Quality Assurance in

Healthcare

Indian Institute of Health Management Research

 Quality of Care

• Why Quality?
• What is Quality?
• Can it be measured?
• How can we do assessment?
BASIC PREMISE OF QUALITY OF SERVICES

Improved Service Quality

Increased Client Satisfaction

Increased Loyalty

Increased Utilization of Services

Increased Revenue

Increased Cure Rate

Improved Health (Reduced Morbidity and Mortality)
! Further use of services
! Sustainability of services
 Changing Trends in
Healthcare
Pay for
Performance Economic Growth
& Private
Globalization Investment
Information &
Technology Corporate
Governance

Healthcare New Healthcare

Research &
Industry Delivery Models
Development

Medical
Human Marketing &
Electronics
Resource Communications
1970 Doctor! I’m not able to
see well in both eyes. I
have come here to see
you what best you
What is could do? You are like
your my God!
problems?
2010….
Doctor! I have immature cataract
in my right eye and please do
phaco with foldable lens and let
me know what lens you are going
to put?
What is your
problems?
 Trust in 1970 Trust in 2010

Clinical knowledge
of Doctor Sophisticated
equipments
with computerized
reports
1970 2010
Patients were Patients demand fast
patient service & Quick result
 Non Clinical Expectations
1970 2010
Hospital as Temple Hospital as five star hotel

Medical Cure Services at Door - step

1970 2010
Change In Attitude of patients
Doctor as God Doctor as Businessman

Treatment

Who cures Selling his treatment

1970 Mishaps Mishaps 2010

Accidental

As Fate As legal treasure hunt

1970 2010
Satisfied patients did publicity Doctor’s do publicity

Dr. Y, MS.,
(Gold Medalist)
Eye
International
• Two minute
glasses…
• Computerized eye
testing…
• No hole surgery
Changing Trends-Ego Levels

Ego Levels vs. Criticality of Organs

Ego Levels of Health Professionals

Anatomy handled
 Why Quality?
• Institute of
Medicine
publication 1999
• Follow up
literature world
wide
• Recognition that
hospitals are high
risk environments
for patients
Indraprastha Apollo Hospital,
New Delhi, India
Patient Incidents per 100 Discharges

2.5

1.5
2005
2006
1

0.5

0
ay

ov
ug
pr
n

p
ar

ec
eb

ct
l
Ju
Ja

Ju

Se

D
M

M
A

A
F
Indraprastha Apollo Hospital,
New Delhi, India
Medication error rate
50.00

45.00
40.00

35.00

30.00

25.00
20.00

15.00

10.00
5.00

0.00
Jan Feb Mar Aprl May Jun July Aug Sep Oct Nov Dec

05 06 UCL CR
 Hospital in Qatar
90
80
70
60
50 Q1 2006
Days

40 Q2 2006
30
20
10
0
MRI delay US Biopsy delay
 Hospitals in Qatar
6

3 Q1 2006
Q2 2006
2

0
% Hosp A Hosp R
Percentage of Radiology films needing repeat
 American Hospital, Dubai,
UAE
•During preparation for re-accreditation:
– Emphasis on prevention of hospital
associated infections
– New Clinical guidelines introduced
12
N/100 device days

10

6
2005
4 2006

0
VAP UTI BSI Post-C/S
Infx(%)
Ludhiana, India
Month wise Hospital Acquired Infection Survelliance Data (VAP)
60

49.2
50
43.4 47.2
44.12
40
33.71
30

20

9.43 10.75 NNIS

10 11.7
5.61
7.09
0 0 0
0
Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06

VAP (No./1000 days) 43.4 11.7 49.2 47.2 9.43 33.71 44.12 10.75 7.09 0 0 0 5.61
Average 20.17 20.17 20.17 20.17 20.17 20.17 20.17 20.17 20.17 20.17 20.17 20.17 20.17
NNIS 90 percentile 8.9 8.9 8.9 8.9 8.9 8.9 8.9 8.9 8.9 8.9 8.9 8.9 8.9
Month
*(Number of ventilator-associated pneumonias / Number of ventilator-days) X 1000
** Source: National Nosocomial Infections Surveillance(NNIS) System Report, October 2004
 Handwashing
Percentage of Handwashing Compliance in the Hospital (July - Dec 2006)

