Health Care Quality

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Dr.Shoeb Ahmed CPHQ

Notes

RUBY MED PLUS TRAINING

INSTITUTE EMAIL:

[email protected]

Comprehensive Health

care Quality manual

covering all the topics

Dr. Shoeb Ahmed Ilyas

BS, BDS, MPH, MS (GH),

MS( PSY), MS (Biotech),

MHA, EMSRHS, M.Phil

(HHSM), PGDMLE, MHRM,

F.H.T.A., F.M.S.P.I.,

Cert. in Health

Economics.

3/9/2016

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Wednesday, March 09, 2016

CPHQ TOP 20 TEST TAKING TIPS

1. Carefully follow all the test

registration procedures

2. Know the test directions, duration,

topics, question types, how many

questions

3. Setup a flexible study schedule at

least 3-4 weeks before test day

4. Study during the time of day you

are most alert, relaxed, and stress

free

5. Maximize your learning style; visual

learner use visual study aids,

auditory learner use auditory study

aids

6. Focus on your weakest knowledge

base

7. Find a study partner to review with

and help clarify questions

8. Practice, practice, practice

9. Get a good night’s sleep; don’t try

to cram the night before the test

10. Eat a well balanced meal

11. Know the exact physical location of

the testing site; drive the route to

the site prior to test day.

12. Bring a set of ear plugs; the testing

center could be noisy.

13. Wear comfortable, loose fitting,

layered clothing to the testing

center; prepare for it to be either

cold or hot during the test.

14. Bring at least 2 current forms of ID

to the testing center.

General Strategies

15. Eliminate the obviously wrong

answer choices, and then guess the

first remaining choice.

16. Pace yourself; don’t rush, but keep

working and move on if you get

stuck.

17. Maintain a positive attitude even if

the test is going poorly.

18. Keep your first answer unless you

are positive it is wrong.

19. Check your work, don’t make a

careless mistake.

20. The most important thing you can

do is to ignore your fears and jump

into the test immediately- do not

be overwhelmed by any strange-

sounding terms.

21. You have to jump into the test like

jumping into a pool- all at once is

the easiest way.

MAKE PREDICTIONS

As you read and understand the

question, try to guess what the

answer will be.

Remember that several of the

answer choices are wrong, and

once you begin reading them,

your mind will immediately

become cluttered with answer

choices designed to throw you

off.

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Your mind is typically the most

focused immediately after you

have read the question and

digested its contents.

If you can, try to predict what

the correct answer will be. You

may be surprised at what you

can predict.

Quickly scan the choices and see

if your prediction is in the listed

answer choices. If it is, then you

can be quite confident that you

have the right answer.

It still won’t hurt to check the

other answer choices, but most

of the time, you’ve got it!

Answer the Question

It may seem obvious to only pick

answer choices that answer the

question, but the test writers

can create some excellent

answer choices that are wrong.

Don’t pick an answer just

because it sounds right, or you

believe it to be true. It MUST

answer the question.

Once you’ve made your

selection, always go back and

check it against the question and

make sure that you didn’t

misread the question, and the

answer choice does answer the

question posed.

Valid Information

Don’t discount any of the

information provided in the

question. Every piece of

information may be necessary to

determine the correct answer.

None of the information in the

question is there to throw you

off (while the answer choices

will certainly have information

to throw you off). If two

seemingly unrelated topics are

discussed, don’t ignore either.

You can be confident there is a

relationship, or it wouldn’t be

included in the question, and

you are probably going to have

to determine what that

relationship to find the answer

is.

Eliminate Answers

Eliminate choices as soon as you

realize they are wrong. But be

careful! Make sure you consider

all of the possible answer

choices.

Just because one appears right,

doesn’t mean that the next one

won’t be even better! The test

writers will usually put more

than one good answer choice for

every question, so read all of

them.

Doesn’t worry if you are stuck

between two that seem right. By

getting down to just two

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remaining possible choices, your

odds are now 50/50.

Rather than wasting too much

time, play the odds. You are

guessing, but guessing wisely,

because you’ve been able to

knock out some of the answer

choices that you know are

wrong. If you are eliminating

choices and realize that the last

answer choice you are left with

is also obviously wrong, don’t

panic. Start over and consider

each choice again.

There may easily be something

that you missed the first time

and will realize on the second

pass.

Tough Questions

If you are stumped on a problem

or it appears too hard or too

difficult, don’t waste time. Move

on! Remember though, if you

can quickly check for obviously

incorrect answer choices, your

chances of guessing correctly are

greatly improved.

Before you completely give up,

at least try to knock out a couple

of possible answers.

Eliminate what you can and then

guess at the remaining answer

choices before moving on.

Brainstorm

If you get stuck on a difficult

question, spend a few seconds

quickly brainstorming. Run

through the complete list of

possible answer choices.

Look at each choice and ask

yourself, "Could this answer the

question satisfactorily?"

Go through each answer choice

and consider it independently of

the other.

By systematically going through

all possibilities, you may find

something that you would

otherwise overlook. Remember

that when you get stuck, it’s

important to try to keep moving.

Read Carefully

Understand the problem.

Read the question and answer

choices carefully.

Don’t miss the question because

you misread the terms.

You have plenty of time to read

each question thoroughly and

make sure you understand what

is being asked.

Yet a happy medium must be

attained, so don’t waste too

much time.

You must read carefully, but

efficiently.

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New Information

Correct answer choices will

rarely have completely new

information included.

Answer choices typically are

straightforward reflections of

the material asked about and

will directly relate to the

question. If a new piece of

information is included in an

answer choice that doesn't even

seem to relate to the topic being

as ked about, then that answer

choice is likely incorrect.

All of the information needed to

answer the question is usually

provided for you, and so you

should not have to make guesses

that are unsupported or choose

answer choices that require

unknown information that

cannot be reasoned on its own.

Time Management

On technical questions, don’t get

lost on the technical terms.

Don’t spend too much time on

any one question. If you don’t

know what a term means, then

since you don’t have a

dictionary, odds are you aren’t

going to get much further.

You should immediately

recognize terms as whether or

not you know them.

If you don’t, work with the other

clues that you have, the other

answer choices and terms

provided, but don’t waste too

much time trying to figure out a

difficult term.

Contextual Clues

Look for contextual clues. An

answer can be right but not

correct.

The contextual clues will help

you find the answer that is most

right and is correct.

Understand the context in which

a phrase or statement is made.

This will help you make

important distinctions.

Don’t Panic

Panicking will not answer any

questions for you. Therefore, it

isn’t helpful.

When you first see the question,

if your mind goes blank, take a

deep breath.

Force yourself to mechanically

go through the steps of solving

the problem and using the

strategies you've learned.

Pace Yourself

Don’t get clock fever. It’s easy

to be overwhelmed when you’re

looking at a page full of

questions, your mind is full of

random thoughts and feeling

confused, and the clock is

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ticking down faster than you

would like.

Calm down and maintain the

pace that you have set for

yourself. As long as you are on

track by monitoring your pace,

you are guaranteed to have

enough time for yourself.

When you get to the last few

minutes of the test, it may seem

like you won’t have enough time

left, but if you only have as

many questions as you should

have left at that point, then

you’re right on track!

Answer Selection

The best way to pick an answer

choice is to eliminate all of

those that are wrong, until only

one is left and confirm that is

the correct answer. Sometimes

though an answer choice may

immediately look right. Be

careful!

Take a second to make sure that

the other choices are not equally

obvious.

Don’t make a hasty mistake.

There are only two times that

you should stop before checking

other answers.

First is when you are positive

that the answer choice you have

selected is correct. Second is

when time is almost out and you

have to make a quick guess!

Check Your Work

Since you will probably not know

every term listed and the answer

to every question, it is important

that you get credit for the ones

that you do know.

Don’t miss any questions through

careless mistakes. If at all

possible, try to take a second to

look back over your answer

selection and make sure you’ve

selected the correct answer

choice and haven’t made a

costly careless mistake (such as

marking an answer choice that

you didn’t mean to mark).

This quick double check should

more than pay for itself in

caught mistakes for the time it

costs.

Beware of Directly Quoted Answers

Sometimes an answer choice will

repeat word for word a portion

of the question or reference

section.

However, beware of such exact

duplication – it may be a trap!

More than likely, the correct

choice will paraphrase or

summarize a point, rather than

being exactly the same wording.

Extreme Statements

Avoid wild answers that throw

out highly controversial ideas

that are proclaimed as

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established fact. An answer

choice that states the “process

should used in certain situations,

if…” is much more likely to be

correct than one that states the

“process should be discontinued

completely.”

The first is a calm rational

statement and doesn’t even

make a definitive,

uncompromising stance, using a

hedge word “if” to provide

wiggle room, whereas the

second choice is a radical idea

and far more extreme.

HealthCare Delivery Settings

Emergency care is:

• Designated hospital trauma centers,

• Emergency department of hospitals,

• Urgent care centers or

• “in the filed” by paramedical

personnel

Acute inpatient (hospital) care

• Intensive/critical care

• Urgent, elective or rehabilitative

care considered unsafe as

outpatient depending on:

• Type of diagnostic or therapeutic

procedure or

• Patient condition including need for

daily physician visit & 24 hour

nursing care

Urgent care for immediate care for

urgent or emergent conditions not

requiring treatment at a fully equipped

(level I) emergency or trauma center.

Ambulatory care including

• Primary care,

• Specialty care, &

• Ambulatory surgery centers providing

outpatient services only

• “in-store health clinics” opened in

pharmacy & retail chains generally

staffed by nurse practitioners offering

patients fast access to routine medical

services.

• Home care providing certain

treatments, services & nursing care in

the patient’s home

• Hospice care providing psychological,

medical & nursing care to the

terminally ill & their families, either in

outpatient or non acute inpatient

settings.

• Transitional, sub acute & skilled

care provide medically necessary

nursing services requiring licensed

professionals or professional

oversight that must be provided

daily & for therapeutic purposes at

a stage of care between acute

hospital & custodial.

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• Assisted Living is group residential

setting providing or coordinating

personal & health-related services &

24 hours supervision & assistance.

• Long term care is Custodial or

supportive nursing services that do

not require skilled, licensed

professional intervention.

• Behavioral Health & substance

abuse programs: are

• Partial hospitalization or

nonresidential” including day or

evening treatment.

• Crisis stabilization in the home

• Residential.

• Wellness & community health are

centers provide special training,

education & monitoring for certain

healthcare needs such as stop-

smoking, weight control, stress

reduction programs or for certain

patient group “with leukemia”

Patient safety

Look-Alike, Sound-Alike Medication

Names

Patient Identification Communication

during Patient Handovers

Performance of Correct Procedure at

Correct Body Site –Control of

Concentrated Electrolyte Solutions –

Assuring Medication Accuracy at

Transitions in Care

Healthcare Customer Expectations in

the 21st Century

• Healthcare customers provide

the perceptive quality

• Both internal and external

customers tend to focus on how

services meet their perceived

needs and whether their

expected outcomes are met.

• Patients add the degree of

caring associated with the

service and the outcome of the

care related to their sense of

well-being and quality of life to

the interpretive mix.

Expectations from Leadership

• Leadership integrity before

dollars;.

• Leadership sensitivity to needs

for:

• More personalization and

genuine attention;

• More time for physician caring

and compassion.

• Leadership involvement in the

local community.

• Leadership attention to the

organization's financial health to

assure high quality clinicians and

technology

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Expectations from Healthcare

Delivery

• More attention to the empowered,

informed customer/patient more

apt to challenge "doctor's orders”

• Reduced hassle, more convenience;

• More practitioner time (lack of time

perceived as disrespect);- Child-

centered orientation;

• Acceptance and coverage of

"alternative" approaches.

