Quality Management

Chapter 12:
Quality
Management in
Health Care
By: Mohammed Hussien (MPH/HSM)
Wollo University
Learning objectives
After completion of this chapter, students will be

able to:
Discuss quality in the context of healthcare
Discuss the dimensions of quality health

care
Describe the components of quality

management in healthcare
Identify quality measurement

models/approaches in healthcare
Discuss quality management cycle

2
Definitions and the concept of

quality
Quality means different things to different people
quality has different meanings for different health

care players
From the providers perspective, quality might

mean providing the best possible care available to
the patient
Quality from the perspective of the administrator

is to provide effective care in a cost-conscious
environment
From the patient's perspective, quality is getting

my care when and where I need it and from
whomever I choose to cure my condition
in the
3
Definitions
The application of medical science and technology

in a way that maximizes its benefits to health
without correspondingly increasing its risks
(Donabedian, 1982)
The degree to which health services for individuals

and populations increase the likelihood of desired
health outcomes and are consistent with current
professional knowledge (IOM ,1990)
An organization's processes and activities are

designed and implemented in order to
continuously meet the organization's customers'
needs and expectations (Al-Assaf, 1996)
4
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 IOMs 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 and5
Dimensions of quality health care

Several authors and organizations have
defined quality by describing the concept
according to a set of dimensions
1.
2.
3.
4.
5.
6.
7.
Effectiveness
Efficiency
Access
Safety
Equity
Appropriateness
Timeliness
8.
9.
10.
11.
12.
Acceptability
Satisfaction
Responsiveness to patient
preferences
Technical performance
Management of the
interpersonal relationship
6
Dimensions of quality.
Effectiveness refers to the extent to which the

intervention in question produces the intended
effects
Efficiency refers to how well resources are used in

achieving a given result
the extent to which objectives are achieved by

minimizing the use of resources
The goal is to maximize the output for a given

input, or conversely to minimize the input for a
given level of output
7
Access refers to the degree to which individuals

and groups are able to obtain needed services
whether a health service or treatment is available

to the person needing it, at the time it is needed
How easily people obtain services depends on:
Cost of service
the providers location
days and times when care is available
how well cultural characteristics and

expectations of the patient match with those of
the provider
8
Safety refers to the reduction of risk
patient safety is freedom from accidental injury

due to medical care, or medical errors,
with medical error being defined as the failure

of a planned action to be completed as intended
or the use of a wrong plan to achieve an aim
Equity implies considerations of fairness
providing care that does not vary in quality

because of personal characteristics such as
gender, ethnicity, geographic location, and
socioeconomic status.
Services are provided to all people who require

9
them (according to their need)
Appropriateness how the treatment corresponds

to the needs of the patient
Timeliness receiving treatment within a

reasonable time frame
Acceptability - care meets the expectations of the

people who use the services
Responsiveness to patients or patientcentredness consideration of individual patients

and societys preferences and values
Satisfaction how the treatment and the

improvement in the patients health meets
her/his expectations
10
Technical Performance
Quality of technical performance refers to how

well current scientific medical knowledge and
technology are applied in a given situation
timeliness and accuracy of the diagnosis, therapy

appropriateness, and skill in performing
procedures
Interpersonal relationship refers to how well the

clinician relates to the patient which is important
to fully address the patients concerns
to elicit a more complete and accurate medical

history
in motivating the patient to follow a 11

prescription
Quality Management
Quality managementincludes all the activities that

organizationsuse todirect, control or
coordinatequality
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
12
Quality Management
Management of quality includes coordination

and facilitation of all activities related to:
Quality Assurance (QA)
Quality Control (QC) and
Quality Improvement (QI)
It involves processes pertaining to the

coordination of activities related to all or any
one of the above three as well as the
administration and resource allocation of
these processes
13
Quality Management
Administration may include training, education,

organization of committees and councils, building
of infrastructure, resource acquisition and
allocation, and so on
Quality management is the umbrella

encompassing all processes and activities related
to quality
Other terms used in the field include such terms