100%

90%
80%
72% 75%
70% 64%
62%
60% 56%
54%
50%
40%
30%
20%

10%
0%
July August September October November December
Handwashing Compliance in 54% 56% 62% 64% 72% 75%
Hospital
Month
 Mohali, India
Trend on Turn Around Time (TAT) for STAT Samples

20
19
% Samples Reported Beyond TAT

18

16
15
14

12

10
9.5

8
7.2 7.1
13 Internal Benchmark
6
10 5 5 5 5
4.7
4 4.4 4.4
3.6
Desired 5 5
2 4
Outcome 2 2 2
3

0
Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07

Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07

Delayed Sample 10 13 5 2 5 4 2 2 3
% Delay 15 19 9.5 4.4 7.2 7.1 3.6 4.4 4.7
Benchmark 5 5 5 5 5 5 5 5 5

n=66 n=68 n=53 n=45 n=69 n=56 n= 55 n=45 n=63

n= Total no. of STAT Sample Tests of IPD

 What is Quality?
• When we say the word “quality,” what
comes to our mind?

• reflect upon various times you’ve

stayed at a hotel and identify what
about their stay made it a “quality
hotel” or a “quality restaurant”?
Quality is different for
different people
 Definitions

Quality is a set of
attributes of a service
 Definitions

Quality is “conformance
to the norms of Input,
Process and Output”
 Definitions

Quality is “conformance
to the requirements and
Customer Satisfaction”
Quality is Doing Right
things Right
 The Quality Grid (Right
things Right)
+ How You Do It
–
Right Things Right Right Things Wrong
EXAMPLES: EXAMPLES:
+ •Conducted lab test as •Completed lab test as requested
requested on schedule, and on schedule, but conducted it
conducted it correctly incorrectly

•Filled out correct form, and

What provided accurate Information •Filled out correct form, but
You provided inaccurate Information
Do
Wrong Things Right Wrong Things Wrong
EXAMPLES: EXAMPLES:
– •Conducted wrong lab test, but •Conducted wrong lab test, and
conducted it correctly conducted it incorrectly

•Filled out incorrect form, but •Filled out incorrect form, and
provided accurate provided inaccurate information.
 The Quality Grid (Right
things Right) / Exercise
+ How You Do It
–
Right Things Right Right Things Wrong
EXAMPLES: EXAMPLES:
+
Wrong Things Right Wrong Things Wrong
EXAMPLES: EXAMPLES:

What
You
Do

–
Quality is Doing Right
Things Right First
Time and Better Next
Time
 Definitions (Contd..)
• Quality Control
• Quality Assurance
• Total Quality
Management
• Continuous Quality
Assurance
 Definitions (Contd..)
• Defining Quality means developing standards that is
statements regarding the inputs, processes, and outcome
standards that the healthcare delivery system must meet
in order for its population to achieve optimum health gains.
• Measuring Quality requires quantifying the current
level of compliance with expected standards.
• Improving Quality requires engaging in appropriate
methodologies to close the gap between current and
expected level of quality. It uses quality management tools
and principles to understand and address system
deficiencies and improve or redesign efficient and effective
healthcare processes.
• All three are elements of Quality Assurance
 Definitions

Quality is different for

different people
 Perspectives of Quality

OBVIOUSLY
Quality has three
perspectives:
 Perspectives of Quality

• User or Client perspective

• Provider’s perspective
• Manager’s Perspective
• Community Perspective
 The Client Perspective

“Services and activities

that meet the needs of
clients in achieving their
expectations and
outcomes.”
The Provider Perspective
“Services and activities
which meet the needs of
clients, which are medically
safe and professionally
ethical, and are accessible,
and acceptable to all.”
 Managers Perspective
“Services and activities that meet the
needs of clients and programme goals
which are safe, satisfying, affordable,
accessible and delivered in a
technically competent manner within
the socio-cultural context of the
country.”
 What to expect from
Healthcare?
Fundamentally, delivery of healthcare
should be
•Safe
•Effective
•Patient-Centered
•Timely
•Efficient
•Accessible
•Equitable , &
 Competence

