Quality Management

1. MPH-Course 2003 Quality Management

2. Step 1 Introduction and Definitions

3. 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

4. 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)

5. 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)

6. 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)

7. 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)

8. 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)

9. 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 awhole. 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 healthcare 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.”

10. 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.

11. 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)

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

13. 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.

14. 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.

15. 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 Common Demotivators

16. Step 2 Quality of Care Policy in Tanzania

17. 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.

18. 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.

19. 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

20. 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

21. 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

22. 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.

23. 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

24. 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

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

26. Step 3 Concepts and Tools

27. ISO 9000 ff EFQM Focus on processes The European Foundation for Quality Management, Non prescriptive, comprehensive Frameworks for Quality Management

28. 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.

29. 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.

30. 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.

31. 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.

32. 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.

33. 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?”

34. 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.

35. What is EFQM Excellence Model? • History of EFQMThe 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.

36. 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.

37. The EFQM Model for Business Excellence People Satisfaction 90 points (9%) People Management 90 points (9%) Business Results 150 points (15%) Leadership 100 points (10%) Processes 140 points (14%) Policy & Strategy 80 points (8%) Customer Satisfaction 200 points (20%) Resources 90 points (9%) Impact on Society 60 Pkte (6%) Results 500 points (50%) Enablers 500 points (50%)

38. The two categories of criteria of the EFQM • Enabler criteria are concerned with how • the organisation undertakes key activities. • Results criteria are concerned with what • results are being achieved.

39. The EFQM Model for Business Excellence 1. Leadership How 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 external organisations. 1d. recognise and appreciate people´s efforts and achieve- ments.

40. The EFQM Model for Business Excellence 2. Policy and Strategy How 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.

41. The EFQM Model for Business Excellence 4. Resources How 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.

42. The EFQM Model for Business Excellence 6. Customer Satisfaction What the organisation is achieving in relation to the satisfaction of its external 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.

43. 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 Tools for QM

44. 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 Causes and effect diagram Tools for QM Resources Rules Insufficiently elaborated Inappropriate Problem Inprecise Lack of knowledge Procedures Personnel

45. 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 Tools for QM

46. 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 Review by colleagues with the same or similar qualification and experience Tools for QM

47. 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 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

48. 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 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

49. 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 Quality discussions Project groups Quality circles Tools for QM

50. 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