as continuous quality improvement and total
Quality Management (TQM)
14
Quality Management
Quality Assurance (QA)
includes the process of planning for quality, the

development of objectives and goals for quality,
setting standards of quality, communicating
standards to users, and developing indicators for
performance monitoring
Monitoring/Quality Control (QC)
Quality control involves monitoring these

standards, using appropriate indicators, and
determining whether there is variation from the
expected outcome and whether there is a need
for improvement
15
Quality Management
Quality Improvement (QI)
QI efforts and processes complement QA and QC

and sometimes overtake them
QI is defined as an organized, structured process

that selectively identifies improvement teams to
achieve improvements in products or services
(Al-Assaf 1997)
It includes all actions to identify gaps

(opportunities for improvement), prioritize and
select appropriate gaps to study, analyze them,
and narrow or close them
16
Figure: Quality Management Cycle
17
Quality improvement steps
According to the USAID quality cycle shown above,

the first three steps of the cycle-planning, setting
standards, and communicating standards-are all
quality assurance steps
Step four, monitoring, is also called quality control
The next six steps are quality improvement steps
Quality improvement, as mentioned above, is a

process of reducing variation from a desired
standard
Therefore, quality improvement is the process and

sub-processes of identifying opportunities for
improvement, selecting an opportunity for
improvement, defining it from an operational
18
standpoint and acting on it
In summary
Quality management includes quality assurance,

quality control and 'quality improvement
Quality assurance includes the process of planning

for quality, and setting and communicating of
standards
Quality control involves monitoring these

standards, using appropriate indicators, and
determining whether there is variation from the
expected outcome and whether there is a need for
improvement
Quality improvement identifies opportunities for

improvement and prioritizes them,
Following analysis, and the design of an

19
intervention, a solution is implemented to improve
In summary
The solution may or may not meet the set

standards, this can be determined only by
monitoring the quality process continuously
Monitoring is based on specific and measured

indicators related to standards
It is a process of measuring variance from

standards and initiating processes to reduce this
variance
Without quality control it is impossible to

determine whether the standards are met and
whether there is an opportunity to improve or not
20
Key success factors in quality

improvement
The following principles are considered as key

success factors towards quality improvement
Leadership
Commitment
Customer focus
Continuous process-oriented and outcomedriven improvements
Employee empowerment
Proactive improvements
Data-driven decision-making
Interdisciplinary team-work
Education, retraining and recognition
21
Continuous Quality Improvement
Improvements are not onetime activities
When a team has worked on a process and

improvement has been accomplished, it should not
abandon this process and move on to the next one
Monitoring should continue, and improvements should

be initiated every time they are needed
Once compliance has been achieved, incremental

improvements in the standards also are important
If high or even perfect compliance with a specific

standard has been documented, upgrading this
standard is the next step to take
Otherwise, the organization will stay in the status quo

and further improvement will not occur
22
Continuous Quality Improvement

QI includes two important components and a
supporting infrastructure
Quality Measurement
Quality Improvement
Infrastructure for QM
Infrastructure
23
Quality Measurement
The initial step required to initiate quality

improvement processes in any kind of institution
Donabedians framework for measurement of

healthcare quality
Structure
Process
Outcome
S-P-O are areas of measures on which information

can be gathered and potentially inferred about the
quality of healthcare.
24
Quality Measurement
Structure
Structure is the setup in which care is being provided
include the education, training, and certification of

professionals who provide care and the adequacy of
the facilitys staffing, equipment, and overall
organization
Evaluations of quality that rely on such structural

elements assume that well-qualified people working in
well-appointed and well-organized settings will provide
high-quality care
However, although good structure makes good quality

more likely to ensue, it does not guarantee it
E.g. To measure the quality of HIV care, one can use