– Technical
– Managerial
– Communication
 Effectiveness
Ability to attain the greatest
improvements in health now
achievable by the best care
 Effectiveness of Care
The degree to which desired results
(outcomes) of care are achieved
Examples:
− an HIV patient receives antiretroviral medication;
− A woman with prolonged second stage labor
receives a needed c-section;
− a pregnant woman who lives in an endemic
malaria area receives presumptive treatment of
malaria during pregnancy;
− a child with persistent fever after initial anti-
malaria treatment has a blood smear to confirm
the continued presence of malaria parasites.
 Efficiency

Ability to lower the cost of care

without diminishing attainable
improvements in health.
 Efficiency of Service
Delivery
The ratio of the outputs of services to the
associated costs of producing those services.
Examples:
− The use of batch processing by the lab to test
blood electrolytes;
− children receive immunizations during routine
growth monitoring services eliminating the need
for another trip to the center;
− the health center acquires more instruments so
that they can run the sterilizer fewer times
during the day;
− the supply officer uses FEFO methods (first
expiry, first out) to avoid wasting drugs because
they are past expiry date.
 Acceptability

Conformity to the wishes, desires,

and expectations of patients and
responsible members of their
families.
 Access to Services
The degree to which healthcare services are
unrestricted by geographic, economic, social,
organizational or linguistic barriers
 Access to Services
The degree to which healthcare services are
unrestricted by geographic, economic, social,
organizational or linguistic barriers
Examples:
− The hospital ward has ramps so people in
wheelchairs can enter;
− a nurse or clinical officer is on duty at all times in a
health center;
− the religious sponsored health center provides
services to the entire population regardless of
religious affiliation;
− outreach services are provided rather than
requiring people to travel to the clinic.
 Safety
The degree to which the risks of injury,
infection or other harmful sentinel/adverse
outcomes, near miss effects are
minimized.

Improving Patient safety

means………………….
Reducing Medical Errors…….
DO NO HARM…………
 Sentinel events experiences
in the US
0f 4064 sentinel events reviewed by JCI during Jan 1995 –Dec
2006:
531 Events of wrong site surgery 125 perinatal death injury
520 inpatients suicides 94 transfusion related events
488 operations/ post-op 85 infection related events
complications
385 medication error 72 death following elopement
302 deaths related to delay in 66 fires
treatment
224 patients falls 67 Anesthesia related events
153 death of patients in restraints 51 retained foreign objects
138 assaults/rape/homicide 763 others

4064
 Safety
Examples:
- The use of protective clothing by staff working
with blood and body fluids;
- needles are disposed in a rigid contained and
either buried 4 feet deep or burned;
- patients with active TB are kept in a separate
ward;
- cleaning staff have access to gum boots to help
avoid slips and falls when washing the floors;
- fire and emergency exit routes are posted on the
walls.
 A Systemic Problem that Harms
Patients
Procedures
DEFENCES Physical
barriers
Training
THE
Culture
GAPS
Disease
manage
protocols
missing or not
Poor compliance,
actioned
poor supplies
Patient
Inadequate knowledge,
harmed lack of training
opportunities
No clear leadership, no
cohesive team structure
• The causes of safety issues can be
classified as
– Latent causes
– Active causes
• Risk Management
 The Dimensions of Quality /
Exercise
Dimension Examples
1. Technical Performance
2. Effectiveness of Care
3. Efficiency of Service
Delivery
4. Safety
5. Access to Services
6. Interpersonal Relations
7. Continuity of Services
8. Physical Infrastructure
and
Comfort
• What are the safety risk in your
hospital ? and how to work with
them?
– OPD
– OT
– Lab
 Safety
WHO Solution to Patient Safety
• Look-Alike, Sound-Alike Medication Names
• Patient Identification
• Communication During Patient Hand-Overs
• Performance of Correct Procedure at Correct Body Site
• Control of Concentrated Electrolyte Solutions
• Assuring Medication Accuracy at Transitions in Care
• Avoiding Catheter and Tubing Mis-Connections
• Single Use of Injection Devices
• Improved Hand Hygiene to Prevent Health Care-
Associated Infections
 Adverse Event Scorecard
S.No Types July ‘08 June ‘08 May‘08
1) Sentinel Events

