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Definition of Quality• Quality of medical care is “the degree to

which the process of care increases the probability of outcomes desired by the patient, and reduces the probability of undesired outcomes, given the state of medical knowledge” (U.S. Congress, Office of Technology Assessment, 1988, x).

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Definition of Quality • The Institute of Medicine (IOM) provided

the following definition: “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” (Lohr, 1990).

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Definition of Quality

• Sutter (1996) suggested the essence of “quality” via the following statement: “Quality is a value no different from integrity or honesty. It is not an objectively measured attribute as much as it is a way of business. There is no acceptable level of quality - products and services either delight or they are doomed”. (p.40)

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Definition of Quality• “In technical usage, quality can have two

meanings: 1) the characteristics of a product or service that bear on its ability to satisfy stated or implied needs and 2) a product or service free of deficiencies” (American Society for Quality, 2000).

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Definition of Quality• The ability to meet or exceed customer

expectation while maintaining a competitive market position.

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Definition of ContinuousQuality Improvement

• A structured system for creating organization-wide participation in planning, implementing, and measuring the effectiveness of a process for continuous improvement to meet or exceed customer needs.

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Historical Foundation of CQI• Walter Shewart (father of statistical quality control)• W. Edward Deming (14 points for management)• Armand Feigenbaum & Joseph Juran (theoretical

constructs for TQM)• Phillip Crosby (emphasized organizational and

management theories relative to quality; originated the “zero defects” concept)

• Genichi Taguchi (Taguchi methods) & Kaoru Ishilawa(cause and effect diagram) (use of statistical techniques for identifying problematic variations)

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Historical Foundation of CQI• TQM (term originally coined by the Naval Air Systems

Command to refer to Japanese-style management approach to quality improvement; since then, the term has taken on many meanings; methods for implementing the approach are found in the teachings of quality leaders (e.g., Crosby, Deming, Feigenbaum, Ishikawa & Juran)

• Malcom Baldrige National Quality Award applied to health care in 1998.

• International Voluntary Quality Frameworks via International Organization for Standardization (ISO). ISO 9000 and ISO 1400 Standards.

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Continuous QualityImprovement Principles

Why should we apply Continuous Quality Improvement to health care?

• Variations in processes, costs, and outcome seem inconsistent with a coherent and authoritative science of care-giving

• The gap between evidenced-based best practice and what we routinely do is a scandal

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Continuous QualityImprovement Principles

• Not all providers use equivalent resources• Recent studies continue to find significant

geographical variations in health care• Within an institution different physicians

use resources and apply care in a widely variable manner

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Continuous QualityImprovement Principles

• Competition• Leadership• High quality at low cost• Improve learner outcomes• Attract students/residents, faculty,

leadership

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Process Demonstration Concepts

• 94% of the problems are in the system, 6% of the problems are with the workers or special causes

• Quality Improvement is focused on improving processes

• Workers are responsible for work within the system

• Managers are responsible for improving the system

• Workers know where to find the problems and the solutions

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Continuous Quality Improvement Principles

• Only the people who do the work understand how the process actually works

• Education and training are essential• Quality improvement applies to daily work,

planning, simple and complex cross functional processes

• Quality improvement is essential to survival of the organization

• Quality improvement involves reducing unintended variation

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Factors Affecting CQI Effortsin Health Care

Driving Forces:• Intrinsic motivation; Medicine historic

stance on quality• External demands for quality• Competition• Increasing quality requirements and

standards• Technology to support quality efforts

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Factors Affecting CQI Effect on Health Care

Constraining Forces:• Unfamiliarity with true competition• Physician culture of personal autonomy• Lack of physician training in CQI• Need for health care personnel with expertise in

CQI methods and statistics• Need for technology and support staff• Need for long-term sustained commitment

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Culture Change• Paradigm shifts• Role of administrators, staff, faculty• Emphasis on system changes• Continuous improvement• Disciplined process• Team, community thinking

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Philosophical Components of Continuous Quality Improvement (McLaughlin and Kaluzny 1999)

• Strategic focus• Customer focus• System view• Data decision analysis• Involvement of implementation• Multiple causation• Identification of root cause and solutions• Optimization of processes• Continual improvement• Organizational learning

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Structural Components of CQI (McLaughlin and Kaluzny, 1999)

• Teams for improvement affect• Quality tools for problem identification and

analysis• Parallel organization• Top management commitment• Statistical analysis including statistical process

control• Customer satisfaction measures• Benchmarking• Redesign of processes/services; innovation

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Cost of Quality• Handley (2000) provides a useful way to examine the cost

of quality, as provided below, and notes that the cost of not doing things right, represented in the figure as PONC, represents as much as 25-40% of operating costs, suggesting a notable cost savings as quality improves.