Expectations from Healthcare System

• Choice of physician and treatment

• Optimizing prevention

• Access for all

• High quality and cost control

• Up-to-date technology for diagnosis

and treatment

The Healthcare Customer Focus

• Being truly committed to delivering

value to patients and other

customers

• Listening to and communicating

with patients and other customers

• Seeking customer feedback and

insight for strategic initiatives and

quality improvement activities

• Identifying and addressing true

needs and value-based expectations

• Committing to long-term, rather

than quarterly (shareholder)

business results

• Optimizing treatment patterns and

outcomes for cohorts of similar

patients

• Clinical

• Functional

• Enhancing the performance of

internal processes to benefit:-

• Patients-

• Vendors

• All who work there.

• Respecting patient confidentiality/

privacy and security needs;.

• Responding timely to practitioners',

providers', and purchasers'

appropriate requests for

information;.

• Building trust, respect, and loyalty

in relationships.

Q. In developing a program to

evaluate the effectiveness of

physician care, a primary care clinic

would select which one of the

following indicators?

a. The patients will express overall

satisfaction with clinic facilities.

b. The contract lab will provide results

within 24 hours of sample delivery.

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c. The staff complies with all infection

control policies and procedures.

d. Newly diagnosed hypertensive

patients are controlled within 6

months.

Healthcare Quality Concepts

• Quality means doing the right things

right the first time.

• Quality can be said to be, at least in

part, compliance with standards.

Standards are created when experts

are able to understand what the

right things are and how the right

things are best achieved based on

Research and Clinical Evidence

• When recipients of care define

quality, they judge whether or not

the right things are done in ways

that meet their own needs and

expectations.

• The Institute of Medicine defines

quality as:

"The degree to which

health care services for individuals

and populations increase the

probability of desired health

outcomes and are consistent with

current professional knowledge of

best practice."

WHAT IS QUALITY?

Quality is not a number but is a

function of positive perception.

Quality, simplistically, means

that a product should meet

one‟s requirement.

Quality is the inherent

characteristic & distinctive

attribute that makes a product

different from others.

Ensures conformity to

requirement.

Products & services should be

essentially free from defects,

there by becoming cost

effective.

Quality consists of doing those

things necessary to meet

&exceed the needs &

expectations of those we serve &

doing those right things right

every time.

It is the result of good intention,

sincere effort, intelligent

thinking and skillful execution.

All dimensions like accessibility,

appropriateness, continuity,

effectiveness & efficiency must

be given equal importance in

quality.

The quality of technical care

consists in the application of

medical science and technology

in a way that maximizes its

benefits to health without

correspondingly increasing its

risks. The degree of quality is,

therefore, the extent to which

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the care provided is expected to

achieve the most favorable

balance of risks and benefits. -

Avedis Donabedian, M.D., 1980.

Total quality management: Doing

the right thing right, right away.

To the ordinary person, quality is

how good something is. This may

be a service e.g. canteen service

or a product eg. wrist watch. A

person's judgement about a

service or product depends on

what he expects of it or from it.

Some of the words used to

describe quality are: Beautiful or

attractive Durable Meeting

standards Healthy Value for

money although different words

are used to explain quality, we

would define it as the extent to

which a product or service

satisfies a person or a group i.e.

how much satisfaction the

person gets from the service.

When we say quality of care, we

mean healthcare activities that

we in the medical, nursing,

laboratory fields etc. perform

daily to benefit our patients

without causing harm to them.

Quality of Care demands that we

pay attention to the needs of

patients and clients. We also

have to use methods that have

been tested to be safe,

affordable and can reduce

deaths, illness and disability.

Furthermore, we are expected

to practice according to set

standards as laid down by

clinical guidelines and protocols.

With Quality of Care we do the

right things at the right time. We

see to patients promptly, make

the right diagnosis and give the

right treatment. With quality of

care we keep on improving on

our standard of services till

excellence is attained.

QUALITY MANAGEMENT

It is a holistic approach to the art of

managing quality output considering

together the people, process and

products rather than independent

factors and driven towards the

objective with effective &efficient

performance output”.

QUALITY REQUIREMENTS

1. Customer participation in QM

2. Leadership for the steering of quality

3. Personnel as a prerequisite for high

quality;

4. QM for preventive as well other

activities;

5. Management of processes as a basis

for QM;

6. Information as a basis for the

continuous enhancement of quality;

7. Systematization of QM;

8. Feed back and detailed

recommendations;

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9. Quality criteria support quality

management;

To provide care as per

• Accessibility

• Social Equity established norms

• Affordability

• Effective public

• Doing the right thing resource

utilization

• Prompt attention

• Doing it the right way

• Standardized care

• Doing it right the first

• Less waiting time

• Cost contentment time

• Receiving the right

•Satisfaction of both

• Doing it on time service for their use

provider and receiver without

exceeding cost

• Being satisfied that their

• Fruitful outcome

• Availability of needs have been met

• Profit margin adequate resources

• Early cure and return to

• Satisfaction with the work final

outcome

• Being treated with

• Helps in improving integrity, courtesy

and skills, efficiency and respect

experience.

ELEMENTS OF QUALITY MANAGEMENT

Errors in the hospital are invariably

due to system failure in85% of cases

(Edward Deming).

Only 15% are attributed to people‟s

performance.

Therefore attention should be given

on bad system than bad people.

Improvement of systemic errors can

be done by:-

Commitment of TOP Management,

Active support of Middle

Management.

Education and training of staff.

Formation of quality management

team.

Developing Quality culture in the

work place.

Making aware all staff about the

goal and objective of the

organisation.

Developing quality policy and

quality manual.

Developing Standard Operating

Procedure for all areas (SOP)

Good Hospital Information System

(HIS).

Formulation of criteria’s and

Standards for measuring activities.

Constant monitoring and Supervision

and feed back.

Introducing Medical Audit System.

Rectification of errors and

Evaluation.

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External quality control.

Three Aspects of Quality

• Measurable Quality

• Appreciative Quality

• Perceptive Quality

Measurable Quality

• Can be defined objectively as

compliance with, or

adherence to standards.

• Clinically, these standards

may take the form of

practice parameters or

protocols, or they may

establish acceptable

expectations for patient and

organizational outcomes.

• Standards serve as guidelines

for excellence.

Appreciative Quality

• Is the comprehension and

appraisal of excellence beyond

minimal standards and criteria.

• Requires the judgments of

skilled, experienced

practitioners and sensitive,

caring persons.

• Peer review bodies rely on the

judgments of like professionals

in determining the quality or

non-quality of specific patient-

practitioner interactions.

Perceptive Quality

• Is the degree of excellence

which is perceived by the

recipient or the observer of care

rather than by the provider of

care.

• Is generally based more on the

degree of caring expressed by

physicians, nurses, and other

staff than on the physical

environment and technical

competence.

Q The perception of quality by a

patient receiving care in an

ambulatory healthcare center is

influenced most by

a. the physical environment.

b. caring staff and physician.

c. new technology.

d. the physician's technical

competence.

ADVANTAGE OF QUALITY

• Improved care wastage

• Shorter lead times– Better team spirit

• Better relationship with– Less staff

conflict, customer’s enhanced job

• Reduced cost, increased satisfaction

profit– Increased efficiency

• Improved systems and– Confidence to

standardized procedures clients,

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• Better workmanship,– less customer •

Guaranteed quality complaints,– lower

rejection rates, less rework

Perspectives on the Meaning of

Quality?

What does quality of health care mean

for the communities and clients that

depend on it, the clinicians who

provide it, and the managers and

administrators who oversee it?

The health staff, health manager,

clients and communities are all

stakeholders in service delivery. Each

of these groups may expect different

things from health services.

The Client For the clients and

communities served by health care

facilities, quality care meets their

perceived needs, and is delivered

courteously and on time. In sum, the

client wants services that effectively

relieve symptoms and prevent illness.

The client’s perspective is very

important because satisfied clients

often are more likely to comply with

treatment and to continue to use

primary health services. Thus, the

dimensions of quality that relate to

client satisfaction affect the health and

well-being of the community. Patients

and communities often focus on

effectiveness, accessibility,

interpersonal relations, continuity, and

amenities as the most important

dimensions of quality. However, it is

important to note that communities do

not always fully understand their

health service needs-- especially for

preventive services--and cannot

adequately assess technical

competence. Health providers must

learn about their community’s health

status and health service needs,

educate the community about basic

health services, and involve it in

defining how care is to be most

effectively delivered. Which decisions

should be made by health professionals

and which should be made by the

community? Where does the technical

domain begin and end? This is a

subjective and value-laden area that

requires an ongoing dialogue between

health workers and the community.

Answering these questions requires a

relationship of trust and two way

communication between the parties.

Research done in various parts of the

country shows that our patients/clients

want services that: are delivered on

time by friendly and respectful staff;

are safe, produce positive result and

that they can afford; provide them with

adequate information about their

condition and treatment; provide them

with all the drugs they need; give

privacy are within their reach

(distance) and given in a language they

can understand.

The Health Service Provider:

From the provider’s perspective,

quality care implies that he or she has

the skills, resources, and conditions

necessary to improve the health status

of the patient and the community,

according to current technical

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standards and available resources. The

provider’s commitment and motivation

depend on the ability to carry out his or

her duties in an ideal or optimal way.

Providers tend to focus on technical

competence, effectiveness, and safety.

Key questions for providers may be:

How many patients are providers

expected to see per hour? What

laboratory services are available to

them, and how accurate, efficient, and

reliable are they? What referral systems

are in place when specialty services or

higher technologies are needed? Are

the physical working conditions

adequate and sanitary, ensuring the

privacy of patients and a professional

environment? Does the pharmacy have

a reliable supply of all the needed

medicines? Are there opportunities for

continuing medical education? Just as

the health care system must respond to

the patients’ perspectives and

demands, it must also respond to the

needs and requirements of the health

care provider. In this sense, health care

providers can be thought of as the

health care system’s internal clients.

They need and expect effective and

efficient technical, administrative, and

support services in providing high-

quality care.

The health provider can provide quality

care if he/she has: adequate

knowledge and skills enough resources-

staff, drugs, supplies, equipment and

transport etc safe and clean workplace

opportunity to regularly improve

himself/herself. is well paid and

rewarded for good work.

The Health Care Manager Quality care

requires that managers are rarely

involved in delivering patient care,

although the quality of patient care is

central to everything they do. The

varied demands of supervision and

financial and logistic management

present many unexpected challenges

and crises. This can leave a manager

without a clear sense of priorities or

purpose. Focusing on the various

dimensions of quality can help to set

administrative priorities. Health care

managers must provide for the needs

and demands of both providers and

patients. Also, they must be

responsible stewards of the resources

entrusted to them by the government,

private entities, and the community.

Health care managers must consider

the needs of multiple clients in

addressing questions about resource

allocation, fee schedules, staffing

patterns, and management practices.

The multidimensional concept of

quality presented here is particularly

helpful to managers who tend to feel

that access, effectiveness, technical

competence, and efficiency are the

most important dimensions of quality.

The health care manager sees quality

care as: managing efficiently the

resources of the health facility. Health

staff achieving set targets. Health staff

being regularly supported and

supervised. Having adequate and

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competent staff to provide care. staff

being disciplined. providing enough

resources for work.

Quality of care can also be seen from

the inputs, processes and outcome of

service delivery. We have to address

these together to improve on quality.

Most of the time we only complain

about lack of inputs without also

looking at how we do things or

activities that we carry out.