1. Patient death due to fall

2. Patient death due
Medication errors

2) Adverse Events

Incorrect Device Insertion

Patient injury due to

Hot Fermentation

3) Near Misses
Wrong Patient Identification before
Blood Transfusion

Broken Glass Piece

in Patient Juice

Wrong Requisitions for Blood

Accidental Drain
Removal

Medication error
 QA Scorecard
Quality Indicators Benchmark Last Qtr July ‘08 August’ 08

Medication Errors /1000 ME- Good

pt days Project.ppt
Falls/ 1000 pt days Fall Alarming
Rate.ppt

Bed Sores/ 1000 pt days Pressure

Sore.ppt
UTI/1000 Catheter days
(GICU)
BSI/ 1000 Central line
days (MICU)
VAP/1000 ventilator days Watch out
(MICU)
SSI/ 100 discharges
• Before we begin learning about the
processes, tools, and concepts
associated with quality improvement
efforts, let’s take a look at what
some other healthcare professionals
and facilities have done to Quality
Improvement in Healthcare.
 QI Success Story 1: Helping
Patients Find Their Way
• A receptionist at a district hospital saw that a patient
appeared to be confused about where to go for her
appointment. She asked the patient if she needed any
help and discovered that the patient had become lost
while looking for the place to have blood drawn.
• The receptionist thought about the problem for a
moment. Although there were signs up in the hospital to
direct patients, she realized that the woman may not
have been able to read or the signs may have been
unclear. The receptionist recognized that the patient
might need some assistance in finding the clinic.
• The receptionist quickly thought of a couple
solutions. At first she considered giving the woman
directions, but then realized that she could
become lost again. Another idea was to call
someone over to assist her, but the receptionist
realized that this could take too much time.
• Finally, she decided that the best solution was to
walk with the patient to the clinic, as it was nearby
and another receptionist was in the office.
• The receptionist offered to accompany
the woman to the clinic so that she would
not get lost again. She was pleasantly
surprised by the courtesy and friendliness
of the receptionist and thanked her.
• After they walked to the clinic together,
the receptionist verified that this was
where the patient needed to be and then
returned to her work.
• Because it does not make sense that the
receptionist always accompanies patients to
areas in the hospital, the receptionist
decided to form a team to address this
issue and prevent it from occurring again.
• The team studied the problem and decided
to code each clinical area with a color. Lines
of the corresponding color were then
painted along the wall to lead patients to
the clinic area. If patients could not read or
became lost, they could follow the line.
1. What was the “quality improvement”
that was accomplished in this setting?
2. What caused the receptionist to
recognize that there might be an
opportunity for improvement?
3. What did the receptionist do to solve
the immediate problem?
4. What course of action did the
receptionist take to develop a more
permanent solution?
• Teams have a way of pooling the knowledge and
experiences of various people to ensure the problem was
understood in its entirety
− Individual health workers were able to identify opportunities
for improvement, take initial steps, and pull a team of
people together
− The success stories may differ in their complexity. Some of
the success stories may take several months to improve
quality while others in a short amount of time
− Sometimes problems are just noticed because of an
observant staff member; other times a process was already
in place to monitor a process
− While in some success stories, the improvement might
seem small; its effects can be far reaching. The woman that
was pleased that the receptionist helped her might be more
inclined to revisit the facility and encourage others to do so,
too
 Case II
National Hospital Thimphu is an apex
hospital in Bhutan. It aims to provide
the best quality care care in the
country.
• Designate three indicators to measure
the quality of products and services
hospital offers
• Three indicators of quality of products
and services
• Mortality
• Non compliance rate
• Suicide rate after receiving the care
• Two indictors each to measure
A: quality of leadership
B: organisational effectiveness
C: financial results
D: customer focus results
E: human resources results
F: strategic planning
Two quality of leadership indictors
• % of staff who are aware of mission an vision
• % of governance meetings at which quality results are
reviewed

