TQM Trainign Workshop

7/31/2019 TQM Trainign Workshop

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Time Topic

Day1

9:00am Historyo Qua ityManagement

10:00am DynamicsofHealthcare

11:00 11:15am CoffeeBreak

11:15 BariarstoQualityImprovements

12:15 QualitManagement

Philosophies

1:15 GeneralDiscussion

Day2

9:00am StepstoQualityImprovement

10:00am Value

of

Including

Medical

Staff

in

Quality

Improvements

11:00 11:15 CoffeeBreak

11:15am TeamBuildingInQualityEfforts

12:15 GeneralDiscussion

Day3

9:00am QualityImprovementTools,ADashthroughData

10:00am TQMSixSigmaTurningStrategyintoResults

3/27/2008Dr. A. Saddique 2

11:00am 11:15 CoffeeBreak

11:15 12:15 Practical

Application

and

General

Discussion

1:30pm GroupsWorkshoponCQIApplications


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Dr. Abdulaziz A. SaddiqueSix Sigma Master Black Belt


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Six Si ma Master Black BeltSix Si ma Master Black Belt



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Wh Hos ital ualit Assurance?

Ethics

Competition ren s o ea t are tan ar s

Economical forces



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2000BC Code of Hammurabi - 2000 BC

The Responsibility For QualityCare Rests Solely With The

Individual Who Provides The Care



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1752AD Benjamin Franklin- first US hospital

The Accountability Of The GoverningBody Was Limited To Fundraising


Brown 1-42


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Florence Nightingale

Advocated a uniform system forcollecting and evaluating hospital

s a s cs.

From statistics on the mortality of British

indicated a drop in mortality rate from

32.% to 2.% within six months

Nutting and Dock, 1907,pg142



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Florence Nightingale -

Early Process Standards For NursingPractice

- First rule of good nursing was to keep the air

the patient breathes as pure as the external air,without chilling the patient

-and symptoms of a change in the patientscondition


Nightingale -Notes on Nursing(1860)


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1863AD

Florence Nightingale

n a e e use o osp a e s o

indicators of health in order to promote

beds.

From this data s ecific medical and sur ical

treatments was correlated with diagnostic

categories and morality rates calculated

(Brook and Avery 1975,pg3)



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Emory Groves, British physician

Established a follow-up system for particular

categories of diseases to allow assessment of

long-term results-



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1908AD

An industrial system called theTaylorsystem

was developed that separated planning from

.

but at the expense of quality



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1 10ADDr Abraham Flexner

Released a study of the quality of medical

schools in the united states which stimulated the

e m na on o p oma m s.



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1912ADEA Codman -

Opened an end results hospital - instituting a

system of medical audit - emphasized:

e mpor ance o censure or cer ca on o prov ers

(2) the accreditation of institutions

(3) the severity or the stage of the disease(4) the issue of co-morbidity

(5) the health and illness behavior of the patient



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1913ADAmerican College of Surgeons

Formed as an accrediting body,- generated minimum standards for

- developed the first hospital standardization

program (They suggested 5 standards only)



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1950

American Nurses Association -

Published A Code For Nurses



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1952

JCAHCO (Joint Commission on Accreditation ofHospitals)

Established as responsible for the quality assurance function

succeeded the American college of surgeons



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1965Darling vs. Charleston Community Memorial Hospital

The Governing Body And The Hospital Held AccountableFor The Selection Of Medical Staff And The ualit Of

Care Rendered In The Hospital.



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1973

-

Legislation enacted - mandated the

implementation of a Quality Assessment

System



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e mo ern are:

W.Edward Demin

Philip CrosbyKaoru IshikawaVilfredo Pareto

Jose h M JuranGenichi Tagushi

W. A. Shewhart


.


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1. Deming14 Points for Management

.Do Things right the first time

Spend less time in rework

Build trust in your products

xpan n e mar e anHire More People


Stay in Business


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Defined the our qua ty a so utes:- The definition of quality is conformance to requirements.-

- The performance standard is zero defects

- The measurement of quality is the price ofnoncon ormance.



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Ishikawais best known for developing

the cause an e ec agram(also called the fishbone diagram)



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ParetoAn Italian engineer

Developed the are o c ar A basic but powerful tool of managerial analysis



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Used the pareto chart and its demonstration of misdistribution

Formulated The Pareto Principle: 80/20 Rule

-The bulk of failures (80%) being

traceable to a vital few (20%)

corrective actions towards thesevital few and awa from

the trivial many



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Genichi



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Created the Poka-Yoke system to ensure-

measures.



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Armand V.

Developed concepts of 'Total Quality

Control', Contributed to 'cost of quality' and quality

systems engineering and practice



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Is responsible for the Control Chart-Another basic tool of ualit control:The control chart is a chart with statistically

determined upper and lower limit, which is used to

cause of the variability.



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1981

JCAHCO -

The joint commission required all hospitals

to have a written quality assurance plan.



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JCAHCO(Joint Commission) -Launched agenda for change. The goal of thisprogram was to develop an outcome-oriented

mon or ng an eva ua on process

Quality Improvementwas dramatic as itcontained two critical elements:

1.Philosophy2. Problem-Solving/Graphical Techniques



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(JCAHCO)

Published principles of organization andmana ement effectiveness in healthcare

organizations-

articulated the concept of total qualitymanagement (TQM)

Then in 1992 Accreditation Manual for Hos ital.

- The Commission initiated aTransition to continuous quality improvement.



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Riyadh Quality Management Networkorme y a s u y group or e exam. rew o

nearly 100 individuals from all major hospitals in riyadhand interested corporations for presentations related toquality implementation

Then in 2001 Healthcare ualit Mana ement Network.became a chapter of the Saudi National Quality Committee

and National Association of Healthcare Quality (USA), its,

Quality Management Network (HQMN).



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arc ,ISO (International Organization for

-

Com leted a re ort on the uidelines for

implementing ISO 9000 quality management systems

in the health care sector goal to establish a standardfor the healthcare sectoraccepted by north America,

Australia, British standards, European commission

-organized by Canadian Standards Association / Standards Council of Canada



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Total uality ManagementIs the concept of a healthcare organizationmeasuring their effectiveness and

establishing projects to improve their

e ec veness a suppor ng e pa en s an

practitioners at the point of care



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y y ,

continuously changing therefore, we

allows adaptation of the changes and

develop.