Dimensions of Quality

QA activities may address one or more

dimensions, such as technical

competence, access to services,

effectiveness, interpersonal relations,

efficiency, continuity, safety, and

amenities.

Joint commission on Accreditation of

Health care organizations (JCAHO) has

described the following criteria’s as

quality dimensions (safety,

effectiveness, efficiency, timeliness,

efficacy and equity Respect and caring,

availability, appropriateness),

Access to Services:

Access means that health care services

are unrestricted by geographic,

economic, social, cultural,

organizational, or linguistic barriers.

Geographic access may be measured by

modes of transportation, distance,

travel time, and any other physical

barriers that could keep the client from

receiving care. Economic access refers

to the affordability of products and

services for clients. Social or cultural

access relates to service acceptability

within the context of the client’s

cultural values, beliefs, and attitudes.

For example, family planning services

may not be accepted if they are

offered in a way that is inconsistent

with the local culture. Organizational

access refers to the extent to which

services are conveniently organized for

prospective clients, and encompasses

issues such as clinic hours and

appointment systems, waiting time,

and the mode of service delivery. For

example, the lack of evening clinics

may reduce organizational access for

day laborers. Where travel is difficult,

lack of home visits or village-based

services may create an access problem.

Linguistic access means that the

services are available in the local

language or a dialect in which the

client is fluent.

Access refers to the ability of the

individual to obtain health services.

Some of the factors that can affect

access are: a) Distance: e.g. where

health facility is sited far away or it is

difficult to get transport to the facility

access to quality health care becomes a

problem. b) Financial: e.g. where

people cannot pay for the services

provided. c) Culture, beliefs and

values: The services provided may not

be in line with the culture, beliefs and

values of some people.

17 | P a g e


Technical Competence

Technical competence refers to the

skills, capability, and actual

performance of health providers,

managers, and support staff.

Technical competence relates to

how well providers execute practice

guidelines and standards in terms of

dependability, accuracy, reliability,

and consistency. This dimension is

relevant for both clinical and

nonclinical services. For health

providers, it includes clinical skills

related to preventive care,

diagnosis, treatment, and health

counseling. Competence in health

management requires skills in

supervision, training, and problem

solving. The requisite skills of

support staff depend on individual

job descriptions.

A lack of technical competence can

range from minor deviations from

standard procedures to major errors

that decrease effectiveness or

jeopardize patient safety. Technical

competence as an indicator of

quality assurance implies that we

should have adequate knowledge

and skills to carry out our functions

in order to provide quality service.

E.g. one must go to a nursing school

and pass the nursing examinations

before she can work as a nurse.

Even though we are no longer in

school, we have to continue to

update our knowledge by reading

health books and attending in-

service training workshops etc.

As health professionals, we should

also know our limits, that is, know

what we can do and what we cannot

do. With respect to what we cannot

do, we are expected to refer them

to other centers or personnel who

are more competent to handle

them. Our practice should also be

guided by laid down standards and

guidelines e.g. Standard Treatment

Guideline.

Appropriateness

The degree to which the

care/intervention is relevant to the

patient's clinical needs, given the

current state of knowledge.

Availability/ Equity

The degree to which appropriate

care/intervention is obtainable to meet

the patient's needs.

Quality services should be provided to

all people who need them, be they

poor, children, adults, old people,

pregnant women, disabled etc. Quality

services should be available in all parts

of the country, in villages, towns and

cities.

Competency

The practitioner's ability to

produce both the health and

satisfaction of customers. The degree

to which the practitioner adheres to

professional and/or organizational

standards of care and practice.(Not a

JCAHO dimension)

18 | P a g e


Continuity

The coordination of needed

healthcare services for a patient or

specified population among all

practitioners and across all involved

organizations over time.

Continuity means that the client

receives the complete range of

health services that he or she

needs, without interruption,

cessation, or unnecessary repetition

of diagnosis or treatment. Services

must be offered on an ongoing

basis. The client must have access

to routine and preventive care

provided by a health worker who

knows his or her medical history. A

client must also have access to

timely referral for specialized

services and to complete follow-up

care.

Continuity is sometimes achieved by

ensuring that the client always sees

the same primary care provider; in

other situations, it is achieved by

keeping accurate medical records so

that a new provider knows the

patient’s history and can build upon

and complement the diagnosis and

treatment of previous providers.

The absence of continuity can

compromise effectiveness, decrease

efficiency, and reduce the quality

of interpersonal relations.

Continuity means that the client

gets the full range of health services

he/she needs, and that when the

case is beyond us, we refer him/her

to the right level for further care.

Continuity may be achieved by the

patient seeing the same primary

health care worker or by keeping

accurate health records so that

another staff can have adequate

information to follow up the

patient.

Effectiveness

The degree to which care is

provided in the correct manner,

given the current state of

knowledge, to achieve the desired

or projected outcome(s) for the

individual.

The quality of health services

depends on the effectiveness of

service delivery norms and clinical

guidelines. Assessing the dimension

of effectiveness answers the

questions, Does the procedure or

treatment, when correctly applied,

lead to the desired results? and Is

the recommended treatment the

most technologically appropriate for

the setting in which it is delivered?

Effectiveness is an important

dimension of quality at the central

level, where norms and

specifications are defined.

Effectiveness issues should also be

considered at the local level, where

managers decide how to carry out

norms and how to adapt them to

local conditions. When selecting

standards, relative risks should be

considered. For example, more

frequent use of cesarean section

might be warranted in a population

with many high risk pregnancies,

despite the associated risks. To

19 | P a g e


determine this strategy’s

effectiveness, the procedure’s

potential harm must be compared

with its potential net benefits.

We are interested in the type of

care that produces positive change

in the patient's health or quality of

life. We therefore use treatments

that are known to be effective, for

example, giving a child with

diarrhea Oral Rehydration Salt (ORS)

Efficacy

The potential, capacity, or

capability to produce the desired effect

or outcome, as already shown, e.g.,

through scientific research (evidence-

based) findings.

Efficiency

The relationship between the

outcomes (results of care) and the

resources used to deliver care.

The efficiency of health services is

an important dimension of quality

because it affects product and

service affordability and because

health care resources are usually

limited. Efficient services provide

optimal rather than maximum care

to the patient and community; they

provide the greatest benefit within

the resources available.

Efficiency demands that necessary

or appropriate care is provided.

Poor care resulting from ineffective

norms or incorrect delivery should

be minimized or eliminated. In this

way, quality can be improved while

reducing costs. Harmful care,

besides causing unnecessary risk and

patient discomfort, is often

expensive and time-consuming to

correct. It would be misleading,

however, to imply that quality

improvements never require

additional resources. But by

analyzing efficiency, health program

managers may select the most cost-

effective intervention.

Efficiency is the provision of high

quality care at the lowest possible

cost. We are expected to make the

best use of resources and avoid

waste of our scarce resources. We

waste resources by : prescribing

unnecessary drugs stocking more

drugs than is required and making

them expire buying supplies and

equipment we do not use What

happens when we stock more drugs

than is required?

Respect and Caring

The degree to which those

providing services do so with sensitivity

for the individual's needs, expectations,

and individual differences, and the

degree to which the individual or a

designee is involved in his or her own

care decisions.

Safety

The degree to which the risk of an

intervention ... and risk in the care

environment are reduced for a

patient and other persons including

health care practitioners.

As a dimension of quality, safety

means minimizing the risks of

20 | P a g e


injury, infection, harmful side

effects, or other dangers related to

service delivery. Safety involves the

provider as well as the patient.

For example, safety is an important

dimension of quality for blood

transfusions, especially since the

advent of AIDS. Patients must be

protected from infection, and

health workers who handle blood

and needles must be protected by

safety procedures.

Additional safety issues related to

blood transfusions include

maintaining aseptic conditions and

using proper techniques for

transfusing blood. While safety may

seem most important when complex

clinical services are provided, there

are safety concerns in the provision

of basic health services as well.

For example, health center waiting

rooms can put clients at risk of

infection from other patients if risk-

reducing measures are not taken. If

a health worker does not provide

proper instruction on the

preparation of oral rehydration

solution (ORS), a mother may

administer to her child ORS

containing a dangerously high

concentration of salt.

Safety means that when providing

health services, we reduce to the

barest minimum injuries, infections,

harmful side effects and other

dangers to clients and to staff. In

providing quality care, we should

not put the patient's life at risk. For

example, we should not give unsafe

blood to patients and thereby infect

them with HIV/AIDS.

Timeliness

The degree to which needed

care and services are "provided to the

patient at the most beneficial or

necessary time.

Amenities:

Amenities refer to the features of

health services that do not directly

relate to clinical effectiveness but may

enhance the client’s satisfaction and

willingness to return to the facility for

subsequent health care needs.

Amenities are also important because

they may affect the client’s

expectations about and confidence in

other aspects of the service or product.

Where cost recovery is a consideration,

amenities may enhance the client’s

willingness to pay for services.

Amenities relate to the physical

appearance of facilities, personnel, and

materials; as well as to comfort,

cleanliness, and privacy. Other

amenities may include features that

make the wait more pleasant such as

music, educational or recreational

videos, and reading materials. While

some amenities -- clean, accessible

restrooms; and privacy curtains in

examination rooms -- are considered

luxuries in most LDC health care

settings, they are nevertheless

important for attracting and retaining

clients and for ensuring continuity and

coverage.

21 | P a g e


These are features that can be

provided by our health facilities to

make life comfortable and pleasant for

clients. They contribute to clients'

satisfaction and make clients willing to

use our services. For example,

comfortable seats, television set,

music, educational materials,

educative video films, etc. at the OPD

and wards.

Interpersonal Relations:

The dimension of interpersonal

relations refers to the interaction

between providers and clients,

managers and health care providers,

and the health team and the

community. Good interpersonal

relations establish trust and credibility

through demonstrations of respect,

confidentiality, courtesy,

responsiveness, and empathy. Effective

listening and communication are also

important. Sound interpersonal

relations contribute to effective health

counseling and to a positive rapport

with patients. Inadequate interpersonal

relations can reduce the effectiveness

of a technically competent health

service. Patients who are poorly

treated may be less likely to heed the

health care provider’s

recommendations, or may avoid

seeking care.

It refers to the relationship between us

and our clients and communities,

between health mangers and their

staff. We should: show respect to our

clients; feel for our patients; not be

rude or shout at them; not disclose

information we get from patients to

other people. These will bring about

good relations and trust between the

clients/communities and us. Clients

consider good interpersonal

relationship as an important component

of quality of care.

Q. The "appropriateness" of care

is:

a. primarily a focus of utilization

management

b. a key dimension of quality care.

c. equivalent to "case management”.

d. the degree to which healthcare

services are coherent & unbroken.

Q. A medication is ordered for a

diabetic patient its capacity to

improve health status, as a dimension

of quality or performance, is its:

a. effectiveness.

b. potential.

c. appropriateness.

d. efficacy.

Q. That dimension of quality/

performance that is dependent upon

evaluation by the recipients and/ or

observers of care are:

a. respect/caring.

b. safety.

c. continuity.

22 | P a g e


d. availability.

Q. If, in the continuous quality

improvement process, we increase

our emphasis on customer satisfaction

and outcomes of care, which two

dimensions of quality/improvement

must be incorporated into all quality

management activities?

a. availability and respect/caring.

b. respect/caring and competency.

c. effectiveness and respect/caring.

d. continuity and competency.

Quality Management Trilogy

• Quality Planning

• Quality Control

• Quality Improvement

Quality Planning includes:

• Identifying and tracking

customers, their needs and

expectations.

• Designing new or redesigning

systems, services, or functions

based on customer needs and

expectations.