COQ + POC + PONCCOQ = Cost of QualityPOC = Price of Conformance (i.e., cost of doing it right the

first time)PONC = Price of Nonconformance (i.e, cost of not doing

things right)

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Types of Quality Problems1. Performance Problems

1.1 Effectiveness Problems1.1 Standardized task(compliance problems)1.2 Nonstandardized task (unstructured performance

problems1.2 Efficiency Problems

2. Design Problems2.1 Processes

2.1.1 Process design problemsProducts/Service2.2.1 Product/service design problems

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Concept of Variation - Two Sources• Common causes• Special causes

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Run Chart

Leve

l or F

requ

e ncy

of M

easu

rSpecial Cause Variation Quality Assurance to Prevent

e

Control limit

System AverageControl limit

Time

Quality Improvement to Achieve Quality

Quality Improved Change to Process

Prior System Average

New System Average

Example: Nosocomial Infection Rate

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Rule of the Seven Basic QC Tools• Identify sources of variation and reduce• Four tasks in daily improvement

– Find problems– Diagnose problems– Cure problems– Control problems once solved

• Primary means to manage with facts• Solve problems not symptoms

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Definition of a Customer• A customer is anyone who accesses, uses or

is effected by your product or service• In a multi-step process, the next person or

people in the process is a customer• External and internal customers

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Continuous QualityImprovement Principles

What is a process?• Repeatable sequence of events• Occurs over a period of time• Leads to a predictable result

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Project Teams• Small (6-8) group of people brought

together to specifically solve just one problem

• The problem defines the composition of the team

• The team’s membership changes as necessary

• The team has a beginning and an end

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Benchmarking• Select focus area/process/service to benchmark• Determine scope of benchmarking effort• Choose relevant measurements• Study performance boosting best-practices• Judge appropriateness (e.g. cost/benefits) and adapt

practices• Identify cultural issues and other factors• Plan and implement changes• Evaluate outcomes of process

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Seven Commonly Used Tools• Run Chart• Pareto Chart• Flow Chart• Cause and Effect Diagram• Histogram• Scatter Diagram• Control Chart

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Usage of Quality Tools

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Fishbone Diagram

Also called a “cause and effect” diagram or an Ishakowa chartUsed to represent the relationship between all possible causes and an effectThe lines originating off of the horizontal axis represent the main causes, the lines coming off of those represent the sub-causes; four common main cause categories include man, methods, materials and machineryUseful for problem identification and problem analysis

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Flowchart

Pictorial representation of the progression through a process or system, using standard symbols to represent specific activities (e.g., a rectangle represents an activity and a diamond represents a decision point)Most commonly used for problem identification (e.g., flowchart the ideal process to compare against a flowchart of the actual process)Several types of flowcharts that are useful in process analysis (e.g., flow process chart using ANSI standard symbols)

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Pareto Chart

Graphical tool that combines the bar graph with a cumulative line graphDisplays the distribution of items, ranking the frequency of problems or conditionsUseful for problem identification & problem analysisBased upon Juran’s Pareto principle (i.e., 80% of the effects arise from 20% of the possible causes)

* Although a problem occurs more frequently does not mean that it warrants greatest attention.

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Run Chart

Displays the pattern of variation according to time or orderCan be used for problem identification or problem analysisCan be used at the beginning of a CQI effort, to determine the baseline pattern, as well as at the end of a process to see improvements

* Variation is ubiquitous; not all variation is indicative of a quality problem.

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Control Chart

Essentially a run chart with the bounds of the upper and lower control limits calculated by applying statistical formulas to data from the process; the chart usually shows a central line or process average Fundamental tool of statistical process control (SPC), developed by Shewhart, that indicates the range of variationUseful for problem analysisVarious types of control charts (e.g., control charts for attributes, such as p and u charts, and those for variables, such as X bar and R charts)

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Scatter DiagramGraphical technique to analyze the possible relationship between two variablesThe closer the points, the stronger the relationship; the slope indicates the type of relationshipUseful for problem analysis

* Note the distinction between correlation and causation; more advanced statistical tests are used to explore the extent to which the relationship is meaningful as well as the nature of the relationship.

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Histogram

Vertical bar chart to display the variation in a set of dataUseful for problem analysisDoes not prove that a process is in a controlled stateSome distributions are predictably skewed and will not display as a “normal” distribution.

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The Plan, Do, Check, Act (PDCA) Cycle (Deming, 1986)

Differing types of data and analytical tools are used throughout Shewhart’s(1939) PDCA cycle, commonly referred to as the Deming cycle, with theappropriate use and selection for specific activities being a primary consideration.

4. Act 1. Plan

3. Check/Study

2. Do