Lecture 6. Defining the quality of health-care services Ass. Prof. PhD. Daina Lucia

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Lecture 6. Defining the quality of health-care
services Ass. Prof. PhD. Daina Lucia
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DEFINING QUALITY

• All characteristics of an entity, which confer it
  the capacity to satisfy the known and the
  potential needs of users.
• The ISO Standard 8402/1995
• To do something correctly, at the right time.
• Deming, 1979
• .. The quality of medical care relates to the
  application of medical science and technology, so
  that the benefits of care increase, without
  increasing risks as well.
• Donabedian, 1930

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DEFINING QUALITY

• Making the appropriate interventions, which are
  known as being safe, may be reimbursed by the
  respective society and may have an impact upon
  mortality, morbidity, invalidity and
  malnutrition.
• WHO, 1988
• Offering affordable, reliable and optimal
  professional services, while always taking into
  account the available resources and aiming to
  obtain users solidarity and satisfaction.

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Why priorities for quality?

• A health system that is still unsafe
• Important variations in terms of performance,
  practice and results
• Inefficient or barely efficient medical
  technologies and services
• Unaccepetable losses
• Dissatisfaction of clients/patients
• Unequal access to health services
• Longer waiting time
• Higher costs for society

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Who is interested?

• The supplier
• The patient
• The third-party payer
• The Ministry of Public Health
• ?

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The Dimension of Quality

• Professional quality
• Quality from the point of view of the customer
  (patient satisfaction)
• Total quality management

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Patients rights

• Are related to human rights
• Express the demands, related to the quality of
  medical care, of each individual
• Technical interpersonal quality
• The patient becomes an active actor within the
  health-care system

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Total Quality Management

• The quality of services the quality of the
  system
• Involves general participation with the view of
  planning and implementing a process of continuous
  quality improvement
• 90 of the problems are process-related

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The TQM Principles

• Focus on the customer,
• The constant improvement of quality,
• Team-work.

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Definitions of quality

• The quality of the health-care system represents
  the level of attaining the intrinsic aims of the
  health-care system, in order to improve health
  and the capacity to respond to the general
  expectations of the population.
• W.H.O.

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Definitions of quality

• The quality of health-care services refers to
  those services that are meant to maximize the
  patients well-being, taking into account the
  balance between expected profits and loses, which
  appear during all the stages of the health-care
  process.
• Donabedian

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THE CLASSIFICATION OF NEEDS

• Expressed needs, the ones that reflect the
  customers points of view and are expressed by
  them in their particular language
• Real needs, which motivate customers behavior
  they might not coincide with the expressed needs
• Perceived needs, based on differences in
  perception between customers and suppliers, as
  regards the notions of product and quality
• Cultural needs, namely the need for self-esteem,
  respect for the others, preserving certain
  customs, traditions, practices, which are
  specific to a particular society
• Needs generated by a different way of using the
  product than the use specified by the producer.

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QUALITY CONTROL

• Quality control is the managerial method
  through which
• the real result is measured (the product
  obtained)
• it is compared with the established objectives
  (standards)
• activities for the remedy of differences.

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CRITERIA A UNIT OF MEASURE MUST MEET

• Be easy to understand
• Provide an accepted basis for making decisions
• Have a large applicability
• Lead to some uniform interpretation
• Be acceptable form the financial point of view
• Be compatible with the existing detectors.

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THE QUALITY AUDIT APPROVES IF

• Quality-related activities and results are in
  accordance with the pre-established standards and
  provisions
• The provisions are efficiently implemented and
  able to meet quality-related objectives
• The completion of task is in accordance with the
  procedure
• The quality of products ensures the satisfaction
  of customers
• The quality of products is competitive on the
  market
• The costs associated with inappropriate quality
  are reduced
• The performance of the company is optimized.

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STAGES IN THE IMPROVEMENT OF QUALITY

• The creation of the infrastructure that is
  necessary for the constant improvement of
  quality
• The elaboration of projects for improvement,
  after identifying what really needs improvement
• Setting up a team with responsibilities for each
  project
• Providing human resources, which are trained and
  motivated for diagnosing causes, find remedies
  and ensure means of control, in order to maintain
  the progress obtained.

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THE QUALITY CIRCLES - STAGES

• Identifying the product
• Describing symptoms
• Elaborating theories after gathering and
  analyzing data
• Identifying the cause
• Suggesting remedies
• Putting into practice remedies
• Testing the remedy
• Determining the control system.