• Identifying function and process

issues critical to effective

outcomes; and developing new

processes capable of achieving

the desired outcome.

• Setting quality improvement

objectives based on strategic

goals.

Quality Control/Measurement

includes:

• Developing process and

outcome performance

measures.

• Measuring actual

performance and variance

from expected.

• Summarizing data and

performing initial

assessment/ analysis.

• Measuring and describing

process variability.

• Measuring and tracking

outcomes of populations.

• Performing intensive

assessment as data dictates.

• Providing accurate, timely

feedback.

• Using the data to manage,

evaluate effectiveness,

maintain Quality

Improvement gains, and

facilitate Quality Planning.

Quality Improvement includes:

• Collaboratively studying and

improving selected existing

processes and outcomes in

governance, management,

clinical, and support activities;

• Analyzing causes of process

failure, dysfunction, and/or

inefficiency;

23 | P a g e


• Systematically developing

optimal solutions to chronic

problems;

• Analyzing data/information for

better or best practice.

Q.The Quality Management Cycle,

based on Juran's Quality Trilogy

(quality planning, quality control,

quality improvement)

a. excludes the lab's activities to

monitor equipment.

b. requires a departmentalized

approach to quality management.

c. encompasses only the non clinical

aspects of QM.

d. incorporates information from

strategic planning.

Q. That function in the Juran Quality

Management Cycle that includes the

initial analysis of data/information is

a. quality planning.

b. quality initiatives.

c. quality control/measurement.

d. quality improvement.

Quality Management Principles

• Leadership commitment is the Key.

• Focus on systems not on individuals.

• All decisions are based on

information derived from reliable

data.

• Quality is what is perceived by the

customer as quality.

• Quality management is preventive

and proactive not reactive or a

quick fix.

• Quality empowers people; it does

not police them.

• The modern approach to quality is

thoroughly grounded in scientific

and statistical thinking.

• Total employee involvement is

critical.

• Sound customer-supplier

relationships are absolutely

necessary for sound quality

management.

• Productive work is accomplished

through effective structure and

efficient processes.

• Defects in quality come from

problems in processes.

Understanding the variability of

processes is a key to improving

quality.

• Quality measurement should focus

on the most vital processes.

• Poor quality is costly.

Q.The major difference between

traditional "quality assurance"

activities and the expanded quality

improvement/performance

improvement activities is the QI/PI

focus on

24 | P a g e


a. people and competency.

b. analysis of data.

c. performance measures.

d. systems and processes.

Q. In the transition from quality

assurance to quality

management/quality improvement,

which of the following emphases has

resulted in the most significant

benefit?

a. Focusing primarily on process rather

than individual performance

b. Focusing on organization wide rather

than clinical processes

c. Organizing activities around patient

flow rather than department or

discipline

d. Initiating more prospective rather

than retrospective improvement efforts

PARTS OF THE QUALITY SYSTEM

Organization, Personnel, Equipment,

Process, Purchasing, Control,

Information (QC & EQA) & Inventory &

Specimen Management, Management of

Documents, Occurrence Management,

Assessment & Records, Process

Customer Facilities & Improvement

Service Safety CDC.

A. INPUT:

These are materials needed to provide

care. Examples include staff, drugs,

buildings and equipment. Input is what

we invest inputs are the various needs

and resources that projects can draw

upon as it sets out to accomplish its

work. Inputs include resources like

manpower, data, and money and

materials. Adequate buildings and

working space.

•Necessary equipments always

available and functioning

•Necessary medications and medical

supplies always available personnel

•Anybody who touches the patient or a

relevant process in the system:-

Departments, physicians, clerks,

pharmacy, nursing, OT, ICU, care

technicians, phlebotomist, patient

transport, administration

B. PROCESS: Process is the ensemble

of activities of planning, implementing

and monitoring the performance of an

activity. Process manipulates the inputs

to get the output. It includes functions,

actions, and operations. Process

management is the application of

knowledge, skills, tools, techniques,

and systems to define, visualize,

measure, control, report and improve

processes with the goal to meet

customer requirements.

All those affecting relevant aspects of

patient care:-Clinical decision making,

order writing, admission intake,

medication delivery, direct patient

care, discharge planning,

communication, discharge follow-up,

etc.

25 | P a g e


This refers to what is done and the way

things are done. An example is the

activities for outpatient care. The

patient has to make a card, go to the

screening table for his/her temperature

and blood pressure to be taken. He/she

then goes to the consulting room after

which he/she goes to the dispensary for

drugs.

C. OUTPUT: Outputs are the results of

processes, which include products,

information, and reports. It

disseminates (output) data and

information and provides a feedback

mechanism to meet an objective.

Outputs are the results of processes.

•Which are the end result of the

process:- Physiologic parameters,

(Meeting standards )functional status,

(Efficiency, Effectiveness, Quality)

Structure, Process, and Outcome

Structure: is the arrangement of parts

of a care system or elements that

facilitate care; the care environment;

evidence of the organization's ability to

provide care to patients, e.g.:

• Resources

• Equipment

• Numbers of staff

• Qualifications/credentials of

staff

• Work space

Process: refers to the procedures,

methods, means, or sequence of steps

for providing or delivering care and

producing outcomes. In other words,

processes are activities that act on an

"input" from a "supplier" to produce an

"output" for a "customer" e.g.

• Clinical Processes

• Care Delivery Processes

• Administrative and Management

Processes

Outcome: refers to the results of care,

adverse or beneficial. It is the Impact

of a process. This is the end result of

the output Patient satisfaction Cost.

It is the Impact of a process.

•It may be a level of performance, or

achievement.

•It may be associated with the process,

or the output.

Outcomes imply quantification of

performance.


performance.

It may include cost reduction,

Product appreciation or client

satisfaction.

The outcome may be Short Term

(learning: awareness, knowledge,

skills, motivations) Medium Term

(action: behavior, practice,

decisions, policies) Long Term

(consequences: social, economic,

environmental etc.)

26 | P a g e


•It may be a level of performance, or

achievement.

•It may be associated with the process,

or the output.


performance.


performance.

It may include cost reduction,

Product appreciation or client

satisfaction.

The outcome may be:- Short Term

(learning: awareness, knowledge,

skills, motivations) Medium Term

(action: behavior, practice,

decisions, policies) Long Term

(consequences: social, economic,

environmental etc.)

e.g.

Clinical:

• Short-term results of specific

treatments and procedures

• Complications - Adverse events -

Mortality

Functional:

• Long-term health status

• Activities of daily living (ADL) status

Perceived:

Patient/family satisfaction

It is the results we get out of health

service delivery. For example, is the

client satisfied with the service he/she

gets after visiting our facility? Has

there been a decrease in outpatient

attendance?

Answers to the two questions are

indications of output/ outcome of our

health service delivery

Q. Monitoring the specific

organization and content

requirements of a medical record

system is a review of which focus?

a. Outcome of care

b. Process of care

c. Structure of care

d. Administration of care

Q. Monitoring phlebitis associated

with IV insertions by nurses in the

Surgical Intensive Care Unit addresses

which focus?

a. Outcome of care

b. Process of care


d. Administrative procedure

Q. Which of the following best

describes the successful outcome of

the quality improvement process?

a. Customer satisfaction

b. Enhanced communication

c. Employee empowerment

d. Improved statistical data

27 | P a g e


Q. What is the most important

relationship between structure,

process, and outcome as types of

indicators of quality?

a. Interdependent: Structure directly

affects both process and outcome.

b. Causal: Structure leads to process

and process leads to outcome.

c. Relational: Useful for comparisons,

but not causal

d. There is no relationship; they are

categories used to group indicators.

Q. Review of the timeliness of high

risk screening for diabetes addresses

which focus?

a. Outcome of care

b. Process of care


d. Administrative procedure

Seven Pillars of Quality

1. Efficacy

This deals with a controlled

environment and examines what is

possible. It sets an upper boundary for

quality and establishes the ideal to

which all should aspire. However, as we

know, the real world is very different

to the laboratory. It is likely that the

less control that is exerted over the

environment; the less probable it is

that practitioners are able to meet

these standards.

2. Effectiveness

The second pillar of quality is

"effectiveness" i.e. to what extent does

the service achieve its intended

outcomes in a real world environment?

Social, economic and individual factors

influence the selection of quality

indicators. Various indicators have been

developed such as cost effective,

socially effective and individually

effective although the way in which

they are measured is not always

universally agreed.

3. Efficiency

The third pillar of quality is

"efficiency". This examines the extent

to which scarce resources are used to

derive the greatest benefits with the

least waste. This is usually measured by

examining the ratio between the costs

and benefits of a service and comparing

these with others who are providing the

same or similar services. This measure

is typically used by socio-economic

forces seeking to select a service which

will result in reduced costs. The

assumption is made that the benefit

stays the same, an assumption that is

frequently not tested.

4. Acceptability

The fourth pillar is acceptability. This

concentrates on the usefulness of the

service to the patient and its perceived

impact on his/ her quality of life. It

takes into consideration patient

preferences regarding access to the

service (e.g. advice), relationship with

health service providers (egg trust,

28 | P a g e


confidentiality), the amenities in which

the service is provided and the cost

utility relationship.

5. Optimality

The fifth pillar is optimality. From the

point of view of society and the

economic system, it is necessary to

ensure that the optimum allocation of

resources is achieved relative to the

benefits derived from the services

provided. Techniques such as cost

benefit analysis and marginal costing

are used to identify the optimum point

of resource allocation: benefits.

Quality indicators are usually of a

global socio-economic nature. Neither

the individual service provider nor

patient is concerned with these

indicators. However, data collection

starts at the interface between the two

and these desires for maximal rather

than optimal benefits may adversely

influence the selection of appropriate

indicators.

6. Equity

The sixth pillar is equity. Society is

concerned that every person should

receive equal treatment, or at best fair

treatment. Equity is compromised when

the quality of service or even the range

of services is determined by the

patient's ability to pay for the service.

Since third party payers play a

significant role in the health care

system, equity would be affected by

the extent to which a third party payer

includes a fee for the service in the

benefits that it offers it members.

7. Legitimacy

The seventh and final pillar is

legitimacy. This is similar to the

concept of acceptability except that

"the preferences and values for

legitimacy are expressed through a

societal rather than an individual

perspective". Clearly, society requires

evidence upon which to make these

judgments.

The Concept of Process Variation

Variation is "change or deviation in

form, condition, appearance, extent,

etc., from a former or usual state, or

from an assumed standard." "Variation"

generally refers to the whole process or

a step in the process.

Variance is "a changing or tendency to

change; degree of change or

difference; divergence; discrepancy."

This term generally refers to specific

data or information.

Clinical Variation

• Variation in clinical practice has

been defended in the past as the

"art" of medicine.

• In fact, variation can be either

positive or negative.

• In healthcare quality, we tend to

think of variation as negative or

adverse, based on the quality

assurance case-specific review

tradition.

• Sometimes the art of medicine

creates a "best practice," which

we now try to capture and

29 | P a g e


replicate as part of quality

improvement process.

Process Variation

1. Common Causes

Random or common cause:

• Intrinsic to the process itself;

• naturally occurring inliers.

“Example: patient response to

medication will always vary, within the

cohort of patients and even for one

patient over time.”

• Common causes" refer to situations,

usually within patient care systems

and processes (within the normal,

bell-shaped curve) that are more

ongoing, chronic, and persistent.

• These common causes contribute to

the "normal range of variation"

within a process.

• The goal of quality improvement is

not to eliminate, but to reduce

variation in a process enough to

produce and sustain "stability. “

• Common causes may also contribute

to what are considered to be the

less than desirable parts of a

process.