,

to identify problems or pending



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QUALITY PRODUCTS SURVIVE


AND SPEAKS FOR ITS CREATORS


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Dr. Abdulaziz Saddique Pharm.D., CPHQ, CSSMBB



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Healthcare is a service that is provided toour patients to cure disease, decreasesuffering, improve the quality of life orprolong life.

The trial for better care is a never endingprocess.

Clinical Research is the key to developmentof new procedures, new drugs, or defining.



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e s rev s ng s s an ar s o

care practically every year to keep up.

Governments and individuals are

healthcare.

devised


The Paradox of Healthcare


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The Paradox of Healthcare

Highly trained practitioners; widespread state-of-the-art technology; unparalleled biomedical

research; unequaled expenditures; excellent care

for some individuals

Care fragmented and difficult to access; too many

people not assured access; uncertain value of

expen itures; growing isenc antment wit care

process by patients, practitioners and payers;



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urrent pract ce epen s upon t eclinical decision makin ca acit

and reliability of autonomousof problems that routinely exceed

cognition.


October 15, 2001IOM Annual Meeting


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ynam cs o ea care

Development of the diagnostic procedures,techniques and understanding of the

. Improvement of Monitoring procedures

Develo ment of Dru Industr Development of healthcare performance

standards ene c ng neer ng an rea men o

hereditary diseases. Escalation of Healthcare Cost



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ynam cs o ea care

a en s eman o ua y erv ce.

Patients and Governments demand toecrease cos .

Governments demand to know more

. Global Quality Awareness.

ange s no op ona s a mus .

Healthcare is a Business.



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ase on a t e eman s.

More Shifting to Privatization.

The Competition.

The New JCAHO Standards. Overall World Economy



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e n t on o ua ty n ea t care

American Medical Association

improvement of /or maintenance of



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e n on o ua y n ea care

e n t on:

The degree of adherence to generallyrecognize contemporary stan ar sof good practice and achievement of

an c pa e ou comes or par cu ar service, procedure or clinical problem



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Definition of Quality In Healthcare

improve the services provided to

meet our patients expectations.



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Regardless of which model is chosen by theOrganization it should contain the following:

Knowledge of systems

Knowledge of Variation

now e ge o syc o ogy; an

Theory of Knowledge

. .

improvement knowledge



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To meet the changing demand ofhealthcare marketplace the organizationmust have:

Short-term initiatives:

Improve effectiveness, time MGMT,efficiency, and other dimensions of

per ormance o t e major processesin their basic services.



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.

Long-term initiatives:

create customer-focused, learning

healthcare system.


Healthcare management system


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pec ca ons

development in healthcare.

staff and maximize their productivity, as

Provide means for Continuosim rovement.

Provide integration of Professionalknowledge with improvementknowledge.



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-

governments organizations to assurethe ualit of services rovided.

Standards are essential in the developedcountries, however, in developingcountr es t s cons ere as t es toindividuals activities.

to another, and this affects theunderstanding of Quality.



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Continuous Quality improvement efforts

and not just Quality Assurance. pp ca on o a managemen sys em

which meets the continuous qualityimprovement based on patients needs.

Determination of customers needs baseon competition.

minimal cost by maximal utilization ofthe available resources.


Examples of Quality Improvement and Cost


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onta nment e orts

Change from problem driven to Goal-oriented

management. re en a ng. Information management utilizing Statistical

methods to evaluate performance andremova o error.

Case management and evaluation of servicesbased on preset standards, to achieve

.

Integration of all these systems in a completedatabase.



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TQM is The

FIDO DIDO

Thank you & Seeyou oon



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r. u az z a que Six Sigma Master Black Belt



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n organ ze osop y a see s

to meet client needs and exceeds

, rework and waste , by using a

identifies and improves all aspects ofcare and services on an on oin basis


Quality Improvement promotes: Client


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1. Identification of clients, their needs,

2. Response to changes in client needs


QI Promotes Leadership


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. rgan za ona cu ure

2. Planning3. Resources

4. Quality



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. ec ve commun ca on among eam

members and between teams. ocus on mprovements to team s

functioning

. ross unct ona nter sc p naryrepresentation



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. eve opmen ,se ec on an

monitoring of indicators. epor ng o n ca or mon or ng

and results

. ee ac on n cator resu ts



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:

Voluntary and not mandatory Private

commitment to safe , highqualityservice



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. v u -

set Standards and improves the

2. Involves examining everyday

standards of excellence


Benefits of Accreditation


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Benefits of Accreditation

1. Shows commitment to Quality

2. Supports learning across organization3. Encourages self-reflection

4. Improves communication, collaboration

an ntegrat on among epartments


Also


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romo es eam u ng

Increases credibility Demonstrates accountability

Improves productivity

Obtain valuable advice fromsurveyors,.


The Value of Accreditation


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Accreditation may benefit health care institution by:

v ng t em a compet t ve a vantage

Accreditation provides evidence of quality patient care thathelps level the playing field for organizations doing the same

Strengthening community confidence

Achieving accreditation is a visible demonstration to patients

providing the highest quality services

Assisting recognition from insurers , associations ,,

Increasingly, accreditation is becoming a prerequisite foreligibility for reimbursement, for association membership ,for communit awareness and for contract or rants


In addition


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Validating Quality Care to Patients

ccre a on an ar s are ocus on one goa . a s ng esafety and quality of care to the highest possible level.

Achieving accreditation is a strong validation that u have

Helping you organize and strengthen your improvementefforts

Accreditation encompass state of the art performanceimprovement concepts that help you continuously improvequality

Enhancing staff education

The survey process is design to be educational, not punitive .Accreditation surveyors are trained to help you improve yourinternal procedures and day to day operation


Also

Improving Risk Management


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Improving Risk ManagementBy enhancing risk management efforts ,accreditation may

, .can also assist in lowering adverse events or outcomes for

the organization ,and more importantly, for the patient theor anization

Facilitating Staff Recruitment

As Staff recruitment become more difficult , achieving

commitment to quality and patient safety will enhancerecruitment efforts

romo ng eam u ng s s s a

The process of obtaining and maintaining accreditationdemands a team approach to good patient care. Establishingprocesses an systems t at support t s emonstrat on sachieved through good team activities

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u y

achieving accreditation ac s a mem er can e p ensure a

safe environment where high quality

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To get Accreditation


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To get Accreditationis

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Chan eis


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manner in which an individual or

behaviors to another

,and becoming different

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maybe


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.

quo of the organization initiated by

impact either or both the work and

.2. Unplanned : any change to the status

on a random . It takes long time

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Factors Enforcing Change

WTOIMF


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WHOGlobalizationWorld Bank

Economic

developments

GovernanceCitizens / Industry

e ec s a

Laws

Rules

Regulations

Local Governance

Guidelines

Implementation

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Execution

wh or anizations need to Chan e?


