quality management mph-course 2003. introduction and definitions step 1

Quality Management

MPH-Course 2003

Introduction and Definitions

Step 1

Extract form the “Hammurabi codex” 5000 b. c.

If a master builder builds a house and fails to make it strong enough, so that it collapses and causes the death of the builder-owner, this master builder shall be killed.

If the collapsing house kills a son of the builder-owner, a son of the master builder shall be killed

Some definitions on Quality of Care:

1. “Quality of care is the extent to which actual care is in conformity with preset criteria for good care.” (Definition by Donabedian)

2. Quality of health care is the production of improved health and satisfaction of population within the constraints of existing technology, resources, and consumer circumstances.

(Definition by Donabedian, Palmer, Povar)

3. Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

(Definition by Lohr)

4. Quality of care is the performance of specific activities in a manner that either increases or at least prevents the deterioration in health status that would have occurred as a function of a disease or condition. Employing this definition, quality of care consists of two components:

.the selection of the right activity or task or contribution of activities, and

.the performance of those activities in a manner that produces the best outcome.

(Definition by Brook, Kosecoff)

5. Appropriate care means that the expected health benefit (increased life expectancy, relief of pain, reduction in anxiety, improved functional capacity) exceeds the expected negative consequences (mortality, morbidity, anxiety of anticipating the procedure, pain produced by the producer, misleading of false diagnoses, time lost from work) by a sufficiently wide margin that the procedure is worth doing.

(Definition by Chassin, Park, Fink)

According to WHO:

“Quality as a characteristic of health care may be understood at two different levels. At the more general level, one may speak of the quality of the health care system as a whole. In this approach, the resources, the activities, the management, and the outcomes of health care are all implicated: quality is the merit or excellence of the system in all its aspects.

At a more restrict level, quality may be considered to be one of the features of the health care resources and activities. Do they comply with certain established standards? Thus, it may be stated that the attributes of a given set of resources included: their category or type, their quantity, their unit cost and their quality..

The attributes of a set of activities include: their type, quantity, effectiveness in regard to the health problems addressed, coverage of the target population, and quality, . In this perspective, the outcomes or effects of the system would depend o the attributes of the resources and activities, including their quality. The quality and other attributes of the resources and activities would themselves depend on the financing, resource development, planning, organization, and management of the system. The more restricted view of quality makes it possible to handle it as a set of variables that can be easily defined, measured, assessed, and improved. It is, therefore, quite appropriate for operational purposes.”

Seven attributes of health care define its quality:

Efficacy: the ability of care, at its best, to improve health Effectiveness: the degree to which attainable health improvements

are realized Efficiency: the ability to obtain the greatest health improvement at

the lowest cost Optimality: the most advantageous balancing of costs and benefits Acceptability: conformity to patient preferences regarding

accessibility, the patient practitioner relation, the amenities, the effects of care, and the cost of care

Legitimacy: conformity to social preferences concerning all of the above: and

Equity: fairness in the distribution of care and its effects on health.

Five key elements for good quality

The working place (hospital, HC, ) is equipped according to assigned tasks

.Adequately trained and motivated staff is available in sufficient number

.Standards and norms exist and are utilized

.The client is satisfied by the service offered to him

.“We can do even better” is shared by everybody (room for improvement)

Quality Control

Quality control focused mainly on the quality of products without taking into account the “human factor”

Quality assurance/assessment

People are making mistakes, therefore they must be controlled. If you control them very carefully, they make less mistakes. This approach focuses on inspection, supervision, checklists, guidelines etc.

Comprehensive Quality Management / Continuous Quality Improvement

The majority of the people is willing to perform will. Problems are mainly caused by the procedures and processes in place. These are often too complicated, faulty and incorrect. Together with the people involved, it should be possible to improve such procedures and processes. CQI puts client’s satisfaction into the focus.

Common Demotivators

No opportunity to influence

Strict hierarchies Low salaries Boring tasks Staff fluctuation Lack of corporate

identity

No recognition Insufficient resources Physical / mental

stress No career prospects No room for

creativity

Quality of Care Policy in Tanzania

Step 2

CQM includes all levels of the health system

The MOH formulates policies, provides standards and guidelines for health care delivery and quality monitoring as well as training manuals.