• Usually finding and resolving

common causes of problems or

variation is more time-consuming

and may be more difficult for

departments, services,

• The resolution of common causes of

problems is often considered to be

key, however, to continuous,

incremental improvement of the

quality of care and services

rendered to patients

2. Special Cause

• Extrinsic to the usual process;

• related to identifiable patient

or clinical characteristics,

• Idiosyncratic practice patterns,

or other factors that can be

tracked ("assigned") to root

causes.

• "Special causes" refer to sentinel

events, one-time occurrences, or

other unique, out-of-the-

ordinary circumstances that give

rise to a variation from what is

normally expected.

• Special causes are usually more

easily identified and resolved,

either by departments or QI

teams.

• Special causes account for the

majority of what we call

"outliers"-those problems that

occur in the "tails" of a normal,

bell-shaped curve representing a

particular process.

Statistical Process Control

• Walter Stewart’s causes of

variation led him to develop a

methodology to chart the

process and quickly determine

when a process is "out of

control.

30 | P a g e


• This ongoing measurement and

analysis is known as "statistical

process control (SPC)."

• As long as assignable or special

causes of variation exist, we

cannot make accurate

predictions about process

performance and probable

outcome.

• Once assignable causes are

eliminated, we can call the

process "stable" and can measure

the "capability of the process" by

rates of deficiencies or rates of

achievement of desired

outcomes.

• At this point we have the data

we need to perform the in-depth

analysis that leads to

improvement.

The Pareto Principle:

Prioritizing Variation

• Joseph Juan noted that

approximately 80% of observed

variation in processes was

generally caused by only 20% of

the process inputs.

• He called this phenomenon the

"Pareto Principle,"

• The "80%" and "20%" are relative

figures, representing

relationship, not absolute

calculations.

• In prioritizing for quality

improvement, it makes sense to

identify and focus on those 20%

of process issues that make up

80% of the variation.

Juran calls this prioritized 20% the

"vital few.

Examples of application of the

Pareto Principle

• 20% of the possible reasons for

dissatisfaction with an ambulatory

clinic are responsible for 80% of the

recorded dissatisfaction on the

survey, enabling the QI team to

prioritize improvement efforts..

• 80% of a physician's practice or a

hospital's admissions is accounted

for by 20% of the classes of

diagnoses providing a focus for

practice guidelines and disease

management..

• 20% of a healthcare organization's

patients account for 80% of the case

managers' time, again providing

data for prioritizing the

development of clinical paths and

disease management protocols.

Q. "Common causes" of problems in

processes refer to?

a. one-time situations.

b. temporary situations.

c. acute situations.

d. chronic situations

Q. Applying the Pareto Principle in

quality improvement is?

31 | P a g e


a. prioritizing process issues.

b. tracking and measuring process

effectiveness.

c. providing meaningful data to support

strategic objectives.

d. prioritizing patient outcome issues.

Q. Special cause variation is to the

process?

a. random, extrinsic, outlier.

b. assignable, intrinsic, noise.

c. random, inlier, identifiable.

d. assignable, extrinsic, outlier.

Q. When common cause process

variation is identified, the goal of

quality improvement is to

a. promote compliance with

established procedure or protocol.

b. eliminate the variation.

c. improve practitioner competency.

d. reduce variation sufficiently to

produce stability.

Q. After first describing the problem,

the best way to look at "patterns of

behavior" over time is to use?

a. storytelling and "The Five Whys."

b. brainstorming and constructing gap

hypotheses.

c. line graphs and story telling.

d. Pareto charts and brainstorming.

Q. In statistical process control, it is

important to first?

a. eliminate assignable causes of

variation.

b. eliminate random causes of

variation.

c. prioritize causes of variation.

d. eliminate all causes of variation.

The Concept of Outcomes

Management

• “Outcomes Management" refers to a

"technology of patient experience

designed to help patients, payers,

and providers make rational

medical care-related choices based

on better insight into the effect of

these choices on the patient's life"

[Ellwood, 1988].

• The resulting data, called outcome

measures, are measures of

performance.

Outcomes management should consist

of

• A common language of health

outcomes, understood by patients

• A national reference database

containing information and analysis

on clinical, financial, and health

outcomes, estimating:-

• Relationships between medical

interventions and health outcomes

• Relationships between health

outcomes and money spent.

32 | P a g e


• Opportunity for decision-makers to

access analysis relevant in making

choices.

Outcomes management depends on

the following four developing

techniques

1. Practitioner reliance on standards

and guidelines in selecting

appropriate interventions

2. Routine and systematic

measurement of the functioning and

well-being of patients, along with

disease-specific clinical outcomes,

at appropriate time intervals

3. Pooling of clinical and outcome data

on a massive scale

4. Analysis and dissemination of results

(outcomes) from the segment of the

database pertinent to the concerns

of each decision maker

Q. The task of setting up an

ambulatory care setting QM/QI

program that focuses on "outcomes"

as a measure of treatment

effectiveness is difficult because:?

a. the patient remains in control of

treatment.

b. patient care outcomes are

determined by the payer.

c. there are no required medical

records.

d. expected outcomes for ambulatory

conditions are too obvious.

Q. The centerpiece of "outcomes

management" in healthcare is?

a. the measurement of the patient's

functionality and quality of life.

b. morbidity and mortality.

c. data reliability.

d. financial impact.

System Thinking

• A body of principles, methods, and

tools focused on the

interrelatedness of forces in systems

operating for a common purpose.

• The belief that the behavior of all

systems follows certain common

principles, the nature of which can

be discovered, articulated,

understood, and used to make

change.

• According to David Mc Camus,

former chairman and CEO of Xerox

Canada, systems thinking "requires

'peripheral vision': the ability to pay

attention to the world as if through

a wide-angle, not a telephoto lens,

so you can see how your actions

interrelate with other areas of

activity"

Definitions

• System: perceived whole whose

elements 'hang together' because

they continually affect each other

over time and operate toward a

common purpose"

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• Systemic structure: Not just the

organizational chart, but the

pattern of interrelationships among

all key components of the system:

• Process flows

• Attitudes and perceptions

• Quality of products and services

• Ways in which decisions are made

• Hierarchy, and

• Systemic structures may be visible

or invisible, built consciously or

unconsciously based on choices and

decisions made over time.

• Interrelationships are discovered by

asking the question: "What happens

if it (process, perception, attitude,

task, etc.) changes?"

Steps in Systems Thinking

1. Describe the problem (one that

is chronic limited in scope, with

a known history) as accurately as

possible, without jumping to

conclusions.

2. Tell the story; build the model,

providing as many divergent

ideas as possible.

3. Ask the question: "How did we-

through our thinking, processes,

practices, procedures-contribute

to or create the circumstances,

good and bad, that we now face?

4. Look for causality:-causal

relationships between events or

patterns of behavior

5. Apply an "Archetype" or pattern

of performance to fill in gaps in

thinking and construct consistent

hypotheses about the governing

forces in systems.

6. Determine strategies for solution

and their ramifications.

7. Redesign the system. You know

you have a good intervention

when you can see the long-term

pattern of behavior shift

qualitatively

Customer Satisfaction

• Customer/supplier Relationships

• Customer needs & expectations

• Measurable characteristics of the

process agreed to

Guiding principles of good customer

service

Identify Customers

Internal

• Nursing

• Pharmacy

• Laboratory

External

Patients

Physicians

Community

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Regulatory

Payers

Tools Used To Identify Customers &

Their Needs

• Identify Customers:

• Wheel & Spoke” “Sundial”

• Customer lists by type e.g. internal

& external

• Customer lists by categories e.g.:

• Patients & families

• Practitioners / clinicians

• Suppliers / Vendors

• Provider organizations ….etc

• Identify Customer needs:

• Surveys

• Assigned interviews

• Focus groups

• Research

Brainstorming

Guiding Principles of Good Customer

Service

• Pay attention to your customer's

needs; a successful, long-term

relationship with your customer

is built day by day

• Own your customer's problem as

if it were your problem

• Be courteous to your customer

• Be positive about all aspects of

your relationship with your

customer

• Show through every action that

your customer is important to

you

• Distinguish your product or

service through the quality of its

delivery to the customer

• Turn a loss into a win by

providing prompt and courteous

attention to your customer when

your product or service fails;

remedy the situation through

effective service

• Look at all situations through the

eyes of your customer, see your

product or service as if for the

first time

• Every job, with all its tasks,

decisions, and responsibilities, is

important, since every action

affects the customer

• Only the customer's perception

of your product or service counts

for quality

Quality Assurance in Health care

Quality assurance is a range of

activities (including review, evaluation,

surveillance, and appraisal and

monitoring) which collectively comprise

the intelligence gathering arm of

quality assurance.

These are:

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Quality consists of doing those things

necessary to meet & exceed the needs

& expectations of those we serve &

doing those right things right every

time.

Review is the process of critical

reflection used by clinicians wishing to

assess their own (or their peers)

performance

Audit is the activity of review when

conducted on a continuous and routine

basis.

Evaluation is one-off assessment of

the impact of a service on indices of

health

Surveillance is routinely repeated

evaluation

Appraisal is ad hoc data collection and

analysis by management in relation to

health care delivery

Monitoring is ongoing appraisal

Components of Quality Care:

Safe

Effective

Patient Centred

Efficient

Equitable

Timely

Quality Assurance is that set of

activities that are carried out to

previously Set Standards to

monitor and improve

Performance so that the care

provided is as effective and as

safe as possible.

Component of Quality

Management that ensures the

Right things are being done-

based on Standards and

Established Goals.

Systematic Process of checking if

a Healthcare Service is meeting

Specified Requirements

Helps reduce waste and

unnecessary activities and

improve Service Delivery

Dr. Donabedian broadly defines

it as all the arrangements and

activities that are meant to

safeguard, maintain, and

promote the quality of care.4

Drs. Ruelas and Frenk, who have

conducted extensive QA work in

Mexico, define it as a systematic

process for closing the gap

between actual performance and

the desirable outcomes. . . .

According to Dr. Heather

Palmer, a QA expert in U.S.

ambulatory care, it is a process

of measuring quality, analyzing

the deficiencies discovered, and

taking action to improve

performance followed by

measuring quality again to

determine whether improvement

has been achieved. It is a

systematic, cyclic activity using

36 | P a g e


standards of measurement.6 Dr.

Donald Berwick, a U.S.-based

clinician, is working to apply

principles of continuous quality

improvement (CQI) to health

services. This approach to QA is

an integrated organizational

approach for meeting client

needs and expectations involving

both management and staff

while improving processes and

services using quantitative

techniques and analytical tools.

According to Berwick, it is . . . a

systematic managerial

transformation designed to

address the needs and

opportunities of all organizations

as they try to cope with

increasing change, complexity

and tension within their

environments.

Quality Assurance is a set of

activities that are planned for,

carried out systematically or in

an orderly manner and

continuously to improve quality

of care. It involves: The setting

of standards? Monitoring to see if

there is a gap between what is

being done now and what is

expected; and addressing the

gap on a regular basis (quality

improvement).

Quality Assurance encourages

health workers to examine the

services they provide, assess

their own work and come out

with what they can do with the

limited resources to improve the

quality of care. For supervisors

and managers, QA calls for

change from the status of an

inspector to that of a facilitator,

and expects the health workers

to identify and solve problems.

Quality Assurance also requires

that health workers understand

the needs of patients and their

communities in order to provide

for them. Quality Assurance

requires active support and

commitment from leaders at the

national, regional, district, sub-

district levels and in the health

facilities.

In essence, quality assurance is

that set of activities that are

carried out to set standards and

to monitor and improve

performance so that the care

provided is as effective and as

safe as possible.

