Chapter 12:
Quality
Management in
Health Care
By: Mohammed Hussien (MPH/HSM)
Wollo University
Learning objectives
After completion of this chapter, students will be
able to:
Discuss quality in the context of healthcare
Discuss the dimensions of quality health
care
Describe the components of quality
management in healthcare
Identify quality measurement
models/approaches in healthcare
Discuss quality management cycle
2
Definitions and the concept of
quality
Quality means different things to different people
quality has different meanings for different health
care players
From the providers perspective, quality might
mean providing the best possible care available to
the patient
Quality from the perspective of the administrator
is to provide effective care in a cost-conscious
environment
From the patient's perspective, quality is getting
my care when and where I need it and from
whomever I choose to cure my condition
in the
3
Definitions
The application of medical science and technology
in a way that maximizes its benefits to health
without correspondingly increasing its risks
(Donabedian, 1982)
The degree to which health services for individuals
and populations increase the likelihood of desired
health outcomes and are consistent with current
professional knowledge (IOM ,1990)
An organization's processes and activities are
designed and implemented in order to
continuously meet the organization's customers'
needs and expectations (Al-Assaf, 1996)
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Important concepts in the
definitions
Quality of healthcare is about
Achieving positive health outcomes
Limiting the negative consequences of health
care
Complying with scientific recommendations
Addressing beneficiaries needs and
expectations
Modification on IOMs definition:
The degree to which health services for
individuals and populations increase the
likelihood of desired health outcomes while
keeping risks minimal and are consistent with
current professional knowledge and5
Dimensions of quality health care
Several authors and organizations have
defined quality by describing the concept
according to a set of dimensions
1.
2.
3.
4.
5.
6.
7.
Effectiveness
Efficiency
Access
Safety
Equity
Appropriateness
Timeliness
8.
9.
10.
11.
12.
Acceptability
Satisfaction
Responsiveness to patient
preferences
Technical performance
Management of the
interpersonal relationship
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Dimensions of quality.
Effectiveness refers to the extent to which the
intervention in question produces the intended
effects
Efficiency refers to how well resources are used in
achieving a given result
the extent to which objectives are achieved by
minimizing the use of resources
The goal is to maximize the output for a given
input, or conversely to minimize the input for a
given level of output
7
Dimensions of quality.
Access refers to the degree to which individuals
and groups are able to obtain needed services
whether a health service or treatment is available
to the person needing it, at the time it is needed
How easily people obtain services depends on:
Cost of service
the providers location
days and times when care is available
how well cultural characteristics and
expectations of the patient match with those of
the provider
8
Dimensions of quality.
Safety refers to the reduction of risk
patient safety is freedom from accidental injury
due to medical care, or medical errors,
with medical error being defined as the failure
of a planned action to be completed as intended
or the use of a wrong plan to achieve an aim
Equity implies considerations of fairness
providing care that does not vary in quality
because of personal characteristics such as
gender, ethnicity, geographic location, and
socioeconomic status.
Services are provided to all people who require
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them (according to their need)
Dimensions of quality.
Appropriateness how the treatment corresponds
to the needs of the patient
Timeliness receiving treatment within a
reasonable time frame
Acceptability - care meets the expectations of the
people who use the services
Responsiveness to patients or patientcentredness consideration of individual patients
and societys preferences and values
Satisfaction how the treatment and the
improvement in the patients health meets
her/his expectations
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Dimensions of quality.
Technical Performance
Quality of technical performance refers to how
well current scientific medical knowledge and
technology are applied in a given situation
timeliness and accuracy of the diagnosis, therapy
appropriateness, and skill in performing
procedures
Interpersonal relationship refers to how well the
clinician relates to the patient which is important
to fully address the patients concerns
to elicit a more complete and accurate medical
history
in motivating the patient to follow a 11
prescription
Quality Management
Quality managementincludes all the activities that
organizationsuse todirect, control or
coordinatequality
In healthcare it involves the process of:
defining what constitutes best healthcare
investing for its achievement
continuously measuring progress with the
purpose of improving processes and outcomes
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Quality Management
Management of quality includes coordination
and facilitation of all activities related to:
Quality Assurance (QA)
Quality Control (QC) and
Quality Improvement (QI)
It involves processes pertaining to the
coordination of activities related to all or any
one of the above three as well as the
administration and resource allocation of
these processes
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Quality Management
Administration may include training, education,
organization of committees and councils, building
of infrastructure, resource acquisition and
allocation, and so on
Quality management is the umbrella
encompassing all processes and activities related
to quality
Other terms used in the field include such terms
as continuous quality improvement and total
Quality Management (TQM)
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Quality Management
Quality Assurance (QA)
includes the process of planning for quality, the
development of objectives and goals for quality,
setting standards of quality, communicating
standards to users, and developing indicators for
performance monitoring
Monitoring/Quality Control (QC)
Quality control involves monitoring these
standards, using appropriate indicators, and
determining whether there is variation from the
expected outcome and whether there is a need
for improvement
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Quality Management
Quality Improvement (QI)
QI efforts and processes complement QA and QC
and sometimes overtake them
QI is defined as an organized, structured process
that selectively identifies improvement teams to
achieve improvements in products or services
(Al-Assaf 1997)
It includes all actions to identify gaps
(opportunities for improvement), prioritize and
select appropriate gaps to study, analyze them,
and narrow or close them
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Figure: Quality Management Cycle
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Quality improvement steps
According to the USAID quality cycle shown above,
the first three steps of the cycle-planning, setting
standards, and communicating standards-are all
quality assurance steps
Step four, monitoring, is also called quality control
The next six steps are quality improvement steps
Quality improvement, as mentioned above, is a
process of reducing variation from a desired
standard
Therefore, quality improvement is the process and
sub-processes of identifying opportunities for
improvement, selecting an opportunity for
improvement, defining it from an operational
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standpoint and acting on it
In summary
Quality management includes quality assurance,