Two quality of organisational effectiveness

• Share of affected people
 Two quality of financial performance
• Unutilised funds
• Bottom line results

Two quality of customer focus

• dates of last two patients satisfaction surveys
• results of the last two patient satisfaction
surveys
 Two quality of human resources
• % of professional staff whose last two performance
evaluations were on time
• Results of most recent staff satisfaction surveys
Two quality of Strategic planning
• dates of last two reviews of the strategic plan
• Level of participation of clinical, social and behavioural
sciences leaders in strategic planning
Operationalizing Quality
• System Approach
 Basic Approach

Plan

Act Do

Check
 Quality Tools
• Pyramid construction case
 Why Learn About Different
Tools?
“To someone with only a hammer in
his/her toolbox, everything looks
like a nail.”
- Source unknown
 Quality Improvement Tools
• Brainstorming
• Histogram
• Bar diagram
• Gantt Chart
• Cause-effect diagrams
• Flow Chart
• Pareto Chart
• FEMA
 Cause Effect Diagram
• Used to identify the root cause
• Used to graphically present multiple
factors
• Shows inter-relationship of various factors
• Pathways of root cause
Cause Effect (Fishbone)
Diagram

MAIN AREA
MAIN AREA LINE
PROBLEM

CENTRAL
SPINE
EFFECT
Cause Effect (Fishbone)
Diagram
COMMUNITY SERVICE

MAIN AREA
MAIN AREA LINE
Low Case
detection
CENTRAL
SPINE
EFFECT
Cause Effect (Fishbone)
Diagram
Patient COMMUNITY SERVICE

MAIN AREA
MAIN AREA LINE
Low Case
detection
CENTRAL
SPINE
EFFECT
Contributory Factors
Contributors (Contd..)
 Flow Charts
• Study the process of service delivery
• Decisions
• Activities
• Errors
 FLOW CHART
STARTS

ACTIVITY 1 DECISION 1

DECISION 2 ACTIVITY 2

ACTIVITY 3

ENDS
• Develop the Process map for
– OPD
– OT
– Lab
• Parato Analysis
• FEMA Analysis
• Develop FEMA for
– OPD
– OT
– Lab
 Reliability Notation

• 10 to the power minus 1 = One

defect in Ten Tries (90%)
• 10 to the power minus 2 = One
defect in One Hundred Tries (99%)
• 10 to the power minus 3 = One
Defect in One Thousand Tries(99.9%)
 AS A PATIENT WHAT QUALITY
LEVELS WOULD YOU ACCEPT
FROM YOUR HEALTH SERVICES?
90%

95%
96%

98%
99%

99.9%
 Happy at 99.9% ?

• 22,000 cheques are deducted from

the wrong bank account every day
• 16,000 mails are lost by the postal
service every hour
• 2,000 unsafe airplane landings are
made every day
• 2 major airplane accidents per week
 IF 99.9% IS ACCEPTABLE TO YOU, THEN…

•YOUR HEART
*20,000 WRONG
FAILS DRUG
TO BEAT 32,000 PRESCRIPTIONS
TIMES EACH YEAR MADE EVERY YEAR
* 500 SURGICAL
OPERATIONS ARE *19,000 BABIES ARE
PERFORMED DROPPED BY
WRONGLY DOCTORS
EVERY WEEK AT BIRTH
WELL …..
“ THERE IS ONLY A 1 %

DIFFERENCE IN THE DNA

GENETIC CODE BETWEEN A

CHIMPANZEE AND A

HUMAN BEING”
•IN OUR PROFESSION THERE IS NO SCOPE
FOR ERROR. FOR ANY ERROR COMMITTED
IS ALL THE DIFFERENCE BETWEEN
LIFE AND DEATH, BETWEEN RELIEF AND
DISABILITY

•THERE IS NO SECOND CHANCE

Then …..
 HOW TO ACHIEVE
EXCELLENCE IN HEALTH

Please
wait…..
THANK YOU