After 1985, WHO and several

projects such as PRICOR and

CCCD began using systems

analysis and facility assessments

to assess the quality of care.

Quality Assessment Methods

System Performance

Health Priorities, System Planning,

Financing and Resource Allocation done

at National Level & Global Level.

General Environment of the Country,

Legislation & Other Regulatory

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Mechanisms, Professional Recognition

and Overall Quality Management.

Institutional and Clinical

Performance

External Assessment

ISO, Accreditation, Licensing,

EFQM, Peer Review

Internal Self-assessment

Patients Rights, Risk Management,

Clinical Governance, Clinical Audit,

Performance Indicators &

Benchmarking

4 Tenets of Quality Assurance:

• Oriented toward meeting the

needs and expectations of the

Patients and other Users.

• Focused on systems and

processes.

• Use data to analyse service

delivery processes.

• Encourage a team approach to

Problem Solving and Quality

Improvement.

Developments in Quality

Assurance:

• 1859- Florence Nightingale

introduced the first standards in

nursing care during the Crimean

War

• 1913-American College of

Surgeons(ACS)- Minimum

Standards for Hospitals

• 1951-Joint Commission- ACS ,

American College of Physicians,

American Hospital Association,

Canadian Medical Association,

American Medical Association

1966-Avedis Donabedian-

‘Evaluating the Quality of

Medical Care’

Structure| Process | Outcome

1998- International Society for

Quality in Healthcare (ISQUA)

ALPHA Program

2004-WHO- World Alliance for

Patient Safety

Quality: Degree of the realisation

of the reasons that the Patient has

come to the care hospital e.g.

patient comes to Hospital for an

Operation.

Safety: Results which are not the

reasons for the Patient coming e.g.

‘not catching an infection’ and he is

implicitly confident he will not run

the risk of this happening.

Quality Improvements:

Hospitals have taken steps to

reduce medical errors and injuries.

Examples:

Computerized prescriptions: 81%

decrease in errors.

Including pharmacist in medical

team: 78% decrease in

preventable drug reactions.

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Team training in delivery of

babies: 50% decrease in harmful

outcomes such as brain damage

in premature deliveries.

Source: Journal of the American

Medical Association

Classification of Medical Errors-

Near Miss: is defined as an act could

have harmed the patient but did not do

so as a result of:

Chance e.g. patient received a

contraindicated drug but did not

experience an adverse drug reaction

Prevention e.g. a potentially lethal

over-dose was prescribed, but a nurse

identified the error before

administering the medication

Mitigation e.g., a lethal drug overdose

was administered but discovered early

and countered with an antidote.

Adverse Events cause harm to

patients—causing a large number of

injury, disability, and death.

Errors of Commission

• Prescribing a medication that

has a potentially fatal

interaction with another drug

the patient is taking.

Errors of Omission

• Failing to prescribe a medication

from which the patient would

likely have benefited, which may

pose an even greater threat to

health?

Why Do Errors Occur—Some Obstacles

Workload fluctuations

Interruptions

Fatigue

Multi-tasking

Failure to follow up

Poor handoffs

Not following protocol &

standard operating procedures

Poor Leadership

Breakdown in Communication

Breakdown in Teamwork

Losing track of Objectives

Excessive professional courtesy

Complacency

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High-risk phase

Task (target) fixation

Team Strategies & Tools to

Enhance Performance & Patient

Safety

Quality Assurance ensures Safety by

assessing:

Adverse Event Reporting

Patient Safety Culture

Leadership Support of Patient

Safety

Adverse Event Analysis

Adverse Event Prevention

Communication and Feedback

Patient Involvement in Care

Environment of Care

Accreditation Standards:

Hospital has a Patient Safety

Program

Hospital Risk Management

Program

Specific Prevention Programs

Transfusion Safety Program

Procedures for identifying

Patients Correctly

Conducts Periodic Patient Safety

Training

Effective Communication

Techniques

Ensures Safety of High-Alert

Medications

Ensures Correct-Site, Correct-

Procedure, Correct-Patient

Surgery

Procedures for reducing Health

Care–Associated Infections

Hand Hygiene Standards

Reduce Patient Harm Resulting

from Falls

Conducts Risk Management &

Infection Prevention for

Healthcare Professionals

Hospital has Procedures for

handling, storage, preparation &

distribution of foodstuffs

Ensures Radiation Safety.

Ensures Injection Safety.

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Principles of Quality Assurance

There are five basic principles of

quality assurance. These principles, as

stated below, clearly show what QA is

intended for.

1. Quality Assurance is oriented

towards meeting the needs and

expectations of our clients 2. Quality

Assurance focuses on systems and

processes 3. Quality Assurance uses

data to analyze service delivery 4.

Quality Assurance encourages the use

of teams in problem solving and quality

improvement 5. Quality Assurance uses

effective communication to improve

service delivery

The Four Tenets of Quality Assurance

s

Quality Assurance is oriented toward

meeting the needs and expectations

of the patient and the community.

Quality assurance requires a

commitment to finding out what

patients and the community need,

want, and expect from the health

services. The health team must work

with communities to meet service

demand and to promote acceptance of

needed preventive services.

Subsequent program planning and

quality improvement efforts should be

evaluated according to these needs and

expectations. Quality assurance also

requires that health workers’

professional needs and expectations be

met.

Quality assurance focuses on

systems and processes. By focusing on

the analysis of service delivery

processes, activities, and tasks as well

as outcomes, quality assurance

approaches allow health care providers

and managers to develop an in-depth

understanding of a problem and to

address its root causes. Rather than

merely treating the symptoms of a

quality-related problem, quality

assurance seeks to find a cure. In the

advanced stages of a QA program, the

health center team can go even further

by analyzing processes to prevent

problems before they occur.

Quality assurance uses data to

analyze service delivery processes.

Simple quantitative approaches to

problem analysis and monitoring are

another important aspect of quality

improvement. Data-oriented methods

allow the QA team to test its theories

about root causes; effective problem

solving should be based on facts, not

assumptions.

Quality assurance encourages a team

approach to problem solving and

quality improvement.

Participatory approaches offer two

advantages. First, the technical

product is likely to be of higher quality

because each team member brings

unique perspective and insight to the

quality improvement effort.

Collaboration facilitates a thorough

41 | P a g e


problem analysis and makes

development of a feasible solution

more likely. Second, staff members are

more likely to accept and support

changes that they helped to develop.

Thus, participation in quality

improvement builds consensus and

reduces resistance to change.

If an organization desires a

comprehensive approach, a QA

initiative can be developed as a

component of a general management

improvement effort or a total quality

management system.

The Quality Assurance Process

Some U.S. models include the quality

assurance cycle used by Palmer in

ambulatory care settings; the 10-step

process developed by the Joint

Commission on Accreditation of Health

Care Organizations; and CQI which

applies total quality management to

health services. The QAP quality

improvement model attempts to

integrate the strengths of the various

models into a simple, logical process

for planning and implementing QA

activities. Consistent with earlier

models, QAP’s quality improvement

model defines norms, conducts an

assessment, works with health care

providers in a participatory fashion,

takes action based on the assessment,

and monitors results. Perhaps most

important, it puts forth a replicable

process for improving the quality of

health care service delivery. This

process can, over time, be integrated

into ongoing program management.

QAP's Quality Assurance Process

In practice, QA is a cyclical, iterative

process that must be applied flexibly to

meet the needs of a specific program.

The process may begin with a

comprehensive effort to define

standards and norms as described in

Steps 1-3, or it may start with small-

scale quality improvement activities

(Steps 5-10). Alternatively, the process

may begin with monitoring (Step 4).

Some teams may even choose to

simultaneously begin in two places. For

instance, comprehensive monitoring

and focused problem solving may start

as a coordinated, parallel effort.

1. Planning for Quality Assurance:

This first step prepares an organization

to carry out QA activities. Planning

begins with a review of the

organization’s scope of care to

determine which services should be

addressed. For most organizations, it is

impossible to improve quality in all

areas at once. Instead, QA activities

are initiated in a few critical areas.

High-priority, high-volume, or problem-

prone services are often selected for

special attention at the start of a QA

program. Once organizational leaders

have decided where the QA effort will

begin, they must select a quality

improvement approach. They may

focus on monitoring desired or adverse

outcomes, or they may study service

delivery and support processes to

determine areas for improvement.

Another component of planning is

assigning responsibilities for the QA

42 | P a g e


activities. This may entail forming a QA

committee or an ad hoc team

responsible for initial QA activities. If

the program mission is unclear or

unresponsive to community needs, or if

overall planning in an organization is

weak, in-depth strategic planning might

be required. Strategic planning begins

with defining the organization’s

mission. The next step is to assess the

opportunities and constraints in the

external environment as well as the

organization’s internal strengths and

weaknesses. Strategic planning

produces a clear vision of what the

organization must do to achieve its

mission in the light of its environment.

The organization can then determine

QA priorities based on the program

mission and vision.

2. Setting Standards and

Specifications

To provide consistently high-quality

services, an organization must translate

its programmatic goals and objectives

into operational procedures. In its

widest sense, a “standard” is a

statement of the quality that is

expected. Under the broad rubric of

standards there are practice guidelines

or clinical protocols, administrative

procedures or standard operating

procedures, product specifications, and

performance standards.

Practice guidelines, sometimes called

clinical protocols or practice

parameters, define how clinical

processes such as antenatal care are

carried out. Guidelines are defined as

“systematically developed statements

to assist practitioner and patient

decisions about appropriate health care

for specific clinical circumstances.”

Administrative procedures,

sometimes

Called standard operating procedures,

define routine nonclinical processes.

Specifications usually pertain to

product characteristics or material

inputs such as drugs or technical

equipment related to health service

delivery.

Performance standards are specific

criteria used to measure the outcome

of service delivery and the activities

that support it. They are also used to

measure compliance with guidelines.

These standards differ from guidelines

or standard operating procedures; they

are designed to evaluate practice

rather than to assist practitioners and

patients. Standards have been defined

as “authoritative statements of (1)

minimum levels of acceptable

performance or results, (2) excellent

levels of performance or results, or (3)

the range of acceptable performance or

results.”

Standards can be related to the care

process by measuring health outcomes

or guideline compliance. While health

outcomes are sometimes difficult and

costly to measure, it is often possible

to monitor intermediate outcomes such

as utilization or coverage in assessing

program effectiveness. Performance

43 | P a g e


standards form the core of the

monitoring system, as discussed in

StEP-4

Guidelines, standard operating

procedures, and performance standards

should be developed for both clinical

and management areas. They should

reflect the perspectives of their com-

munities and health care specialists.

Both perspectives are essential to

ensure the effectiveness of planned

activities and their accessibility and

acceptability to the community.

Program staff should periodically

review and revise guidelines and

standard procedures.

For some programs, setting standards

and specifications involves a simple

review of current guidelines and

standard operating procedures to

ensure that they are up-to-date. For

others, it may be important to develop

consensus among professionals to

ensure support. Others may require

creating new guidelines and standards.

In such cases, some widely accepted

re-sources are available. For example,

WHO helps in defining service delivery

protocols appropriate for health

centers and small hospitals in

developing countries? The PRICOR

Project developed clinical guidelines

for use in primary health care in

developing countries. The PRICOR

Thesaurus sets forth guidelines for

seven child survival services:

immunization, oral rehydration

therapy, prenatal care, family

planning, growth monitoring, treatment

of acute respiratory infections, and

malaria. The project also developed

guidelines in seven management areas:

planning, supervision, training,

logistics, financial management,

management information systems, and

community organization. In sum, the

Thesaurus is a useful reference for

setting standards.