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Improve market share Increase effectiveness Increase learning Improve public image

Increase client satisfaction Improves outcomes ,

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Forces that pushes organizations to


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Forces that pushes organizations toChange

1. External changes

. 3. Environmental factors

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Changes in law and regulations

Changes in customer needs and want Changes in technology

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structure such as new changes.

better work environments

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Environmental factors


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with the improvement of information,technology . All leading to increase inthe speed of individual events

Environmental com lexit :organizations become very complex

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One of nastiest and most debilitating


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There is not a more potent killer of

to change

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Resistance to is one of the


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Positive resistance is based on rational

evidence that the cost of change

Negative resistance based on emotions

of the outcomes of change because oftheir ersonal needs or fears

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Fear of unknown Social relations

Habits Failure to recognize the need for change

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continue


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Loss: change has unacceptable personal

costs Inadequacy : the benefit from the change

are not seen as sufficient

Anxiety : fear of being unable to copewith the new situation

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Organizational level


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Threat to existing balance of power Structural inactivity

Work group inactivity

Previously unsuccessful efforts

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Other sources

of

Resistance to Change


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g

Ignorance : a failure to understand the

Mistrust : motives for changes areconsidered sus icious

Disbelief : a feeling that the way forwardwill not work

Powercut : a fear that sources of

influences and control will be eroded

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Other sources

of

Resistance to Change


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: The way forward is dislikeecause an a ternat ve s pre erre

Change threatens the

estruction o existing socia networ

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r ca y assess ngwhether change will

vo ng ea ng wurgent and pressing

personalconse uences of

what really needs to bedone

change3/27/2008Dr. A. Saddique 118

ey e emen s o e ec ve


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Change agent skills Teamwork

Supportive organization culture

Implementation plan

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organization goes through a structural

Address the resistance to change

se a par c pa on approac

Communicate the change effectively

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continue


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u

personal agenda u an ma n a n comm men

Monitor to ensure compliance

Predict the likely impact of change onthe organization

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Process


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influential mangers and workers on

compelling need to change roa part c pat on o wor orce must e

engaged and committed for changeinitiatives

Management must constantly communicatemission, vision, philosophy, process and

Change and process improvement takestime and is a never ending process

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continue


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gnor ng c ange on y causes trou e

Change is happening everywhere ,whoever

The sooner the change is addressed theless ad ustment is necessar

To change is to be fearless

Ada t to the new chan e behavior

Enjoy being flexible to the changingenvironment

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Th i s quo t e f r om chap t e r s ix o f Th e Pr in ceon i n i t i at i ng

change ,


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"We must bear in mind, then, that there is nothing

,

success, than an attempt to introduce a new order of

ngs n any s a e. or e nnova or as orenemies all those who derived advantages from the

old order of things, whilst those who expect to be

benefited by the new institutions will be but

lukewarm defenders.

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Machiavelli and the Difficulty of Change

This indifference arises in part from fear of theird h f d b h l


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adversaries who were favored by the existing laws,

and partly from the doubt of men who have no faithin anything new that is not the result of well-

established experience. Hence it is that, whenever

the opponents of the new order of things have the

of partisans, whilst the others defend it but feebly,''.

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. .. .

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129


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o Inspection

o Quality Control

o Quality Assurance

o Total Quality Management

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Inspection


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Quality Control


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Quality Control


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Quality Control

QC is the systematic assessment ofgoods and services to check their


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goods and services to check their

conformance

It will not improve quality, just

highlight when it is not present

In many cases QC does not identifythe root cause of the non-conformance

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Quality Assurance


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Quality Assurance


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Quality Assurance

y u


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yorganizational activities to increase

opt on an use o t r partyapproval, such as a major customer

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Total Quality Management

Represents the most advanced stage ofqua ty eve opment


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q y p

A Management philosophyApplication of QM to all aspects of business

Focused on the requirements of the customer

Recognizes the importance of suppliersCompany wide approach

Continual improvement

Integration of all quality systems and procedureseve opmen o organ za ona cu ure

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TQM Principles

Internal customer supplier relationship

Continuous Improvement


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Continuous Improvement

TeamworkEmployee participation/ development

Suppliers and customers integrated into

Honesty, sincerity & care

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W. Edwards Deming

Defined ualit as continualimprovement of a stable system.


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improvement of a stable system.

Most quality problems (90%) arecaused by poor systems, not byworkers. Management is responsible.

ate t e term .14 points of management must be

choose).

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Demings 14 Points

. wi f d d


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improvement of products and

become competitive and staying in-

creating jobs), rather than short-runrofits.

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Demings 14 Points

Two problems 1) problems of today,and 2) problems of tomorrow, for the


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company that hopes to stay in.

Problems of tomorrow require

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Demin s 14 Points

. A opt t e new p i osop y yf i ll l d


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refusing to allow commonly accepted, , ,

and errors. Accept the need toestablish leadershi for chan e. The

new philosophy must start at the top,with senior management, if it is toave cre y w cus omers,

suppliers, and employees.

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Demings 14 Points


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Demings 14 Points


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Demings 14 Points


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Demin s 14 Points

Continuous: oin on or extendinwithout interruption or break.


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p

1) not changing, remaining the same,

specifically

a) remaining firm in purpose,b) remaining steady in loyalties,

c) remaining free from variation or change;

stable..

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Demings 14 Points


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Demings 14 Points


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Demings 14 Points


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Demings 14 Points


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Demings 14 Points


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Demings 14 Points


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Demings 14 Points


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Demings 14 Points


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Demings 14 Points


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Demings 14 Points


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3/27/2008Dr. A. Saddique 161

Metanoia

The first process that must be


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p

managers. It involves how theyerceive the business and their

relationships with customers,suppliers, and employees.

T is trans ormation is iscontinuous.

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1. Lack of constancy of purpose

2. Emphasis on short-term profits


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3. Evaluation of performance, merit rating, orannua rev ew

4. Mobility of top management

5. Running a company on visible figures alone("counting the money")

.