The professional organisations should be involved in developing performance standards and guidelines (code of conduct).

The RHMT co-ordinates the CQM activities in the Region

The Local Government has got the overall responsibility for the district health system.

The DHMT is responsible for the close follow-up (supervision, MTUHA, but can also initiate quality circles and peer groups).

The health workers themselves are responsible for their performance with regard to their client’s needs.

Finally the clients and their representatives in the community have to be involved in the process of improvements, too.

Some key - statements in the foreword:

The mission of the MoH is to provide the highest affordable quality of Health services

This training introduces health workers to the concept of quality

Quality assurance focuses on assisting health workers to achieve full potential through improvement of the systems and processes

Its primary goal is to support health workers rather than blame individuals

Quality of care can ensure greater satisfaction for the clients

Definitions

Quality is a measure of how good something is. Something has quality if the object or the service meets or exceeds the expectations of the user. There are various definitions of quality.

Respect of standards “Doing the right think in the right way at the right time” Doing best with the resources available

Components of quality

1. Policy 2. Technical competence 3. Efficiency 4. Interpersonal relationship 5. Effectiveness 6. Accessibility 7. Continuity 8. Safety 9. Acceptability 10. Equity

Policy:

Thus it is important for the government to have sound policies to protect the poor, unprivileged and the at risk groups as one aspect of quality of care

Equity

There are two dimensions to ensuring equity in health care. These are the issue of density and geographical distribution of health services and equitable funding in the national health system.

According to the guidelines Quality contains also:

How to plan? Monitoring and evaluation Supportive / facilitative Supervision Managing Time, Space, Equipment and Supplies Communication in Health care Organization a Health Education Session Population Estimates in Health Services Utilization of Data in Health Facilities

The guidelines don’t answer the following questions:

Quality in Health as a Public issue Scoring and Ranging Quality circles / Peer group review Continuous Quality Management as a new concept Accreditation/ Certification / Licensing

Summary:

Quality assurance in Tanzania has become an issue for the MoH and the different departments, but a clear concept is yet lacking.

Concepts and Tools

Step 3

Frameworks for Quality Management

ISO 9000 ff

EFQM

Focus on processes

The European Foundation for Quality Management,

Non prescriptive, comprehensive

What is ISO?

The International Organization for Standardization (ISO) is a worldwide federation of national standards bodies from some 140 countries, one from each country.

ISO is a non-governmental organization established in 1947. The mission of ISO is to promote the development of standardization and related activities in the world with a view to facilitating the international exchange of goods and services, and to developing cooperation in the spheres of intellectual, scientific, technological and economic activity.

ISO's work results in international agreements which are published as International Standards.

What are standards?

Standards are documented agreements containing technical specifications or other precise criteria to be used consistently as rules, guidelines, or definitions of characteristics, to ensure that materials, products, processes and services are fit for their purpose.

For example, the format of the credit cards, phone cards, and "smart" cards that have become commonplace is derived from an ISO International Standard. Adhering to the standard, which defines such features as an optimal thickness (0,76 mm), means that the cards can be used worldwide.

International Standards thus contribute to making life simpler, and to increasing the reliability and effectiveness of the goods and services we use.

How are ISO standards developed?

ISO standards are developed according to the following principles:

ConsensusThe views of all interests are taken into account: manufacturers, vendors and users, consumer groups, testing laboratories, governments, engineering professions and research organizations.

Industry-wideGlobal solutions to satisfy industries and customers worldwide.

VoluntaryInternational standardization is market-driven and therefore based on voluntary involvement of all interests in the market-place.

There are three main phases in the ISO standards development process.

First phase: involves definition of the technical scope of the future standard. This phase is usually carried out in working groups which comprise technical experts from countries interested in the subject matter.

Second phase: Countries negotiate the detailed specifications within the standard. This is the consensus-building phase.

Third phase: comprises the formal approval of the resulting draft International Standard

It is now also possible to publish interim documents at different stages in the standardization process.

