meeting Out Process
PHI Water test
Homeowner
• names of positions/departments
Mission:
Promote Physical and Mental Health
and
Prevent Disease, Injury, and Disability
Public Health in America. What
does Public Health entail?
Prevents epidemics and the spread of disease
Protects against environmental hazards
Prevents injuries
Promotes and encourages healthy behaviors
Responds to disasters and assists communities
in recovery
Assures the quality and accessibility of health
services
10 Essential Services of Public Health
• Monitor health status • Enforce laws and
• Diagnose and regulations
investigate • Link people to needed
• Inform, educate, and services / assure care
empower • Assure a competent
• Mobilize community workforce
partnerships • Evaluate health
• Develop policies and services
plans • Research
What are the components of performance
management?
Performance measurement. Various measures
to assess achievement of standards
• Reasons
• Disparate change groups. In many hospitals there are multiple
change groups; management, quality team, nursing, medical, etc. They
are often disconnected silos. Quality team often plays second to the
operations team.
• Uncontained change. Change made by many disparate groups in an non-
uniform, uncontained, and often poorly understood way.
• Only after the operator lets the process settle, and doesn’t keep changing
parameters will the process begin to perform consistently and better.
• Only simple tools are employed often missing the linkage between tools
so they build on one another. Organizational infrastructure at program
levels fails to prioritize, align, and appropriately resource change.
• Often times the system gets blamed when what really failed was the process.
And not all problems get resolved if you put in place a new system. (Ex.
Electronic medical records system.)
• Focus on people, not on process. Doing this is coming a the problem from
the wrong end. The initial focus should be on the physics and engineering of
the process, the mechanics, activities, layout, triggers, flow, roles,
accountabilities, metrics.
• Simply changing the head of the emergency dept or surgical suite may not
solve any problems or make improvements.
• Changes are not based on any form of evidence and thus are prone to a
reversal of subjective opinion and support.
• Focus tends to be on people, not the process, so process context is lost when
people are the primary focus.
Structuring Change
Structuring Change
• Change should be transparent and contained. It should occur in
visible pieces or packets (call it a project).
• All these projects should be clearly defined and scoped, not overlap,
counteract or clash with each other, and no two groups should be
working on essentially the identical problem.
• Projects are born from strategy and are the strategic projects.
• Lasting and sustainable. Identify and tackle the root causes of issues
needing change.
• Appropriate methods and tools within projects and across projects
(program level).
• Use tools that are objective and data driven.
• Rather than try to win the game you are playing (against the odds) try to
find a different game to play that few or no one is playing and thus
greatly increase your odds of business success.
• Usually meets monthly after the initial first few months of program
commencement.
Steering Group membership
• Executive champion for the program, usually a VP. Acts as chair.
• Finance representative.
• Human resource representative - a critical role.
• Key change leaders. Ex. medical quality and clinical quality directors.
Focus on Process
• LS is a process improvement methodology
• The changes to the process along they way are significant, not just try
something and hope it works,
Breakthrough change examples
• Process Metric Result
• Emergency Dept: length of stay 40% reduction
In the US Urinary tract infection (UTI) accounts for up to 40 percent of health care-associated infection,
and up to 80 percent of UTIs are catheter-associated (CAUTI).
Identifying opportunities
• LS focus is on maintaining a meaningful set of potential projects at all
times.
• Cycle time. The time between patients as they pass a certain point in the process. Ex.
Blood collection.
• Throughput. Number of patients seen per hour/ per day/per week etc.
• Aim for a high (loftier) goal. There’s a higher chance to achieve it, and then
you’re more likely to maintain it.
• A recommended way is to set the goal at 50% of the way between current
performance and optimum performance (known as entitlement).
Ex. Patient registration is at 92% accurate now, optimum is 100%, therefore
set goal at 96%, midway between the two.
Lean Sigma Project Leaders
• In LS project leaders are referred to as Belts.
• Team members must remain consistent for duration of project and others
must be available to take on any of their other organizational roles.
• Six Sigma looks at what we should be doing and aims to get it right from
the beginning.
• Define. Is this the right project? Is it the right project for now?
• Measure. How is the process performed? How well is the process performed.
• Improve. What should the new process be to perform the right way? At this
stage the newly performing process is operating.
• Also as a leader you don’t often get the best view of how the work is
done and how it might be done better.
• Quality of care is generally understood as providing the right care for the
right person at the right time—every time.
Main drivers of Quality measurements,
Improvements and Safety standards
1. Survey, certification, and accreditation of facilities, laboratories, health
plans, and providers
• In addition, the quality and safety focus areas for public health and clinical
care have been poorly aligned, with health systems focused more on specific
clinical areas such as treatment for acute cardiac conditions and avoidance of
localized nosocomial infections.
• Public health systems are traditionally more focused on communicable disease
control and prevention of chronic disease and injuries.