Health workers at all levels should

participate in developing guidelines and

setting standards. Because health

workers often understand local

conditions better than high-level

managers, the resulting guidelines are

likely to be more appropriate and

effective. Also, staff participation will

generate commitment to quality

because health workers are more likely

to implement and support an effort

that they have helped to develop.

Finally, staff members are more likely

to accept QA activities if they have

been involved in defining quality.

Their standards will become the

measure for judging the quality of their

services.

44 | P a g e


Communicating Guidelines and

Standards

Once practice guidelines, standard

operating procedures, and performance

standards have been defined, it is

essential that staff members

communicate and promote their use.

This will ensure that each health

worker, supervisor, manager, and

support person understands what is

expected of him or her. This is

particularly important if ongoing

training and supervision have been

weak or if guidelines and procedures

have recently changed. Assessing

quality before communicating

expectations can lead to erroneously

blaming individuals for poor

performance when fault actually lies

with systemic deficiencies.

Additionally, QA efforts that begin with

a surprise examination are likely to

cause suspicion rather than support.

Managers and the health center team

share a mutual responsibility for

quality; the notion of this partnership

should be communicated along with

guidelines and standards. A dialogue

about guidelines and standards can

take place in the context of

supervision, training, or other

channels. Activities that communicate

guidelines and standards include

developing job descriptions, translating

performance guidelines into job aids,

developing and conducting training

programs, holding formal conferences

or informal presentations about new

procedures, providing on-the-job

training through supervisory activities,

and informing providers of changes in

protocols through administrative

announcements.

Monitoring Quality

Monitoring is the routine collection and

review of data that helps to assess

whether program norms are being

followed or whether outcomes are

improved. By monitoring key

indicators, managers and supervisors

can determine whether the services

delivered follow the prescribed

practices and achieve the desired

45 | P a g e


results. QA involves a new process

orientation that has profound

implications for monitoring and

collecting data in LDCs. Outcome

measures alone, or other service

statistics that are generally part of LDC

monitoring systems, offer limited

Guidance in problem solving. Detailed

assessment of processes through special

comprehensive studies or routine

assessments can provide useful

information about specific service

delivery problems.

The monitoring system is central to a

QA program. Unfortunately, existing

data collection systems in many

developing countries can be difficult to

use for QA. At some point, existing

monitoring systems may require

redesign. However this is not

recommended as an initial activity; it is

likely to be very time consuming and to

meet resistance. It is often better to

involve program staff members in using

data to solve problems (see Steps 5-11)

and to work with them in redesigning

their system.

Designing (or redesigning) a monitoring

system requires translating statements

about expected quality into measurable

indicators. It also demands setting

performance thresholds, selecting

information sources, designing a system

for collecting data and compiling

results, and carrying out monitoring

activities. (Each of these activities is

briefly discussed below.) It is

important to define which data are to

be used at the various levels in the

system. For example, a front-line

supervisor may collect a great deal of

information about service quality and

delivery, but may summarize only some

of this information for higher-level

managers.

Generally, all levels of staff should be

involved in designing a monitoring

system so that everyone receives all

necessary information.

Selecting indicators: An indicator is a

measurable characteristic of actual

system performance that determines

the extent to which desired outcomes

are achieved, or the degree to which

guidelines and standard operating

procedures are adhered. Indicators are

used to monitor the quality or

appropriateness of important clinical

and management activities. It is

unnecessary to choose an indicator for

every standard or specification. The

number of indicators should be

minimized when assessing key

processes and identifying potential

problem areas.

Setting thresholds: Thresholds define

a program’s acceptable performance

levels, as measured by indicators, at a

given point in time. They allow

program staff to detect potential

problems or areas for improvement.

Performance thresholds can be based

on clinical or medical knowledge of

risks or on what is operationally

feasible.

46 | P a g e


For example, some immunization

programs set 80 percent coverage as a

threshold.

The acceptable level of performance is

relative and should be revised as

conditions and priorities change. The

role of thresholds is to trigger action

when the monitored indicators suggest

inadequate program performance.

Performance thresholds are not needed

in all cases and should be set only after

consultation with program staff.

It is important to note the potential

drawbacks of using thresholds in a

quality improvement effort. Rather

than encouraging continual

improvement, using thresholds may

give the mistaken impression that some

errors are acceptable and that, Once

met, there is no need for further

improvement.

In spite of these potential drawbacks,

performance thresholds, used

correctly, can help teams to set

priorities and can promote gradual

improvement.

Selecting information sources:

Because many organizations already

collect data, the first information

source to examine is the existing

information systems. Some-times it is

possible to make a minor change that

would provide information without

major efforts. Other information

sources include suggestion boxes,

complaint registers, clinical records,

health center registers, interviews,

facility review, and job performance

observations. Because monitoring is a

routine exercise, additional data

collection should be kept to a

minimum. It is especially important to

minimize the burden of data collection

on peripheral health workers.

Generally, health workers should not

be asked to collect data that they

cannot use in their work. Data that are

used at the local level and then

compiled for higher-level managers are

more likely to provide a basis for a

constructive dialogue between health

workers and managers about problems

and priorities.

Designing a system for collecting and

compiling data: It is important to

specify who will collect and compile

the data, determine the frequency of

collection and compilation, and

develop a mechanism and schedule for

disseminating the results.

This system should be developed with

staff participation at all levels, and it

should

be periodically reviewed. Over time,

staff members should become adept at

self-

monitoring, relying less on district- and

central-level managers.

Implementing the monitoring

activities:

Once the system has been designed and

responsibility has been assigned, data

collection and compilation can begin.

During the initial phase of a monitoring

system, health workers will need

assistance in collecting and using data.

47 | P a g e


This support is essential if monitoring is

to serve as a screening tool. Rather

than constantly monitoring all

activities, monitoring systems might

use an index of activities or tracer

conditions that cover various program

dimensions. For example, a program

manager could monitor immunization,

hypertension, and treatment of

pneumonia. Together, these tracer

conditions might cover preventive

services and management of chronic

and acute illness, encompassing both

child and adult care. Eventually, the

conditions monitored should be rotated

or modified to meet the community’s

changing needs. They should also

expand with the QA effort.

It is important to limit the monitoring

system by emphasizing the collection

and use of only essential data.

Systems analysis is another assessment

method that can be used to identify

service delivery problems. The service

quality assessment technique originally

applied to LDC primary health care by

PRICOR consists of a comprehensive

assessment of standard procedures and

health worker performance. It is based

primarily on observing actual or

simulated performance.

Such systems analyses can be carried

out as a baseline in identifying and

measuring major problems before a QA

program is launched. They can also be

carried out periodically, in whole or in

part, to evaluate general improvement

and to prove the validity of program

institutionalization.

Identifying Problems and Selecting

Opportunities for Improvement Program

managers can identify quality

improvement opportunities by

monitoring and evaluating activities.

With effective monitoring systems,

health programs can conduct special

community or patient surveys or

comprehensive assessments such as

PRICOR II’s systems analysis

methodology.

These studies highlight specific service

delivery problems requiring attention.

Other means include soliciting

suggestions from health workers,

performing system process analyses,

reviewing patient feedback or

complaints, and generating ideas

through brainstorming or other group

techniques. Employing a participatory

approach to problem identification

offers several advantages. First, the

quality of the assessment and

preliminary analysis is likely to be

superior because those who are directly

involved with the processes are

participating. Second, staff members

are more likely to contribute and to

cooperate if they are involved in

identifying problems.

Once a health facility team has

identified several problems, it should

set quality improvement priorities by

choosing one or two problem areas on

which to focus.

48 | P a g e


Selection criteria will vary from

program to program. Two important

principles should guide this process.

The criteria should reflect team, not

individual, priorities. They should also

be explicit so that the decision-making

process is as objective and as thorough

as possible. Criteria might include the

technical feasibility of addressing the

problem, the potential impact of

improving quality on the population’s

health, or the adequacy of the

necessary available resources.

PRICOR II’s quality improvement work

in developing countries resulted in

some noteworthy insights about priority

setting. First, the problem must be

within the scope of responsibility and

authority of those carrying out the QA

effort. Trying to change something

that is outside local control is a

frustrating experience that has little

hope for success. In the same vein, it

is often preferable to begin QA efforts

by focusing on a smaller, manageable

problem rather than on a large,

complex one. Tackling a solvable

problem encourages confidence in the

QA process.

Teams can select priorities using

various group decision-making

techniques such as ranking and voting

exercises or decision matrices that

consider several criteria in the priority-

setting process.

Defining the Problem

Having selected a problem, the team

must define it operationally--as a gap

between actual performance and

performance as prescribed by

guidelines and standards. The problem

statement should identify the problem

and how it manifests itself. It should

clearly state where the problem begins

and ends, and how to recognize when

the problem is solved.

Developing a problem statement is a

crucial step in the QA process, and its

apparent simplicity is deceptive.

Often, the initial formulation of a

problem will include only the cause of

a problem “we don’t have a

laboratory”--or its premature solution--

“we need more staff.” Sometimes

problems are too general to permit

concrete, incremental action--“we

don’t work as a team.”

Problem statements also may err by

focusing on blame rather than on the

problem description--“nurses are not

willing to be polite to patients.”

Problems should explicitly relate to the

quality of services or the health of the

population. They should refer to

specific processes or activities so that

the improvement effort is well focused

and measurable.

Problem definition is an iterative

process: as team members attempt to

define a problem, they will be forced

to rethink many of their steps. They

may decide to narrow the problem or

49 | P a g e


choose to address one cause of a

multifaceted problem. While defining

a concrete operational problem, team

members are likely to vacillate

between large, unmanageable

problems and the smaller one that they

are trying to define. They may even

feel that the discrete operational

problem they are defining is not worth

addressing because it is such a small

part of the wider problem. It is

important for a team to take the time

to develop clarity about the Problem

and consensus about its importance.

Without these ingredients, the QA

effort will stall.

Choosing a Team

Once a health facility staff has

employed a participatory approach to

selecting and defining a problem, it

should assign a small team to address

the specific problem.

The team will analyze the problem,

develop a quality improvement plan,

and implement and evaluate the

quality improvement effort. The team

should comprise those who are involved

with, contribute inputs or resources to,

and/or benefit from the activity or

activities in which the problem occurs.

This ensures the involvement of those

most knowledgeable about the process.

Learning to work effectively as a team

is a challenging and continuous process.

Health center teams often will need

training in basic skills related to

planning and facilitating meetings,

communicating effectively, making

group decisions, and resolving conflict.

Building a high performance team takes

time, requiring patience and

persistence.

Analyzing and Studying the Problem

to Identify the Root Cause

Achieving a meaningful and sustainable

quality improvement effort depends on

understanding the problem and its root

causes. Given the complexity of health

service delivery, clearly identifying

root causes requires systematic, in-

depth analysis.

Analytical tools such as system

modeling, flow charting, and cause-

and-effect diagrams can be used to

analyze a process or problem. (See box

below.) Once several potential causes

are identified, the team should

determine which ones are the most

damaging, since two or three causes

may be responsible for up to 80 percent

of quality problems. By addressing

these critical causes, a problem solving

team can realize significant

improvement with minimal effort.

Analytical tools alone will not always

provide enough information. A

problem-solving team may need to

conduct an in-depth examination. Such

studies can be based on clinical record

reviews, health center register data,

staff or patient interviews, service

delivery observations, or any

combination of the above. These

50 | P a g e


studies must go beyond documenting

the problem; they should examine root

causes.

At this stage, problem-solving teams

often employ some basic statistical

tools. These may include check sheets,

histograms, scattergrams, pareto

charts, run charts, and control charts.