Most standards require periodic revision. Several factors combine to render a standard out of date: technological evolution, new methods and materials, new quality and safety requirements. To take account of these factors, ISO has established the general rule that all ISO standards should be reviewed at intervals of not more than five years. On occasion, it is necessary to revise a standard earlier.

To date, ISO's work has resulted in some 12 000 International Standards, representing more than 300 000 pages in English and French (terminology is often provided in other languages as well).

A list of all ISO standards appears in the ISO Catalogue.

EFQM

The EFQM Model is a non-prescriptive framework recognizing that there are many ways to achieve sustainable excellence. It helps organizations to understand the gaps, and allows them to stimulate solutions.

Why EFQM?

Quality management tool It is sector-independent Helps to understand the gaps Gives components to estimate whoeness Makes organization ask ”How?”

Key statement of the EFQM Model

Customer Satisfaction, People (employee) Satisfaction and Impact on Society are achieved through Leadership driving Policy and Strategy,People Management, Resources and Processes,

leading ultimately to excellence in Business Results.

What is EFQM Excellence Model?

History of EFQM

The European Foundation for Quality Management (EFQM) was founded by the presidents of 14 major European companies in 1988.

EFQM’s mission is:

To stimulate and assist organizations throughout Europe to participate in improvement activities leading ultimately to excellence in customer and employee satisfaction, influence society and business results; and to support the managers of European organizations in accelerating the process of making Total Quality Management a decisive factor for achieving global competitive advantage.

Overview of EFQM Excellence Model

The EFQM Model is a non-prescriptive framework that recognizes there are many approaches to achieving sustainable excellence. The model’s framework is based on nine criteria. Five of these are ‘Enablers’ and four are ‘Results’. The ‘Enabler’ criteria cover what an organization does. The ‘Results’ criteria cover what an organization achieves. ‘Results’ are caused by ‘Enablers’. The nine criteria are:

Leadership Policy and Strategy People Partnership and Resource Processes Customer Results People Results Society Results Key Performance Results

EFQM gives great ground for self-estimation.

Leadership100 points

(10%)

Processes140 points

(14%)

BusinessResults

150 points(15%)

PeopleManagement

90 points (9%)

PeopleSatisfaction

90 points (9%)

Policy &Strategy

80 points (8%)

CustomerSatisfaction

200 points (20%)

Resources90 points

(9%)

Impact on Society

60 Pkte (6%)

Enablers 500 points (50%) Results 500 points (50%)

The EFQM Model for Business Excellence

The two categories of criteria ofthe EFQM

• Enabler criteria are concerned with how the organisation undertakes key activities.

• Results criteria are concerned with what results are being achieved.


1. LeadershipHow the behaviour and actions of the executive team and all other leaders inspire, support and promote a culture of Total Quality Management.

Evidence is needed of how leaders:

1a. visibly demonstrate their commitment to a culture of Total Quality Management

1b. Support improvement and involvement by providing appropriate resources and assistance.

1c. are involved with customers, suppliers and other externalorganisations.

1d. recognise and appreciate people´s efforts and achieve-ments.


2. Policy and StrategyHow the organisation formulates, deploys, reviews and turns policy and strategy into plans and actions.

Evidence is needed of how policy and strategy are:

2a. based on information which is relevant and comprehensive.2b. developed.2c. communicated and implemented.2d. regularly updated and improved.


4. ResourcesHow the organisation manages resources effectively and efficiently.

Evidence is needed of how:

4a. financial resources are managed.4b. information resources are managed.4c. supplier relationships and materials are managed.4d. buildings, equipment and other assets are managed.4e. technology and intellectual property are managed.


6. Customer SatisfactionWhat the organisation is achieving in relation to the satisfaction of itsexternal customers.

Evidence is needed of:

6a. the customers perception of the organisation´s products,services and customer relationships

6b. additional measurements relating to the satisfaction of the organisation´s customers.