• There was no existing data infrastructure across these systems that included key
variables and metrics around readiness to inform preparedness and the response
capacity of the health care system.
System weaknesses
• Among the weaknesses highlighted by the pandemic was the inability of the
U.S. to develop clinical guidelines, related decision supports, and quality
measures, quickly.
• Limited accreditation surveys resumed in June 2020, with virtual surveys being
tested in several sites. The resultant impacts of virtual surveys on the public’s
health and safety remain unknown and should be studied.
Future attention
• Attention should also be paid to the effectiveness of accreditation requirements
to determine which requirements should be retired in favor of standards that
reflect health care system readiness for future pandemics and are more likely
to support quality and safety.
Survey, certification, and accreditation:
Nursing homes
• Prior to COVID-19, fewer than 4,000 of the nation’s 15,400 Medicare-
certified nursing homes voluntarily reported health care-associated infections
(HAIs) to the CDC’s National Health Safety Network (NHSN), which
provides health care facilities with a system to track infections and prevention
measures.
Outcome
• The CDC developed a new COVID-19 module for reporting data that
subsequently became required for reporting on May 8, 2020.
1. resident impact,
2. facility capacity,
3. staff and personnel supplies and PPE,
4. ventilator capacity and supplies.
Nursing home surveys during pandemic
• Survey findings of nursing homes often pointed to a breakdown
in basic infection control processes such as proper hand hygiene, doffing and
donning PPE, social distancing, staff screening, and precautions.
• The findings point out that it is not sufficient to just have regulations in place.
Training, technical assistance, oversight, and enforcement must also be in
place to ensure adherence to quality and safety standards
Quality measurement, incentives, and payment
reforms.
• Quick pandemic action halted quality efforts that were not specifically
necessary during the pandemic so that providers could focus on caring for
patients. Health care quality data reporting was mostly suspended.
• Examples:
• Incorporation of patient and personnel vaccination as part of quality measures
in nursing homes and dialysis facilities.
• Merit based Incentive Payment System Program offered credit for clinicians
participating in COVID-19 clinical trials and registries. In March 2021,
Medicare began paying approximately $40 per required dose of COVID-19
vaccines.
Quality improvement learning and action networks.
Quality improvement networks were activated immediately to provide training
and support to the health care system, with particular attention to nursing
homes.
• Revisit the consensus definition of preparedness at the national, state, and local
levels, with attention to planning and execution and robust health surveillance
and vulnerability detection.
Challenges to address
• Simultaneous threats to public health in the form of:
• climate change,
• regional and ecological reservoirs of known and novel disease,
• national and regional outbreaks and epidemics,
• global pandemics,
• mass refugee migration, and cyberthreats.
Metrics to consider
• Develop short-term metrics to assess interventions with rapid results over the
days and weeks immediately following an emergency.
• Transmit data across local, state, and regional public health departments,
schools, outpatient health delivery entities, and short-term and long-term
institutional living facilities.
3. Improving population health measures
• Create and implement local, state, and regional metrics for population health
status and assessment of vulnerabilities using sensible geographic
demarcations.
• Investments in the public health entities serving highly vulnerable areas
followed by direct financial incentives and additional investments for
improved performance and decreased population vulnerability over time.
• Develop a new system of metrics that increases the use of digital measures.
4. Streamlining metrics
• The process for data capture, implementation of novel measures, and removal
of measures that are no longer useful must be addressed.
Quality Metrics
True versus substitute performance
measures
Public/Customers - use “true” performance measures.
Ex: The water from our municipal supply smells and
tastes good.
It is often the best people who make the worst mistakes and
far from being random, mishaps tend to fall into recurrent
patterns.
The layers are like slices of Swiss cheese, having many holes—
though unlike in the cheese, these holes are continually opening,
shutting, and shifting their location.
The Problem
Process mapping
After identifying likely causes to the problem investigate them
further, such as patient interviews, surveys and process mapping.
staff routinely looking for and reporting minor safety problems and
sharing a willingness to invest time and resources in identifying and
learning from errors.
Demand, capacity and flow
Some backlogs and delays in health care services are attributable to
resource shortages or increases in demand. An example is the
backlog of appointments and procedures created by the COVID-19
pandemic.
However, not all delays are the result of capacity problems. It may be
that the capacity is in the wrong place or is provided at the wrong
time.
Non-clinical staff, who are often the first point of contact for
patients, play a key role in improving care.
Treating each other with respect and courtesy, listening carefully to the
views of others and valuing their ideas, regardless of their hierarchical
position.
More recently, Don Berwick has become known for his work in
the US, leading the pioneering work of the Institute for
Healthcare Improvement.
Model for Improvement
Continuous improvement where changes are tested in small
cycles that involve planning, doing, studying, acting (PDSA),
before returning to planning.
Key questions:
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in improvement?