7. Excessive costs of warranty, fueled by

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. ,

Deadly Diseases, Obstacles


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2. Management takes pride and develops

courage for new direction

3. Management explain to personnel in the

4. Divide every company into stages identifyingthe next stage as the customer

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.

(using Deming Cycle)


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( g g y )

6. Everyone can take part in a team to improve

7. Embark on construction of or anisation for

quality (involving knowledgeable

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1. Ne lect of lon -ran e lannin andtransformation


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2. The supposition that solving problems,au oma on, ga ge s, an new mac nery wtransform industry

.

4. Our problems are different

5. Obsolescence in schools

6. Reliance on quality control departments

7. Blaming the workforce for problems

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.

9. False starts


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10. The unmanned computer

. ee ng spec ca ons

12. Inadequate testing of prototypes

13. "Anyone that comes to try to help us must

"

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.


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2. Knowledge of statistical theory

3. Theory of Knowledge

4. Knowledge of Psychology

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Phili Crosb

3/27/2008Dr. A. Saddique 169

Quality is Free - Crosby

Quality is free. Its not a gift, but it is free.at costs money are t e un-qua ty

things-all the actions that involve not doing


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. If you do things right the first time, you will

not spend money fixing them or doing

them all over again. Crosby claimed that all quality

. .quality is free

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In Quality is Free, Crosby defined an

ddi i l li b ildi l


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additional ualit buildin toolsincluding the Quality ManagementMaturity Grid which enables a company

to measure its present quality positionand pinpoint areas that needimprovement

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14-steps to Quality Improvement - Crosby

Crosby identifies fourteen steps to qualityimprovement, whether you manage a


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arge p ant or run a sma us ness:

1) Make sure that management people

are committe to qua ity.2) Gather representatives from each

department to form quality

improvement team.

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3) Measure processes to determinewhere current and potential qualityproblems lie.


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4) Evaluate the cost of quality andexplain its use as a management tool.

5) Rise to all employee the qualityawareness and personal concern.

6) Take actions to correct problems

identified through previous steps.

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3/27/2008Dr. A. Saddique 175


ncourage emp oyees o commun ca eto management the obstacles they face


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.12)Recognize and appreciate those who

artici ate.

13)Establish quality councils tocommunicate on a regular basis.

14)Do it all over again to emphasis that the

quality improvement program neveren s.

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Fishbone (Cause and Effect or Ishikawa)


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3/27/2008Dr. A. Saddique 178

Fishbone (Cause and Effect or Ishikawa)

vQuality

ea s o ncrease un ers an ng o


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ea s o ncrease un ers an ng ocomplex problems

sua an presentat ona too

3/27/2008Dr. A. Saddique 179

Fishbone (Cause and Effect orIs i awa

y y

Recently some computer programs

ave een crea e o ma e s one


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ave een crea e o ma e s oneDiagrams

3/27/2008Dr. A. Saddique 180

u v y u ,process, or service


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3/27/2008Dr. A. Saddique 181

e ps r ng a pro em n o g


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3/27/2008Dr. A. Saddique 182

Creating Fishbone Diagrams(1 of 4)


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3/27/2008Dr. A. Saddique 183

Creating a Fishbone Diagram


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3/27/2008Dr. A. Saddique 184

Creating a Fishbone Diagram (3 of 4)

.each of the major causes


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.their respective major causes

-

causes dividing with increasedspecificity

3/27/2008Dr. A. Saddique 185

Creating a Fishbone Diagram (4 of 4)


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3/27/2008Dr. A. Saddique 186

xamp e

:


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Poor Service(backbone)

(head)

3/27/2008Dr. A. Saddique 187

xamp e

:

Appearance


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pp

Poor Service

ReliabilityAttention

3/27/2008Dr. A. Saddique 188

xamp e

, , :

ResponsivenessAppearance

timeequipment


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personnelfacility

q p

Poor ServiceOne on one

accuracy

Attention Reliability

serv cedependability

3/27/2008Dr. A. Saddique 189

xamp e


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3/27/2008Dr. A. Saddique 190

xerc se

,Ishikawa) Diagram for the following:

that the productivity of its workers is well


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that the productivity of its workers is wellbelow the standard. After interviewing itsemp oyees, was no ce a a vas ma or y

felt dissatisfied and unhappy with their work.Your boss has asked you and a group of yourpeers to n t e causes o wor erdissatisfaction . Include all possible causes to

at least the secondary level.

3/27/2008Dr. A. Saddique 191

ummary


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3/27/2008Dr. A. Saddique 192

ummary


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3/27/2008Dr. A. Saddique 193

ummary


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3/27/2008Dr. A. Saddique 194

-

Italian Economist


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3/27/2008Dr. A. Saddique 195

The Pareto Diagram

It is a s ecial t e of vertical bar chart

in which the categorized responses

are lotted in the descendin order oftheir percentages, and combined with


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p g ,a cumulative percentage polygon on

the same scale. Useful when there are many

categories

Vertical axis shows the %, horizontalaxis categories.

3/27/2008Dr. A. Saddique 196

Pareto diagram

Axis for bar50

100

120chart shows

% i d


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4080

100% invested

10

20 40

60

category.

0 0

graph shows

cumulative

3/27/2008Dr. A. Saddique 197

Stocks Bonds Savings CD % invested.

Jurans Quality Trilogy


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3/27/2008Dr. A. Saddique 198


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Quality Planning


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Quality Control


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3/27/2008Dr. A. Saddique 202

Quality Improvement


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Quality Improvement (cont.)


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206

:


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)(

3/27/2008Dr. A. Saddique 207

ua ty n ea t care: erspect ve

The right care

At the right time

Delivered safely

Delivered efficiently


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e ve ed e c e t y

Constantly improved

3/27/2008Dr. A. Saddique 208

Performance Im rovement is theprocess by which we assure the

delivery of Efficacious and

ppropr a e care or n v ua pa enin a Timely manner, Effective and


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y ,,

Safe and Efficient with Respect andCaring for the patient.

3/27/2008Dr. A. Saddique 209

1. Vision and values driven

.3. Physician involvement


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. us omer- ocuse

5. Infrastructure for continuous improvement

. ommun cat on

3/27/2008Dr. A. A. Saddique 210


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3/27/2008Dr. A. Saddique 211

Not h in g Happens Un less you hav e ad ream

Integration of Quality

Vision.

The vision of the organization


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g

eg ns w s ea ers p.

