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

1. Lecture 6.Defining the quality of health-care servicesAss. Prof. PhD. Daina Lucia

2. 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

3. 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.

4. 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 Daina Lucia

5. Who is interested? The supplier The patient The third-party payer The Ministry of Public Health ? Daina Lucia

6. The Dimension of Quality Professional quality Quality from the point of view of the customer (patient satisfaction) Total quality management Daina Lucia

7. 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 Daina Lucia

8. 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 Daina Lucia

9. The TQM Principles Focus on the customer, The constant improvement of quality, Team-work. Daina Lucia

10. 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. Daina Lucia

11. 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 Daina Lucia

12. 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. Daina Lucia

13. 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. Daina Lucia

14. 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. Daina Lucia

15. 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. Daina Lucia

16. 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. Daina Lucia

17. 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. Daina Lucia

18. The dimensions of quality professional competence accessibility effectiveness efficiency interpersonal relations continuity safety physical infrastructure and comfort choice Daina Lucia

19. 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 Daina Lucia

20. Brainstorming Technique that uses the power of a group’s 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 Daina Lucia

21. 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. Daina Lucia

22. 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 Paretto’s 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. Daina Lucia

23. 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 Daina Lucia

24. 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?” Daina Lucia

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26. 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. Daina Lucia

27. Rapid response Correct and quick diagnosis Quick hospitalization Correct intervention Correct observations Correct and rapid treatment Efficient treatment Pain relief Adequate drugs and equipments in the unit supplying services The expectations of the hospitalized patient empathy care Auxiliary staff alleviation Finding and communicating with relatives trust Providing correct information The tree diagram Quick access to medical care Daina Lucia

28. 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 Daina Lucia

29. 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. Daina Lucia

30. 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 Daina Lucia

31. 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). Daina Lucia

32. 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. Daina Lucia

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

34. 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. Daina Lucia

35. 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.). Daina Lucia

36. The ISO standards Set of basic requirements for any system of Total Quality Management. Daina Lucia

37. 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 Daina Lucia

38. 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 Daina Lucia

39. 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. Daina Lucia

40. Quality measurement the internal evaluation of quality, monitoring quality, the external evaluation of quality. Daina Lucia

41. 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. Daina Lucia

42. 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. Daina Lucia

43. 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. Daina Lucia

44. Quality indicators “Variables that help one measure the degree of change”. World Health Organization Daina Lucia

45. 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. Daina Lucia

46. 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 Daina Lucia

47. 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 Daina Lucia

48. 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 Daina Lucia

49. 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 Daina Lucia

50. 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 Daina Lucia