LEAN method (began in the Japanese auto industry)
Lean emphasizes the patient’s central position to all activities and
aims to eliminate or reduce activities that do not add value to the
patient.
Five principles
Defining what is value-adding to patients.
Mapping value streams (pathways that deliver care).
Making value streams flow by removing waste, delay and
duplication from them.
Allowing patients to ‘pull’ value, such as resources and staff,
towards them, so that their care meets their needs.
Pursuing perfection as an ongoing goal.
Clinical microsystems
These are small groups of people who work together
regularly to provide care to a specific group of patients.
7. Record keeping.
http://haccpcanada.net/
Design Thinking in
Healthcare
Many aspects of design and design thinking can be
incorporated in improving quality in hospitals and healthcare in
general
Legacy infrastructure: Health systems and pathways which are not fit for
purpose anymore; for staff, hospitals or patients. Systems simply
Why Design Thinking
Design thinking offers different ways to develop
services around people’s needs, to work openly and
collaboratively, reducing risk through iterative
development, continual testing, user feedback and
improvement.
9. Use the same language and the same design patterns wherever
possible. But when this isn’t possible make sure our approach is
consistent.
https://www.healthdesignlab.com/
Watch the video talk below by Dr. Bon Ku of the Health Design Lab
‘Inspiring the Future of American Health Care’, He talks about how
design thinking prevented him from ‘burning out’ as an emergency
physician.
User-centered Design
Focuses on the user of a product, service or process to
maximize revenue or efficiency through a good user
experience.
Highly engineered
https://www.youtube.com/watch?v=WPc-VEqBPHI
Double Diamond Design Process
The Double Diamond is a schematic meant to visually
convey a design process.
The two diamonds represent a process of exploring an issue
more widely or deeply (divergent thinking) and then taking
focused action (convergent thinking).
Or Solution
Problem
Problem
definition at
cross point
Discover. The first diamond helps people understand, rather
than simply assume, what the problem is. It involves speaking
to and spending time with people who are affected by the
issues.
Define. The insight gathered from the discovery phase can
help you to define the challenge/problem in a different way.
Develop. The second diamond encourages people to give
different answers to the clearly defined problem, seeking
inspiration from elsewhere and co-designing with a range of
different people.
Deliver. Delivery involves testing out different solutions at
small-scale, rejecting those that will not work and improving the
ones that will.
Discovering and defining the problem
Design projects usually start with a problem defined by
a client (ex. health authority). The double diamond
illustrates a process of better understanding what the
problem is from the user’s (patient) point of view. The
is the discover phase or the first part of the Double
Diamond.
In-situ interviews:
Shadow a worker and talk to them about their tasks. This
captures some immediate feelings, anxieties and reactions to
a situation. It captures non-verbal cues as well.
Discovery Phase-Approaches/Methods
Journey Mapping
A visual representation of the journey a user goes through
from start to finish, often using post-it notes, mapping out each
step of the journey. Shows where the key touchpoints are,
where there are goals, inefficiencies and frustrations.
Discovery Phase-Approaches/Methods
Personas
Create a set of hypothetical service users — these might be based on
real users, or potential users of a new service, to allow us to test our
assumptions. The personas play out the users stories.
User stories
Short descriptions of the actions of a particular user or group of users
that explain how they came to interact with the product or service, from
the perspective of the user.
An example of a persona
Discovery Phase-Approaches/Methods
Empathy Map
Visually map out what users see, hear, think and do and
how they feel about something, and how different users
empathize with each other.
Why do people behave in a certain way?
Questions your own assumptions?
Be curious about others.
Know the difference
Empathy means people feel with you.
Sympathy Empathy
Discovery Phase-Approaches/Methods
Empathy Map examples. Consider an out patients clinic.
Assume you are a patient waiting to be seen.
Desk Research
Read literature, websites, etc. Check user reviews of these
services. This helps to understand what is being done
elsewhere.
Discovery Phase-Approaches/Methods
Project Space
Locate a big wall or board where you can stick up photos,
images, maps and lots of post-its. People should be able
to move around, interact with each other and with the
evidence, etc.
Reduce the time needed for implementation, by testing how elements of the
solutions work within current processes, systems and environments
Gain buy-in from users and prospective users through collaboration and
giving people space to interact with tangible prototypes and feed into the
development process
A MVP is the most basic version of your solution that you can
make ‘live’ i.e. that you can put out to market or put into
practice for real users to interact with it.
The project has taken over the warehouse area of the former
Scotsburn Dairy in Sydney where two and three-dimensional
mockups of future hospital rooms are temporarily housed.
Troy Penney, clinical director, CBRM Health Care Redevelopment Project, shows a
mockup unit
CBRM Health Care Redevelopment Project
Staff of the Highland Arts Theatre in Sydney helped create a full-
size mockup of various hospital rooms that will be found in both
facilities, from patient rooms, and emergency rooms to a suite of
operating rooms.