Tools for QM

The Deming Cycle Ishikawa (fish bone)

diagram Pareto analysis Peer review Benchmarking Quality

improvement teams Guidelines,

standards Improvement

projects Self assessment External

assessment, audit Accreditation/certifi-

cation/awards

Deming - Cycleof continous improvement

check(Q-assurance)

(implementation management)

(standardiseimprove)

Q-policy / planning

actdo

plan

Tools for QM

The Deming Cycle Ishikawa (fish

bone) diagram Pareto analysis Peer review Benchmarking Quality





cation/awards

Problem

Procedures Personnel

RulesResources

Inprecise

Causes and effect diagram

Lack of knowledge

Insufficiently elaboratedInappropriate

Tools for QM The Deming Cycle Ishikawa (fish bone)






cation/awards

Pareto Kurve

100%

80%

-50%

0%

20%50%100%

INPUT

RESULT

Tools for QM


diagram Pareto analysis Peer review Benchmarking Quality improvement

teams Guidelines,




cation/awards

Review by colleagues with the same or similar qualification and experience

Tools for QM



teams Guidelines, standards Improvement projects Self assessment External assessment,

audit Accreditation/certifi-

cation/awards

Benchmarking: ... the continuous process of

measuring products, services and practices against the leading health care providers.

Lead question: Not only who is best, but

how can I become best

Tools for QM



teams Guidelines,

standards Improvement projects Self assessment External assessment,

audit Accreditation/certifi-

cation/awards

Guidelines:

Instructions or principles, which precisely describe actual or future ways of acting

Standards

Standards are fixed indicators which are derived from actual practice and are generally used to compare medical care in one setting with that in another

Tools for QM







cation/awards

Quality discussions

Project groups

Quality circles

Quality Circles

Voluntary peers (preferably without hierarchy)

Self selected problems/topics Moderated group discussion

- up to 15 participants

- inclusion of experts on request

- increased job satisfaction- continuous learning

Tools for QM



teams Guidelines,




cation/awards

Self-Assessment is a comprehensive, systematic and regular review of an organisation’s activities and results referenced against a model of excellence

Example for self-assessment

Criterion Yes No

Every day there are ward rounds in each ward with documentation on the inpatient card

All deliveries are monitored by a partograph

In all wards a morning meeting to share information on crucial events takes place

All maternal and infant deaths are audited and a written document exists

All wards of the hospital have a functioning water supply and functioning toilets

Self-assessment in regard to HIV/AIDS at Hospital Level

Criterion Yes No

Are we sure that all blood transfusions are tested for HIV- and Syphilis?

Are the results of our laboratory checked in a quality assurance process?

Is there always a laboratory technician on call providing these test also outside working hours?

Do we have a functioning VCT-service at our hospital?

Do we have a correct waste management of infectious material (needles, blood bags, syringes?)

Do we offer to all dismissed PLWA provide home base care?

Is equipment sterilized according to guidelines?

Self-assessment in regard to HIV/AIDS at HF- Level

Criterion Yes No

Is the STD-service integrated with FP and MCH service?

Does the STD-Clinic take place every day?

Is the STD register book filled correctly?

Are the STI drugs always availably and stored safely?

Is there a minimum equipment to provide SDI services?

Are condoms available in the catchment area of the health facility?

Was the health education on STDs and HIV/AIDS done by the health facility staff?

Are all instruments correctly sterilized?

Personal self-assessment in regard to HIV/AIDS at HF-Level

Criterion Yes No

Do I keep always privacy?

Do I examine patient correctly (patient undressed, genitalia exposed – adequately, foreskin retracted)?

Do I perform always a vaginal examination if needed?

Do I always emphasize partner notification?

Do I always demonstrate the correct use of condoms?

Do I have the most updated version of the STI treatment guidelines at hand?

I never run out of condoms during the last 6 months

I always follow up my patients if the don’t respect the revisit appointment?

Introducing QM

Announcement of quality policy by leadership Introduce basic principles of QM to DHMT Self Assessment Prioritisation of areas for improvement Training of moderators Formation of quality circles Plan of action and indicators

Tools for QM



teams Guidelines,




cation/awards

Special projects initiated to improve particular quality aspects which have been identified as a problem

Tools for QM



teams Guidelines,




cation/awards

In-depth assessment and evaluation of efficiency and effectiveness of the structure and processes of an organisation or section. Audits are carried out by independent specially qualified experts.