quality control and 'quality improvement
Quality assurance includes the process of planning
for quality, and setting and communicating of
standards
Quality control involves monitoring these
standards, using appropriate indicators, and
determining whether there is variation from the
expected outcome and whether there is a need for
improvement
Quality improvement identifies opportunities for
improvement and prioritizes them,
Following analysis, and the design of an
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intervention, a solution is implemented to improve
In summary
The solution may or may not meet the set
standards, this can be determined only by
monitoring the quality process continuously
Monitoring is based on specific and measured
indicators related to standards
It is a process of measuring variance from
standards and initiating processes to reduce this
variance
Without quality control it is impossible to
determine whether the standards are met and
whether there is an opportunity to improve or not
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Key success factors in quality
improvement
The following principles are considered as key
success factors towards quality improvement
Leadership
Commitment
Customer focus
Continuous process-oriented and outcomedriven improvements
Employee empowerment
Proactive improvements
Data-driven decision-making
Interdisciplinary team-work
Education, retraining and recognition
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Continuous Quality Improvement
Improvements are not onetime activities
When a team has worked on a process and
improvement has been accomplished, it should not
abandon this process and move on to the next one
Monitoring should continue, and improvements should
be initiated every time they are needed
Once compliance has been achieved, incremental
improvements in the standards also are important
If high or even perfect compliance with a specific
standard has been documented, upgrading this
standard is the next step to take
Otherwise, the organization will stay in the status quo
and further improvement will not occur
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Continuous Quality Improvement
QI includes two important components and a
supporting infrastructure
Quality Measurement
Quality Improvement
Infrastructure for QM
Infrastructure
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Quality Measurement
The initial step required to initiate quality
improvement processes in any kind of institution
Donabedians framework for measurement of
healthcare quality
Structure
Process
Outcome
S-P-O are areas of measures on which information
can be gathered and potentially inferred about the
quality of healthcare.
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Quality Measurement
Structure
Structure is the setup in which care is being provided
include the education, training, and certification of
professionals who provide care and the adequacy of
the facilitys staffing, equipment, and overall
organization
Evaluations of quality that rely on such structural
elements assume that well-qualified people working in
well-appointed and well-organized settings will provide
high-quality care
However, although good structure makes good quality
more likely to ensue, it does not guarantee it
E.g. To measure the quality of HIV care, one can use
Percentage of hospitals with medical doctors
trained on
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HIV care as an indicator
Quality Measurement
Process
Process, which refers to what takes place during
the delivery of care, also can be the basis for
evaluating quality of care
The quality of the process in turn can vary on two
aspects: appropriateness, which refers to whether
the right actions were taken, and skill, which
refers to how well actions were carried out and
how timely they were
Assumption: if healthcare is provided in
compliance with scientific recommendations,
potentially attainable outcomes will be achieved
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Quality Measurement
Outcome
the costs of care and patients health outcome
outcomes typically refer to health status-related
indicators - the change observed on
beneficiaries of healthcare that is attributable to
healthcare
may include intermediate or longer term
outcomes
change in health status
change in health behavior
client satisfaction
Challenge: attribution
many factors that determine clinical outcomes
including genetic and environmental
factors
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Quality Measurement
Steps to measure quality
Identify priority areas for improvement
Select quality of care indicators related to
priority areas of improvement
Collect data
Analyze data
Expected results
Opportunities for quality improvement
identified
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Quality Improvement
the step during which series of actions will be
taken to:
Plan and implement potential solutions to
address underlying root causes of problems
Study if changes bring improvement
Expand those changes that are found effective
and modify those found ineffective
Act
Plan
Demings Cycle
Study Do
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Quality Improvement
PLAN
Based on findings of Quality Measurement
Investigate the root causes of performance
gap
Come up with a prioritized list of feasible
solutions
Set objectives for improvement
Plan implementation (who, what, where, when)
DO
Carry out the plan small scale
Document problems and unexpected
observations
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Begin analysis of the data
Quality Improvement
STUDY
Analyze data completely
Compare findings with expectations and previous
findings
Draw conclusions on what to expand and what to
further improve
ACT
Expand changes that brought improvements
Modify changes that need modifications to bring
more improvements
Find out other solutions for areas with no
improvement
Start the next cycle
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Quality Improvement
Examples of actions to improve quality of
healthcare:
Training on specific topics
Development of standards, guidelines and job
aids
Electronic diagnostic support
Physician reminders
Process redesign
Change in technology
Reallocation of resources (human, financial,
material)
Patient education programs
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Infrastructure
Quality management needs to be institutionalized
if improvements have to be made continually
QM is not a onetime activity; always, there are
rooms for improvement
It should include the human and material
resources that are required to:
Plan for CQI processes
Measure quality of care
Test and implement quality improvement
actions
Monitor and evaluate if the quality
management program is working 33
A quality culture
Establishing a quality culture is the next
milestone
Institutionalization is achieved when appropriate
healthcare quality activities are carried out
effectively, efficiently, and on a routine basis
throughout a system or an organization
It is a state of achievement whereby healthcare
quality is practiced and maintained without
additional outside resources
In such a state, expertise is available within and
commitment is fully integrated and maintained
A quality environment or culture is achieved when
quality activities become day-to-day activities
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A quality culture
Such activities are not separate from the normal
activities carried out daily by the system and its
personnel
It is a state in which each employee is aware of
the quality concept, believes in it, practices its
principles, and makes it part of his or her
responsibility and not the responsibility of a
department or another individual
In such a culture, each individual is responsible
for his or her tasks own quality structure,
process, and outcome
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Thank
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