3/27/2008Dr. A. A. Saddique 212


2. Leadership

3 Ph i i i l t


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3. Ph sician involvement

4. Customer-focused

6. Communication

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Vision to unify all the quality improvement

ro ect .

Chief motivators during the massivechange in philosophy as a result of


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change in philosophy as a result ofapplying TQM.

They have the power to change the systemsbefore crisis is reached.

3/27/2008Dr. A. A. Saddique 214

They have the ability to allocate resourcesnecessary for solving the problems and

. Priority for quality improvement can be


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for it. Allocate ade uate trainin time for ever

level of the organization.

3/27/2008Dr. A. A. Saddique 215


. ea ers p3. Physician involvement


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4. Customer-focused

5. Infrastructure for continuous improvement

6. Communication

3/27/2008Dr. A. A. Saddique 216

Medical Staff involvement

Medical staff are:

The driving force of the healthcare facility.

The heads of the healthcare teams.


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The heads of the healthcare teams.

The operators of the organization.

Carry the responsibility of the well beingof the patients.

3/27/2008Dr. A. A. Saddique 217


2. Leadership

3 Ph sician involvement


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4. Customer-focused

6. Communication

3/27/2008Dr. A. A. Saddique 218

Healthcare is a business:

In business the customer is always right

us omer sa s ac on s e ma n o ec ve othe healthcare facility


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facilities We are for the service of the atient

We are all customers for one another

3/27/2008Dr. A. A. Saddique 219


2. Leadership

3 Ph sician involvement


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4. Customer-focused

6. Communication

3/27/2008Dr. A. A. Saddique 220

Infrastructure for Continuous

improvement

sta s ment o an n rastructure.

The organization must establish aninfrastructure within which the cycleof improvement can operate. The


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p p

JCAHO standards is the optimalinfrastructure that any health carefacility should adopt.

3/27/2008Dr. A. A. Saddique 221


JCAHO infrastructure com osed of: Quality council of steering committee ualit im rovement adviser or coach


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ualit im rovement adviser or coachand Quality improvement teams

3/27/2008Dr. A. A. Saddique 222

Inte ration of ualit Im rovementConcepts

u u .

Quality council or steering committee.

qua y mprovemen a v ser or coac an . quality improvement


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improvement process.

3/27/2008Dr. A. Saddique 223

Policy & Procedure

Indicators Benchmarks


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DataTIPTIPTIP

Stay in the solution, not the

problem. Green light thinking is

an energizing way to solve

problems and build

3/27/2008Dr. A. Saddique 224

team sp r t.


2. Leadership



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4. Customer-focused

6. Communication

3/27/2008Dr. A. A. Saddique 225

Staff involvement's through:

Top management vision communication

Suggestion programs Teams

ro em so v ng ee ac mon or ng


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ro em so v ng ee ac mon or ng

Quality improvement programs

3/27/2008Dr. A. A. Saddique 226

P OPL WHO PLAN TH,


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,

BATTLE THE PLAN..

3/27/2008Dr. A. Saddique 227


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Ten-Step process approved by JCAHOcont. :

Initiate evaluation

Take actions to improve care and service

A th ff ti f th ti d


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Assess the effectiveness of the actions and

ensure that improvement is maintained

and groups

3/27/2008Dr. A. A. Saddique 230

Stage I:

heads and use the feedback form to assess

de artments views re ardin their services.


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Encouraging each department to have- -

Procedure manual.

3/27/2008Dr. A. Saddique 231

Assist departments that require

assistance with the develo ment of their

Policy and Procedure manual, by

id idi l P li d


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guidance, providing sample Policy and

3/27/2008Dr. A. Saddique 232

and set a priority listing of the problems

assessment tasks to evaluate the

.


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Incident reports evaluation to identify the

poss e pro ems.

Administration views and comments.

3/27/2008Dr. A. Saddique 233

patients and employees satisfaction.

In-patients survey (completed).

- .


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Employees survey. .

Trainers training program.

3/27/2008Dr. A. Saddique 234

Stage II: Assessing t e current po icies an

procedures with respect to theCAHO CI and other hos itals o eratin

standards. Revising the Policies and procedures as

.


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Reengineering some of the policies androcedures as needed.

This will continue along with the trainingof the trainers and moving to training of

.

3/27/2008Dr. A. Saddique 235

Continue monitorin of the

problems lists and working with theadministrations and the departments

to so ve ex st ng an new pro emsas they occur.

v -


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policy and procedures.

program for all new staff (Mandatory

for three da s .

3/27/2008Dr. A. Saddique 236

Stage III:

Completion of the P & P revision andupdate.

ev ew cos cen ers: Services that consume the majority of the

bud et.

Services that shows inappropriate use of


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Services that shows inappropriate use of

the resources..

Establishment of policies to arrest

excessive cost.

3/27/2008Dr. A. Saddique 237

Development of standardization in

routine clinical operations. Clinical Policies.

r t ca at ways. Carry out an Auditing System: .


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External Auditing. .

3/27/2008Dr. A. Saddique 238

for:

. Problem solving.

.


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Prepare for accreditation.

resources.

3/27/2008Dr. A. Saddique 239


Quality Improvement (QI) Plan

uca ng anagers an s a Focusing QI activities


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TIPTIPTIPThere is no Quality

Improvement without

3/27/2008Dr. A. Saddique 240


u u v y y

Information Summarization,

oor na on, ssem na on anPresentation

mp ementat on o rgan zat on-w e


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Monitoring and Evaluation Activities

3/27/2008Dr. A. Saddique 241

. Select the new Standards.

and evaluation activities.

Get your benchmarking.

Document your actions.


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y

Get your Physicians involved.

3/27/2008Dr. A. Saddique 242


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3/27/2008Dr. A. Saddique 243


Improvement Concepts

Developing a quality improvement plan

ommun ca on ro e n Training for CQI

Customer focus

Quality council role


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Quality council role

Quality coach/advisor ucat ng managers an sta

3/27/2008Dr. A. A. Saddique 244


Focusing on quality improvement

activities Concurrent support systems

Quality improvement projects


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Q y p p j

Financial considerations

3/27/2008Dr. A. A. Saddique 245

easur ng qua y requ res useof both standards and

performance measures.


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TIPTIPTIPListening to you customers

will till you a lot about

3/27/2008Dr. A. Saddique 246

the quality of your

services

v y z woperating standards even if it was not

.Your responsibility is to find and


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try to change it or modify it.