Framework for QM in the German Health System

Step 4

BASIC PRINCIPLES OF THEGERMAN HEALTH CARE SYSTEM

• First: Principle of solidarity - everyone should have access to the same quality of care on equal terms independent of financial means * the wealthier pay for the poor * the young pay for the old * the healthy pay for the sick * small families (singles) pay for large families


• Second: Principle of Supplementarity - government as regulator only when the system fails to meet social goals * government spends relatively little directly on health care * government is only marginally involved in direct service provision * the health care sector is left to govern itself, within set federal rules


"Governance by Competition"

• Third: Patients have freedom of choice of doctors and hospitals

- uniform compensation system for providers

Quality Management in Tanga Region

Step 5

Why introduce CQM in Tanzania

The applied methods and tools for quality monitoring in district services include traditional ones like

Integrated regular supervision of all health facilities (HF) by the DHMT

Reporting by using the MTUHA system

Training of health workers to improve technical and communication skills

Active community participation

Supervision has proved to be of limited effectiveness, with two major problems:

As the responsibility for quality is not shared by the staff as a whole, but becomes the specialty of the supervisors, the supervision easily becomes perverted to a mere control with the threat of sanctions, the staff rather trying to hide problems than discussing them frankly. Even if staff manages to “survive” supervision, daily practice hardly improves.

Superiors who are supposed to supervise, tend not to like this job and prefer to stay in their office, consulting room or theatre.

There is a huge network of HF but low level of quality

Q-control / Q-assurance (supervision, HMIS) with little impact so far

HSR can only succeed if quality of care is improving

People request better quality (cost sharing)

New quality tools

Commitment of leadership Health workers themselves take responsibility for

monitoring (e.g. in quality circles) Client / community satisfaction with the health services is

considered as important part of quality Strict monitoring using a standardised set of indicators

with scoring and ranking of the health facilities according to their performance

Information of the public and local authorities (and creating public concern)

Awarding of well performing services

How the 8 areas of CQM were assessed in Tanga Region?

During routine supervision once per quarter a checklist was filled by checking topics related to these 8 areas

An additional annual questionnaire focused mainly on output indicators

A third questionnaire was worked out to assess user satisfaction

The findings of these three questionnaires were computer proceeded by the CHMT themselves and analyzed by a computer based ranking and scoring approach

Further steps of CQM in Tanga?

Awarding of good performing HF during the Public Health Day

Regular supervisions are crucial to assess the performance of all Health Services

Individual instructions and support by the DHMTs for low performing HF’s

Annually information of the public about quality in the health sector

Constraints to overcome

Scoring and ranking is only fair, if all CHMTs conduct regular supervision and fill in the supervision checklist thoroughly

There should be a fair competition between private and public providers. Criteria are lacking, how to compare the performances of both systems

How to take into account factors like “remoteness” and “lack of staff” on which the staff itself has no impact?

Case study: QM in a Tanzanian Health Region

Health indicators in Tanga Region in %

1. Utilization rate of curative care (visits/ inhabt./year) 54.22. DPT 3 coverage of children < 1 y 86.1 3. ANC First Attendances 86.14. Proportion of deliveries with medical assistance 43.75. Proportion of caesarian sections per expected births 1.56. Maternal mortality among reported deliveries 0.37. Couple Year Protection (CYP) 16.48. Detection rate of new TB cases 0.29. Bed occupancy rate in Hospitals 73.610. Case Fatality Rate of Malaria in all HUs 3.911. HIV-Prevalence among blood-donors in 8.512. Severe Malnutrition Rate 5.113. Safe water in surveyed households 44.814. HH with acceptable toilets 77


Why introduce CQM in Tanzania?