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The dimensions of quality

• professional competence
• accessibility
• effectiveness
• efficiency
• interpersonal relations
• continuity
• safety
• physical infrastructure and comfort
• choice

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The instruments of quality

• A coherent set of practical devices used with the
  view of improving either performance or a
  particular service, or with the aim of
  understanding a complex situation, the
  identification of causes and making of decisions

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Brainstorming

• Technique that uses the power of a groups
  collective thinking, in order to generate ideas
  to which no single member of the group would have
  thought of by himself/herself.
• Is efficient especially in small-group activities
• The why-because technique can be used
• It is used for
• -identifying problems
• -analyzing causes
• -emphasizing possible solutions
• Helps to avoid conflicts generated by the
  divergence of ideas

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Histogram

• Simple graphic representation of a continuous
  variable distribution.
• Allows viewing the recurrence of these values at
  different categories. The abscissa of the graph
  indicates the classes of values, while the
  ordinate shows the frequency of these values.
• It is one of the 7 basic instruments of quality
• It is used for the purposes of a quantitative
  study on a continuous process
• It is used for representing graphically the
  distribution of a group of data or measures. The
  variables must be continuous.

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The Paretto Diagram

• Is a histogram that classifies, in a descending
  order, the causes of a certain problem, with the
  purpose of indicating the main causes of that
  particular problem.
• Starts from Parettos empiric principle,
  according to which about 20 of the causes
  explain 80 of the problems.
• Represents graphically the relative importance of
  different causes of a particular problem
• Requires the existence of previously gathered
  data
• It is used for the classification and
  visualization of the group of potential causes
  associated with a certain problem.
• The basic condition is the interdependence of
  causes.
• It is used mainly prospectively.

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QQUQCQQQuis, quid, ubi, quibus auxilis,
quomodo, quando

• Technique used for structuring the information
  about a subject starting from the following
  questions Who, what, where, when, how, why? It
  is used for process investigation
• It is a systematic research of information
  related to a problem that should be known better
• The problem must be identified beforehand
• It uses the brainstorming technique.
• It presents arguments for each stage in the
  identification and implementation of solutions

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The Ishikawa cause-effect diagram

• Allows the quality team to identify, explore and
  graphically represent in detail all the possible
  causes related to the presence of a certain
  problem, in order to eventually identify the
  essential causes of the problem.
• The basic technique used in the construction of
  this diagram is the repetition of the following
  question Why does this phenomenon occur?

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The tree diagram

• Is used to determine how a problem actually
  occurs, in order to find the most efficient means
  for attaining a goal. It allows the division of
  an element in sub-elements
• It is employed
• for highlighting key points concerning activities
• for resuming the affinities diagram
• for setting up quality policies
• for highlighting roles and responsibilities
• for re-organizing the cause-effect diagram.

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The tree diagram
Quick access to medical care
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Instruments for the improvement of quality

• PDCA (planning, implementing, monitoring, making
  decisions)
• The quality circles (teams made up of 5-12
  persons form the same medical unit, with similar
  activities)
• Benchmarking

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Benchmarking

• Benchmarking is the process of identifying
  the best practices anywhere in the world, in
  order to obtain information that would help the
  organization adopt those measures that would
  improve its performance.

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The benchmarking methodology

• Selection of the process
• Selection of the team
• Study and documentation
• Determining the measuring method
• Identifying the organization that would help in
  the implementation of benchmarking
• Collaboration

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Standards - definitions

• Standards represent the level of performance
  that is observable, achievable, measurable,
  approved by professionals and appropriate for the
  population they refer to.
• (Joint Commission of Accreditation of Health Care
  Organization).

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The characteristics of a good standard

• be measurable and easy to monitor
• be expressed clearly
• be realistic and achievable in relation to the
  existing conditions
• represent an indicator of quality
• be in accordance with the values and the aims of
  the organization
• be practical and easy to put into practice and
  evaluate.

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Criteria

• Are descriptive elements of performance,
  behavior, circumstance or clinical state.
• (Joint Commission of Accreditation of Health Care
  Organization)

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The characteristics of criteria

• be measurable and concrete
• be specific to the standard they illustrate
• produce a clear description of resources,
  behaviors, required or wanted processes
• be easy to identify
• be relevant for the level of performance
  described
• be realistic and achievable
• be clear and easy to understand
• allow possible periodical modifications.