3/27/2008Dr. A. Saddique 247

Basic Ste s In PerformanceImprovement

Find your operating standards Understand your system

ent y pro ems Quantify the size of each problem


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People are not problems,

make our eo le roblem

3/27/2008Dr. A. Saddique 248

solvers

s : n a ays an e

Assess the Situation. Get the facts.

enera e poss e so u ons w greenlight, non-judgmental thinking.

.


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TIPTIPTIPLook at problems as

opportunities for Improvement

3/27/2008Dr. A. Saddique 249

e term per ormance mp es t ata responsible health care providing

y: Can be identified.

s e accoun a e or s o serve


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behavior.

the aspect of care being evaluated.

3/27/2008Dr. A. Saddique 250

Concentrate on the Process.

Identify areas of improvement.

Set priority listing for improvement tasks. Use a systematic approach to problem

so v ng.


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Involves people who does the work.

problem on hand.

3/27/2008Dr. A. Saddique 251

Health care performance measurement

on research (a "performancemeasure") to evaluate a: Managed care organization (MCO).


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Health plan or program. Hospital.

Health care practitioner.

3/27/2008Dr. A. Saddique 252

Looks at past performance

Measures outcome

TIPTIPTIP


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Look for your staff satisfaction

and use them to empower

your performance

im rovement rocess

3/27/2008Dr. A. Saddique 253

" " uthe approach being used is:

. Systematic.


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3/27/2008Dr. A. Saddique 254

,purchasers make informed choices

Increase accountabilit in health care

Compare providers

Desi n health lans

And benefit packages


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Teamwork empowers

people.

3/27/2008Dr. A. Saddique 255

power to improve Hel or anizations demonstrate

performance Good data leads to action, and

e er ou come

I l d i li TIPTIPTIP


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Involves doctors in quality TIPTIPTIPMaster the basics. High

achievers are skilled at what

3/27/2008Dr. A. Saddique 256

.

What Does PerformanceMeasurement Require?

umust:

. Be based on scientific evidence.

.


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3/27/2008Dr. A. Saddique 257

What Do Performance MeasurementResults Tell Us?

u udescribe an observed level of

,of parental satisfaction with referrals,

,of morbidity or mortality secondary to


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medical intervention

3/27/2008Dr. A. Saddique 258

What Types of Measures Can We Use?

apply to various aspects of health care,no standardized set of categories has yet

. Early Quality Categories Avedis Donabedian, M.D., a pioneer in the

science o measuring ea t care qua ity,established a set of quality categoriesin ol ing str ct re process and o tcomes


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involving structure, process, and outcomes.

Structure. The resources and organizationalarrangements are in place to deliver care.

3/27/2008Dr. A. Saddique 259

Examples

.

Percentage of physicians who are

oar cer e . Presence of quality improvement

programs.


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3/27/2008Dr. A. Saddique 260

provider activities are carried out todeliver care.

Examples: Percentage of females of specified age

rece v ng mammograp y.

Percentage of patients with asthma forh i t di ti d d


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Percentage of patients with asthma forwhom appropriate medications are ordered.

Number of times adolescents are providedguidance on smoking avoidance.

3/27/2008Dr. A. Saddique 261

provider activities.

Number of patients successfully treated.

effective functioning.


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deaths.

3/27/2008Dr. A. Saddique 262

.

Use of the best currently available medicalknowledge.

measures. However, outcomes are difficult tointerpret because they can be significantly affectedby patient characteristics such as: Age. Age can affect health care outcomes.

Health status Healthier people are likely to havebetter health care outcomes


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Health status. Healthier people are likely to havebetter health care outcomes. Socioeconomic characteristics. Better diets and

healthier environments relate to better health careoutcomes.

3/27/2008Dr. A. Saddique 263

Difficulties with Rates

-for some areas of health care treatmentand services. It is thus ossible in

these areas, to say that a rate is "high"or "low" or that a quality problem doesor does not exist.

Example: Standards exist for the


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Example: Standards exist for theappropr ate types, num er, an t m ngof vaccinations for children. Thus, rates

3/27/2008Dr. A. Saddique 264

Quality Improvement

one of the tools needed for effectiveualit im rovement initiatives. You

can use performance measurement toestablish the initial or baseline level ofper ormance an to re-measure

performance after the quality


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performance after the quality .

3/27/2008Dr. A. Saddique 265

GET and MAINTAIN STAKEHOLDER AGREEMENT

e er ormance mprovemen rocesse er ormance mprovemen rocess

CONSIDER

INSTITUTIONAL

DEFINE

DESIRED

PERFORMANCE

CONTEXT

MISSION

FIND ROOTCAUSES

Why does the

SELECTINTERVENTIONS

What can be doneGAPGAP

IMPLEMENT

INTERVENTIONS

STRATEGIES

CULTUREDESCRIBE

gap exist?

performance gap?


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CULTURE

CLIENT and

COMMUNITY

PERSPECTIVES

PERFORMANCE

3/27/2008Dr. A. Saddique 266

Eff ic iency

Qua l i t y


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Pat ien t Safe t y

3/27/2008Dr. A. Saddique 267

following:

Means to evaluate performance

Means to decrease Cost

Means to improve performance


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3/27/2008Dr. A. Saddique 268

To establish quality program it requires a set

the basis for accreditation of the healthcareorganization.

ets wor ing stan ar s or a stairrespective of their background andex ertise


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ex ertise.

Allows staff contribution in decision making

3/27/2008Dr. A. Saddique 269

Quality provides tools to evaluate

as staff performance. Also it provide the ground for overall

ea t care organizationa assessment.


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3/27/2008Dr. A. Saddique 270

Cost containment is essential especially in a

Quality management can provide means todecrease waste and maximize the utilization

.


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3/27/2008Dr. A. Saddique 271

Measure determination

Ex ert anels for s ecific measures

Evidence in peer-reviewed journals

Adoption of other robust outcome reports


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p p

3/27/2008Dr. A. Saddique 272

A roach

urrent ocus o measurement

Clinical evidence-based measures

Vo ume Measures

Process Measures

Adoption of staffing standards


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3/27/2008Dr. A. Saddique 273


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Recommendations

possible

specifications and user guides Promote o en s stemsincludin risk

adjustment

Accept notion that reports can differ int t


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spec c ty or erent au ences

3/27/2008Dr. A. Saddique 275

Policy Agenda

ssess nee or man a ory repor ng o

healthcare information in specific quality areas

ssess s a e vs. e era vs. pr va e ro e n

assuring quality in healthcare

public reporting


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3/27/2008Dr. A. Saddique 276

teps o er ormance


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3/27/2008Dr. A. Saddique 277


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. .