The applied methods and tools for quality monitoring in district services include traditional ones like

Integrated regular supervision of all health facilities (HF) by the DHMT

Reporting by using the MTUHA system

Training of health workers to improve technical and communication skills

Active community participation


New quality tools

Commitment of leadership Health workers themselves take responsibility for monitoring

(e.g. in quality circles) Client / community satisfaction with the health services is

considered as important part of quality Strict monitoring using a standardised set of indicators with

scoring and ranking of the health facilities according to their performance

Information of the public and local authorities (and creating public concern)

Awarding of well performing services


There is a huge network of HF but low level of quality

Q-control / Q-assurance (supervision, HMIS) with little impact so far

HSR can only succeed if quality of care is improving

People request better quality (cost sharing)


Adaptation of the EFQM model to local needs


Leadership100 points

(10%)

Processes140 points

(14%)

BusinessResults

150 points(15%)

PeopleManagement

90 points (9%)

PeopleSatisfaction

90 points (9%)

Policy &Strategy

80 points (8%)

CustomerSatisfaction

200 points (20%)

Resources90 points

(9%)

Impact on Society

60 Pkte (6%)

Enablers 500 points (50%) Results 500 points (50%)


EFQM Adaptation Leadership Leadership People Management Personnel Management Resource Management Resource Management Processes Health Care Performance People satisfaction Staff Satisfaction Consumer Satisfaction Client Satisfaction Impact on Society Health Service Output Business Result Health Service Outcome


HF provide good CQM, if

1. Leadership is strong 2. Personnel Management is powerful 3. Resource Management is appropriate 4. Health Care Performance is in line with national and

international standards 5. Staff Satisfaction Staff is motivated and

satisfied at the working place 6. Clients Satisfaction Clients attend and

appreciate the HF 7. Health Service Output HF achieve set goals 8. Health Service Outcome is strengthened by the HF


Step 6:

Organization of a baseline study to get data on service quality


How the 8 areas of CQM were assessed in Tanga Region?

A baseline study was perceived by the Regional Health Management Team as the starting point of the CQM process

Elaboration of appropriate questionnaires by the RHMT

All public health facilities in the Region were visited by DHMT members, who applied the questionnaires

Analysis of the results and scoring of the HF according to their performance


3. How the questionnaires look like?

MainQuestionnaire

Usersatisfaction

Clientsatisfaction


OPD Handeni Tanga Region

No HF 32 154

Privacy provided 59% 54% Patient greeted 43% 44% Pat. given enough time to explain 67% 32% Appropriate counselling 38% 32% History taken 60% 52% Proper examination 51% 42% Appropriate lab investigation 7% 10% Diagnosis consistent 64% 53% Treatment accordingly 68% 58% Drug dosage appropriate 64% 58% Pat instructed correctly 41% 45% Card filled correctly 56% 50% Pat understanding checked 41% 26%


Family Planning

Handeni Tanga Region Qualified FP nurse/midwife available 81% 84% FP service offered daily 94% 94% HF offers pills 78% 72% HF offers injectables 84% 94% HF offers IUD 31% 33% HF offers condoms 69% 78% HF ensures privacy 81% 82% FP cards correctly filled in 66% 57% Pills out of stock 31% 32% Injectables out of stock 25% 29% IEC available 72% 71% Assess drop outs 47% 63%


Scoring and Ranking


Answer the following questions:Which are the different categories of HF?

Are their any areas with cannot be scored?

How to weight the remaining areas?

How weighting should be done within an area?


1. Leadership 50 10% 2. Personal Management 50 10% 3. Resource Management not scored 4. Health Care Performance 200 40% 5. Staff Satisfaction not scored 6. Clients Satisfaction 75 15% 7. Health Service Output 125 25% 8. Health Service Outcome not scored

Max. Points 500 100%


Why these areas were not scored?

Financial Management: HF are not comparable because of different financial schemes

Staff Satisfaction: In this first round the questionnaires was anonymous

Health Service Outcome Difficult to measure from a HF perspective

** Only Health Centers could reach 500 points, for dispensaries without IPD and laboratory the denominator is 363 points

This approach was not accepted!

1. Supervision was not done according to the planned schedule

2. Supervisions checklist have not been filled in

3. If Supervision checklist have been filled in, filling in was very often incomplete

quality management mph-course 2003. introduction and definitions step 1

Documents

quality of care

quality of health care

health care resources

outcomes of health care

health care system

characteristic of health

actual care

good care