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The classification of criteria

• structure (related to buildings, environment,
  infrastructure, organization, support services,
  pharmacy, laboratory, technology, human
  resources, expertise, staff abilities,
  informational procedures)
• process (related to prevention, diagnosis and
  treatment procedures, documentation,
  doctor-patient relationship, etc)
• result (the percentage of nozocomial infections,
  mortality, fatality, relation to a certain
  procedure etc.).

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The ISO standards

• Set of basic requirements for any system of
  Total Quality Management.

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The requirements of ISO standards

• The existence of a well-defined purpose
• Well-defined responsibilities
• Clear indications for services
• Clearly defined processes for the achievement of
  specifications
• Means of monitoring processes and their results
• Periodic evaluation of processes and of their
  efficiency
• Systematic rectification of errors

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Requirements of ISO standards

• systematic investigation of errors, in order to
  prevent their recurrence
• means for ensuring the quality of medical care
• the systematic maintenance of equipments
• clear identification of staff formation and
  training needs
• the registration of all elements mentioned above
• periodic re-evaluation of all elements mentioned
  above, by the organization management

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Quality measurement

• represents the systematic identification of the
  current level of quality in a medical unit or
  system, and deals with the quantification of the
  performance level, in accordance with the
  provisioned standards.

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Quality measurement

• the internal evaluation of quality,
• monitoring quality,
• the external evaluation of quality.

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Quality evaluation

• is a stage in the process of ensuring quality,
  which refers to the provision of feedback, the
  formation and motivation of the staff and the
  identification of solutions for the improvement
  of quality.

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Quality evaluation

• Quality evaluation represents an approach that
  allows each patient to benefit from diagnosis and
  therapeutic acts with the best results related to
  health, in accordance with the current state and
  development of the medical science, at the best
  prices for the best result and with the lowest
  iatrogen risk and for the best satisfaction of
  patients with regards to procedures, results and
  inter-human relations within the health-care
  system.
• O.M.S.

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Methods of quality evaluation

• observation of services
• evaluation of patient satisfaction
• the anonymous patient technique
• re-evaluation of registered data
• testing the medical staff
• survey on the medical staff
• surveys answered by patients, after the
  hospitalization period.

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Quality indicators

• Variables that help one measure the degree of
  change.
• World Health Organization

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Fundamental attributes

• Source WHO
• validity measure what needs to be measured
• relevance for the community needs or for the
  problem identified
• possible to reproduce measure each time what
  needs to be measured
• realistic, applicable, reliable and easy to use
  in practice
• measurable and observable in the form of
  frequencies, percentages, average numbers
• be familiar to and accepted by the team whose
  performance is being measured
• be used continuously in time for evaluation
  purposes.

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1. Access indicators

• hospitalizations possible to avoid
• waiting time
• physical barriers (distance, absence of doctor,
  absence of specialist etc.) in relation to access
  to medical services
• financial barriers hindering access to medical
  services
• financial barriers for the continuation of
  treatment

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2. Result indicators

• percentage of patients with post-surgery
  infections
• percentage of relapse cases
• percentage of nosocomial infections
• percentage of survival after 5 years from the
  surgical intervention
• the incidence of a disease after vaccination
• the incidence of cases for a specific disease
  after screening

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3. Indicators of patient experience

• percentage of patients that received
  contradictory information form different
  suppliers
• percentage of patients who did not receive
  answers to their questions
• percentage of patients who did not get
  information about the treatment they were subject
  to
• percentage of patients who were not asked for
  agreement in relation to treatment procedures
• percentage of patients who did not benefit from
  psychological/emotional support

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4. Process indicators

• percentage of patients not satisfied in relation
  to treatment,
• percentage of patients who needed treatment
  modification,
• number of births by Caesarean operation, without
  indication
• percentage of patients immunized after a certain
  age
• incidence of fever cases after immunization

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The constant improvement of quality - principles

• Focus on patients (customers)
  needs/expectations
• Focus on systems and processes
• Focus on the creation of a data-base system, that
  can be used in the process of decision-making
• Focus on participation and team-work

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ICC

• Identifying potential areas for improvement
• Agreement over criteria for problem-selection
• The selection of the problem