Guiding Cycle

RGANISE

LARIFY

NDERSTAND


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ELECT

Dr. A. Saddique279


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3/27/2008Dr. A. Saddique 280

Obst acles a re t hose f r i gh t fu l t h in gs yousee w hen you fa i l t o f ocus on you r goal s.

rganize a team that knows the

process

nderstand causes of processi ti


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pvariation

Dr. A. Saddique281

ot

Anal ze


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Anal zeModify

3/27/2008Dr. A. Saddique 282

Surgery Process Chart:

Elec

Adm

OP workup

OP visit InvestigationAnaes

ConsultnDay Booking

AdmitFit

Prep &Premed

PostopPreopReassess

Unfit

IP

Workup

urgeryRecovery


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EndDischargeDisch Planning

OP Follow-Up

Dr. A. Saddique283

Quality Improvement TechniquesCauseCause--effect / Ishikawa Diagram / Fishbone:effect / Ishikawa Diagram / Fishbone:

EFFECT

M M M

M P

9


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2849

Policy & ProcedureSupplyDelay

Waiting time

Short

Schedule Slow

ComputerSickness


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p

StaffSickness

Dr. A. Saddique285

1600

1800

UCL

1000

1200

LCL

x-

400

600

Procedures


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0

Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec

Dr. A. Saddique 286


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QI is a Science: Statistical Approachvera mprovemen ra egy

Remove special causes Process change Process change

Outcome


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Stable rocess Stable rocess Stable rocess

Dr. A. Saddique288

Special causes present

Average is too high

Common causevariation is high

Average is too high

Common causevariation reduced

Average too high

Common causevariation low

Average reduced

Techniques

TOOLS


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Dr. A. Saddique289

. . . Evaluate processes, not individuals

workplace

Benchmark for continuous improvement

decisions


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Build strong customer-supplier relations

Dr. A. Saddique29005/04/97


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Dr. A. Saddique29105/04/97

. .

Guiding Cycle

LAN O

HECK


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Dr. A. Saddique292

PLAN THE STRATEGY FOR THE CHANGE

CHECK THE RESULTS OF THE CHANGE

EVALUATE THE PROCESS CHANGES

QUARTERLY)


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Dr. A. Saddique293

Find a Process to Improve

rgan ze a eam at nows t e rocess

Clarify current knowledge of the process

Understand the causes of process variation

Select the process improvement

PDCA Cycle

PLANACT

* Improvement* Data collection

* To hold gain

* Continue

Improvement


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* Improvement

* Data collection

* Data for Process

improvement

Dr. A. Saddique294

DO

CHECK

* Data analysis- us omer v ew- Worker view

PDSA Cycle: ImplementationPLAN Hypothesis: What do you expect to accomplish?

Action Plan: Who? Does What? When?

What are the data collection procedures?

How will the chan e be im lemented?

What are the results? What are the process indicators?

STUDY What happened? What are we learning?

as ere successWhat will we do with the results?

ACT


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What will we do with the results?What else needs to be done?

Dr. A. Saddique295

Are there more change ideas?What do we do to hold the gains ?

Priorities Opportunities for change Forming the team to evaluate the

rocess

Setting the team to work


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Dr. A. Saddique296

z

z


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z

Dr. A. Saddique297

Summary

Quality can be measured Methods of measurement should be publicly

available to allow for replication and

improvement Public reporting will differ across user types

and is different from internal quality

improvement Consensus is goodbut will it drive change?


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Policy makers are involvedwhether or not

t ey want to e.

3/27/2008Dr. A. Saddique 298

,

STARTS WITH ONE

STEP


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3/27/2008Dr. A. Saddique 299


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Overuse e . Antibiotics C-Section Underuse (eg. Mammography, Beta-

Misuse (eg. Medical errors)

i.e., appropriateness of care


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3/27/2008Dr. A. Saddique 303

Standards Implementation

ua ty anagement

Computers & Information Technology

Evidence Based Guidelines Local Knowledge Based Pathways

Science of Improvement


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3/27/2008Dr. A. Saddique 304

z

z


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3/27/2008Dr. A. Saddique 305

* Not all change is improvement but all

im rovement is chan e

* Not all improvement is qualityimprovement

QI has a defined methodology

Defined statistical a roach Defined set of tools


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3/27/2008Dr. A. Saddique 306

Im rovement in Healthcare

Expert knowledge

Content knowledge

System Thinking

Statistical Variation

Scientific Method

Psychology of Change

Traditional Improvement Continuous Quality


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p Q y

3/27/2008Dr. A. Saddique 307

Paul Batalden MD

ystem t n ng

Knowledge of variation

Knowledge for improvement Ps cholo of chan e


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3/27/2008Dr. A. Saddique 308

Deming


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3/27/2008Dr. A. Saddique 309

Focus on systems (Systems theory) Develop ideas for change and test

em c en c me o Understand the variation of data

Understand reasons and motivation of

people to act on data Use a balanced set of measures (Value

compass)


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compass)

3/27/2008Dr. A. Saddique 310

Once we be in to measure im ortant

quality characteristics and outcomes, wenotice variation.

We question measurements that display

no variation.


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3/27/2008Dr. A. Saddique 311

Often, single data points alone areuninformative, but data displayed overtime can provide information formprovemen .

The primary purpose of understanding.

Interaction among process variables,

methods, procedures, people,i i f i


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e ui ment information measurement

3/27/2008Dr. A. Saddique 312

and environment.

SHAPE

READ

CENTER

SP

SEQUENCE


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3/27/2008Dr. A. Saddique 313

1990 Paul E. Plsek & Associates - Used with permission


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v Organization change tools

Epidemiology methods

Outcomes assessment (Value Compass)

General financial accounting

Activit based cost accountin


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3/27/2008Dr. A. Saddique 315

I science is a ma or business stratefor leading corporations such as GeneralElectric (Six Sigma), Toyota, Motorola,

Hewlett Packard and medical groupssuch as Mayo Clinic.

Baldrige Award for the Healthcare Sector.


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3/27/2008Dr. A. Saddique 316

QI science in healthcare is worldwide

National forum has 2000+ attendeeseach year from around the world

The European forum has almost 1000attendees from around the world

There are peer reviewed journals devotedexclusively to improvement research and


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3/27/2008Dr. A. Saddique 317

y w w w How do we know what we do works?