Percentage of hospitals with medical doctors
trained on
25
HIV care as an indicator
Quality Measurement
Process
Process, which refers to what takes place during

the delivery of care, also can be the basis for
evaluating quality of care
The quality of the process in turn can vary on two

aspects: appropriateness, which refers to whether
the right actions were taken, and skill, which
refers to how well actions were carried out and
how timely they were
Assumption: if healthcare is provided in

compliance with scientific recommendations,
potentially attainable outcomes will be achieved
26
Quality Measurement
Outcome
the costs of care and patients health outcome
outcomes typically refer to health status-related
indicators - the change observed on
beneficiaries of healthcare that is attributable to
healthcare
may include intermediate or longer term
outcomes
change in health status
change in health behavior
client satisfaction
Challenge: attribution
many factors that determine clinical outcomes
including genetic and environmental
factors
27
Quality Measurement
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
28
Quality Improvement
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
Act
Plan
Demings Cycle
Study Do
29
Quality Improvement
PLAN
Based on findings of Quality Measurement
Investigate the root causes of performance
gap
Come up with a prioritized list of feasible
solutions
Set objectives for improvement
Plan implementation (who, what, where, when)
DO
Carry out the plan small scale
Document problems and unexpected
observations
30
Begin analysis of the data
Quality Improvement
STUDY
Analyze data completely
Compare findings with expectations and previous
findings
Draw conclusions on what to expand and what to
further improve
ACT
Expand changes that brought improvements
Modify changes that need modifications to bring
more improvements
Find out other solutions for areas with no
improvement
Start the next cycle
31
Quality Improvement
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
32
Infrastructure
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 33
A quality culture
Establishing a quality culture is the next

milestone
Institutionalization is achieved when appropriate

healthcare quality activities are carried out
effectively, efficiently, and on a routine basis
throughout a system or an organization
It is a state of achievement whereby healthcare

quality is practiced and maintained without
additional outside resources
In such a state, expertise is available within and

commitment is fully integrated and maintained
A quality environment or culture is achieved when

quality activities become day-to-day activities
34
A quality culture
Such activities are not separate from the normal

activities carried out daily by the system and its
personnel
It is a state in which each employee is aware of

the quality concept, believes in it, practices its
principles, and makes it part of his or her
responsibility and not the responsibility of a
department or another individual
In such a culture, each individual is responsible

for his or her tasks own quality structure,
process, and outcome
35
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Chapter 12:

After completion of this chapter, students will be

Discuss quality in the context of healthcare

Discuss the dimensions of quality health

Describe the components of quality

Identify quality measurement

Discuss quality management cycle

Definitions and the concept of

Quality means different things to different people

quality has different meanings for different health

From the providers perspective, quality might

Quality from the perspective of the administrator

From the patient's perspective, quality is getting

The application of medical science and technology

The degree to which health services for individuals

An organization's processes and activities are

Important concepts in the

Quality of healthcare is about

Achieving positive health outcomes

Limiting the negative consequences of health

Complying with scientific recommendations

Addressing beneficiaries needs and

Modification on IOMs definition:

The degree to which health services for

Dimensions of quality health care

Effectiveness refers to the extent to which the

Efficiency refers to how well resources are used in

the extent to which objectives are achieved by

The goal is to maximize the output for a given

Access refers to the degree to which individuals

whether a health service or treatment is available

How easily people obtain services depends on:

the providers location

days and times when care is available

how well cultural characteristics and

Safety refers to the reduction of risk

patient safety is freedom from accidental injury

with medical error being defined as the failure

Equity implies considerations of fairness

providing care that does not vary in quality

Services are provided to all people who require

Appropriateness how the treatment corresponds

Timeliness receiving treatment within a

Acceptability - care meets the expectations of the

Responsiveness to patients or patientcentredness consideration of individual patients

Satisfaction how the treatment and the

Quality of technical performance refers to how

timeliness and accuracy of the diagnosis, therapy

Interpersonal relationship refers to how well the

to fully address the patients concerns

to elicit a more complete and accurate medical

in motivating the patient to follow a 11

Quality managementincludes all the activities that

In healthcare it involves the process of:

defining what constitutes best healthcare

investing for its achievement

continuously measuring progress with the

Management of quality includes coordination

Quality Assurance (QA)