How can we improve what we do?


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3/27/2008Dr. A. Saddique 318

Model for Improvement

What are we trying to accomplish?

How will we know that a change

Is an improvement?

What changes can we make thatWill result in an improvement?

PlanAct

Check Do


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3/27/2008Dr. A. Saddique 319

Small rapid cycles of change

Plan

Check Do

Act


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3/27/2008Dr. A. Saddique

320

Focus on processes of careFunctional

Access Assess Dx Rx Follow-up

to improve outcome

Clinical Satisfaction

Costs

Patientwith need

Patientwith need

met

Feedback


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3/27/2008Dr. A. Saddique 321

unc onaHealth Status

General and Disease-specific Physical function Mental function Pain/Symptom Relief

SatisfactionClinical

Mortality Complications

Patient

Staff

Referring Physician

Access, Retention & Loyalty

Costs

Mutual Respect & TrustGot what I want and need when I

wanted it and needed it


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Indirect Social Market Share & Volume

UNDERSTAND PROCESS: What is the current

process or baseline state of affairs?

SatisfactionClinical

Access

SystemAssessment Dx Rx

FunctionalHealth Status

Physical function

Mental function

Process-Outcome Model of Care

Costs

Mortality

Complications

Cost

Market Share

Follow-up

Patient with I Tool

nee or:

Team Work: Who should work on this improvement?Multidisciplinary Team

Pareto Charts

Focus Groups


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Baseline DataBenchmark Data

III. CHANGE IDEAS: What changes

at eas o we ave or c ang ng w at sdone (process) to get better results?enera e ange eas:

ClinicalAccess Assessment Dx Rx

FunctionalHealth Status

(What we are trying to improve).Process-Outcome Model of Care

Satisfaction

Costs

Outcomes

Follow-up

need for:

1.

PDCA ProjectsPre

Assessment Diagnosis Treatment Discharge&F/U

2.

3.


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PLAN Hypothesis: What do you expect to accomplish? Action Plan: Who? Does What? When?

What are the data collection procedures?

What are the process indicators?

What happened?

What are we learning?

Was there success?

What will we do with the results?

What else needs to be done?

ACT


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Are there more change ideas? What do we do to hold the gains ?

Rudimentar Ri orous

Problem Solving now needs

an Implementation Plan

Publishable

Research


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All CABG (22 month period)

9

10

6

7

Rate%

2

3

4

Mortality

0

1

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18


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Surgeon

OConnor et al JAMA 266:803, 1991

Standardized ost-o mana ement

Implemented an extubation protocol

Decreased number of pre-op coag tests ange type o prop y act c ant ot c

Changed myocardial preservationtec n ques


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Standardized ost-o care and transfers

Critical pathways in care units

Multidisciplinary work groups to

Redesigned existing operating rooms

e ocate ypass pump n


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Dedicated o eratin room staff for

cardiac surgery program

One perfusionist rather than two

Enhanced internal review of all deaths

ssessment o surgeon resourceutilization


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Expected and Observed Mortality for

All Patients Undergoing CABG

10

Expected Mortality Observed Mortality

Preintervention

=

Intervention

=

Postintervention

=

67

8

2

34

01


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Quarter

OConnor et al JAMA 275:841, 1996

Example of Performance

Improvement


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Intensified atient education

Outpatient treatment of rejection

Reduced # of lab tests m te t e use o arentera nutr t on

Switch from IV cyclosporine to PO


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80%

90%

50%

60%BeforeAfter

20%

30%Benchmark

0%

2 Year SurvialRate

Rejection Steroid ResistantRejection


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21

20

25

1415Before

5

10fter

0

Length of Stay


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(P


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(P 0.01)


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Ive got two jobs, doing my job seeing the

patient and helping to make my job in thesystem I work in betterimproving the system

as a w o e.

that is the real new challenge for doctors.

..Don Berwick, M.D.


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is Accountability


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Knowledge

Skill

Professionalism

Communication

Improvement & continual learning


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Model for im rovement I Framework

Focus on Process of Care

Involve everyone (Systems Thinking)

Collaborative practice (Teamwork)

Balanced set of measures (Value Compass)

Do cycles of change to gain knowledge(Scientific Method)


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Facilitation of Teams

None of us is as smart as all of us

.Six Sigma Master Black Belt


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346

Team w or k i s t h e ab i l i t t o w or k t o et h er

t o w a r d s a co m m o n v i si on I t i s a fu e l t h a t a l l o w s


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t o w a r d s a co m m o n v i si on . I t i s a f u e l t h a t a l l o w sco m m o n p eo p le t o at t a i n u n co m m o n r e su l t s .

A high performing task group whose

common performance objectives .

A team is

a group o peop e w o co ec ve y wor

towards the accomplishment of team goals.


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348

What is Team Buildin ?

effective team

A-team approach is important and beneficial to quality

improvement processes


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QUALI TY MANAGEMENT I N ACTI ON

Customer satisfaction

rment

Mission

,Vision, ValuesEducation Manage By Fact

processes

Teamwork


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omp ex an mu - ace e pro ems n ea care.Integration of divergent points of view.

Collaboration & cooperation to achieve rapid

progress/success .

Knowledge process..

Greater number of ideas.

Greater acceptance of solutions.

g er mp emen a on ra e ,overcom ng pro ems n

relationships, commitment and lack of clarity.

Mutual support

A positive Team experience can contribute to the sense ofempowerment and a satisfying Work climate


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A positive Team experience can contribute to the sense ofempowerment and a satisfying Work climate .

Essentials For a performanceImprovement Team :

Recognized and supported by leadership .

Limited in sco e to a workable roblem

, opportunity for improvement .

.

Include all the people involved in the process

.

Be driven by data .

Be clear in role and expectations


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Be clear in role and expectations .

Task Teams .

ro ec eams .

Functional Teams

Self Directed Team


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Teamwork requires leadership with vision

of a clear goal, a flow of strong

communication and the inspiration anddrive to get the job done.


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Individual concernThe Task

Team skills


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The Team

TEAM

= eam ac a or


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Forming Closing

Storming Performing

Norming


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Stages Of Team Development

Occurs when the team gets togetherForming

Stormin Occurs when the team hits its first

disagreement or conflict

Normingee ng o re e

Documents

TQM Trainign Workshop