(See box below.) The check sheet is a

data collection tool used in assessing

variables related to a specific process.

The resultant data can be presented in

a histogram that assesses the extent of

variation, in a distribution scattergram

that indicate trends, or in a pareto

chart that classifies problems according

to cause in descending order of

importance. Run charts make it easy

to monitor change in a process over

time. Control charts help to monitor

variation and provide clues that can

help to identify the type of variation.

Some causes are inherent to the

process, while others have their roots

outside the process.

Developing Solutions and Actions for

Quality Improvement

The problem-solving team should now

be ready to develop and evaluate

potential solutions. Unless the

procedure in question is the sole

responsibility of an individual,

developing solutions should be a team

effort. It may be necessary to involve

personnel responsible for processes

related to the root cause.

Solutions to quality problems or

quality improvement activities can

take several forms. A solution may be

very straightforward: it may be as

simple as reminding staff about clinical

guidelines through supervision or

focused in-service training. Solutions

may also take the form of job aids such

as wall charts and checklists. They

become part of the process that

provides information and checks at the

point of service delivery, thereby

reducing error or variation. Often,

solutions and improvements are rooted

in management systems related to

supervision, training, and logistics.

Some problems, however, are more

difficult to solve because they require

procedural redesign. This should be

considered if the team determines that

there is no existing process in the

problem area or that the defined

process is not responsive to the clients’

needs and expectations. In such cases,

tools such as flowcharts and design

matrices can be very helpful in

designing solutions that build on the

strengths of existing practices and take

client requirements into account.

Problem-solving teams are encouraged

to think creatively and to generate a

variety of solution options. Choices

among potential solutions should be

based on an examination of the

option’s potential costs and

effectiveness. Teams may employ

techniques such as multiple criteria

utility assessment or multivoting to

51 | P a g e


help them in evaluating solutions and

making a decision. The team also

should gauge potential opposition to

change and develop a plan to minimize

resistance.

Implementing and Evaluating Quality

Improvement Efforts

Implementing quality improvement

requires careful planning. The team

must determine the necessary

resources and time frame and decide

who will be responsible for

implementation. It must also decide

whether implementation should begin

with a pilot test in a limited area or

should be launched on a larger scale. A

pilot project is merited if the solution

requires substantial resources or if

there is considerable uncertainty about

the solution’s potential effectiveness.

The team should select indicators to

evaluate whether the solution was

implemented correctly and whether it

resolved the problem it was designed

to address. In-depth monitoring should

begin when the quality improvement

plan is implemented. It should

continue until either the solution is

proven effective and sustainable, or

the solution is proven ineffective and is

abandoned or modified. When a

solution is effective, the teams should

continue limited monitoring. Teams

should modify solutions as needed and

should fully document results and

lessons learned.

Once the solution has proved to be

effective, program managers should

codify and disseminate the new process

so that others can learn from the

experience. The QA team should also

make plans to identify a new problem,

either through a team process or

through data generated by an existing

monitoring system. The team may then

repeat the quality improvement cycle.

Building a Quality Assurance Program

A QA program is a comprehensive set of

quality assessment and improvement

activities that is incorporated into an

organization’s routine management

functions. As health care organizations

learn more about the QA process, they

are likely to discover that some of their

current activities are related to quality

improvement. In fact, most

organizations already do some type of

QA. These existing activities provide a

foundation upon which to build a

comprehensive QA program. The

previous section describes how program

managers and staff can conduct

quality-related activities more

thoroughly. The following section

discusses how QA can be permanently

integrated into health program

management in developing countries.

There are two distinct approaches to

building a QA program. The first is the

comprehensive QA strategy; the second

is the problem-oriented strategy. The

two approaches are contrasted here to

provide an overview of the wide range

52 | P a g e


of strategic options available to

program managers. In practice, most

organizations will want to combine

these approaches as they introduce

quality assurance.

In the comprehensive approach, QA

policies, procedures, and processes are

implemented simultaneously, starting

at the top and moving down the

organizational structure. A

comprehensive approach typically

begins with a thorough review of

standards and specifications.

This may be followed by an assessment

of health care and support services.

This assessment may be conducted

through an existing management

information system or through a

monitoring system specifically

developed to measure service quality.

Start-up also includes an extensive

training effort to strengthen technical

competencies and to impart quality

improvement knowledge and skills.

Comprehensive service quality

assessments are useful in countries

where information systems are

inadequate. Systems analysis allows

managers to use interviews and

observation to assess primary health

care services and their associated

support activities. Priority areas for

quality improvement can be identified

based on the results of comprehensive

monitoring or systems analysis. The

comprehensive approach works best

when there is a commitment

throughout the system to addressing

quality of care and when organizations

have the neces-

sary resources to implement a QA

program on a large scale.

The problem-oriented approach to QA

emphasizes practical, small-scale,

quality-related activities that produce

incremental quality improvements.

Rather than carrying out a

comprehensive assessment, individuals

or teams focus on a single problem that

is important to them.

In this model, comprehensive

assessment and monitoring are de-

emphasized in favor of immediate

action. This is based on the assumption

that monitoring systems and a more

systematic approach can be developed

over time once problem solving has

become part of the organizational

culture. Often, the problem-oriented

approach is introduced early at a few

clinics rather than throughout the

organization. This allows an

organization to modify and adapt the

problem-solving strategy before wider

implementation.

With careful planning, problem-

orientation can evolve into a more

comprehensive approach. Eventually,

all types of services can be covered by

the QA effort and a simple monitoring

system can be emplaced. It is also

important to note that a

comprehensive approach can benefit

from some small-scale, problem-

53 | P a g e


oriented activities. One danger of an

exclusively comprehensive approach is

that staff at all levels may grow

impatient with the tedious process of

setting up systems and of participating

in training activities that do not yield

immediate, concrete results. Potential

resistance can be averted by

conducting small-scale, quality

improvement activities that

demonstrate quick, short-term

outcomes. Also, these results can

be incorporated into training efforts,

thus providing local examples of QA.

There is no recipe for developing a QA

program. It is a creative process that

requires flexibility in order to adapt to

a given health program’s unique

features. This section describes key

activities that are usually carried out in

building a QA program. Most of the key

activities described take place

concurrently, and many must be

continually renegotiated as the

program evolves and conditions change.

Key Activities in the Development of

a Quality Assurance Program

Foster commitment to quality Conduct

a preliminary review of QA-related

activities Develop the purpose and

vision for the QA effort Determine level

and scope of initial QA activities Assign

responsibility for QA

Allocate resources for QA

Develop a written QA plan

Strengthen QA skills and critical

management systems

Disseminate QA activities

Manage change

A QA program may be developed

gradually through a carefully planned,

phased process, or it may be

implemented in one step as part of a

fundamental organizational change. A

gradual, phased approach is frequently

appropriate for organizations with

rudimentary management systems.

Foster Commitment to Quality Building

a permanent QA program requires the

early support of top- and mid-level

managers. Over time, this commitment

to QA should be shared by all staff and

reflected in the organization’s mission,

purpose, and procedures. The process

of fostering and developing

commitment is not an isolated activity;

it must continue throughout the life of

a project and at all levels of the

organization.

Commitment is developed by raising

awareness and by fostering a dialogue

among top-level managers. This can be

done through awareness-raising

seminars, special planning meetings, or

one-to-one discussions with an

organization’s leaders. During the

awareness-raising process, basic

concepts are introduced that relate to

quality and quality assessment and

improvement methods. Discussing the

importance of quality and presenting

empirical information about quality

54 | P a g e


problems at the local level can also

foster commitment.

Conduct a Preliminary Review of

Quality-Related Activities

Before introducing new QA activities, it

is important to conduct an initial

review of the organization and to

develop a general description of the

existing system. This review will allow

the new QA effort to build on existing

strengths.

QA efforts will likely be sustained if

they are built into the existing system

in a logical way. For example, an

existing supervisory system that

monitors compliance with technical

norms is a logical place to begin QA

activities. Failing to recognize such an

opportunity can result in turf battles

between managers and in confusion

among service providers. One

important function of the initial

assessment is to determine the best

place in the organization to launch a

QA initiative.

This preliminary analysis can include

the following:

Review of the program’s clinical and

managerial standards or norms. Are

they technically sound? Are they

appropriate for local conditions? Are

they complete? Are they up-to-date?

Are they available to staff?

Assessment of the quality of service

currently provided, and patient and

community satisfaction with the

services.

Review of the supervisory system and

related management activities to

determine which type of QA is already

in place. What problems are faced by

supervisors? Are they able to solve

them?

Examination of the management

information system. Consider the

scope, validity, sensitivity, specificity,

and reliability of the indicators

currently being monitored. Are data

used for management and decision

making? Could the existing data be

used to support

QA program?

Review of existing training capacity.

Could training be carried out by the

organization or would outside help be

needed? Do current training programs

include skills that could be used in QA?

Study of the organizational structure.

Profile the organization’s lines of

communication and authority. Who is

doing QA now? Who should be doing QA?

s Assessment of the adequacy of

facilities, logistics, and equipment.

Different approaches can be used to

conduct a preliminary assessment.

Depending on the resources available,

the assessment can be a comprehensive

study. It may include collecting new

55 | P a g e


data or a rapid assessment based on

available data and the expert opinion

of key informants.

Develop the Purpose and Vision for

the Quality Assurance

Effort Building commitment to QA

within an organization requires that top

managers and their staff share an

overall vision of quality improvement.

The purpose of a vision statement is to

build consensus between managers and

to set boundaries for the QA effort.

The vision statement will help staff at

all levels to understand how their day-

to-day work relates to quality

improvement. It can be developed

through a variety of consensus-building

techniques that can be employed by

the senior management team. The

vision statement should be developed

at the QA effort’s outset and revised

periodically if there are strategic

changes in the organization or if there

is a significant staff turnover.

Determine Level and Scope of Initial

Quality Assurance Activities

The level and scope of initial QA

activities depend on the resources

available, the implementation time

frame, and the receptivity of

management and program staff to the

idea of QA. An organization must also

consider external political factors.

A QA effort can be implemented at the

national, regional, and district level or

within a single health facility. Where

services are organized as vertical

programs, one program may be the

focus of initial QA activities.

An organization must also use a small-

scale effort such as a pilot study or

series of demostration projects in

testing QA strategies and in learning

more about their local application.

Small-scale efforts are often attractive

to managers because they offer

progress at little risk, and because

successful programs can be replicated

or expanded. Unfortunately, it is

frequently difficult to replicate

developed models, often because the

demonstration sites have advantages

over the rest of the organization.

Assign Responsibility for Quality

Assurance

To ensure continuity, accountability for

QA activities must be clear, and QA

must be a prominent organizational

emphasis. In some organizations a

single person may be responsible for

QA, while in others it may be the

domain of quality committees.

Occasionally, an existing committee or

management body will take on

responsibility for QA, integrating it into

the general management structure. In

others, a QA program will be

established whose role is defined in

relation to other departments. The

titles of those responsible for QA should

denote a facilitative rather than a

56 | P a g e


directive role; they might be called

quality coordinators, coaches, or

advisors. QA coordinators and the QA

committee are responsible for

monitoring and supporting QA

activities, providing technical

assistance to teams, assigning staff to

develop indicators, and facilitating

communication about QA issues

between top-level management and

staff.

Develop a Written Quality Assurance

Plan

A QA plan is a written document that

describes the program objectives and

scope, defines lines of responsibility

and authority, and puts forth

implementation strategies. The plan

should help staff members to relate

quality goals and objectives to their

routine activities. It should also be a

living document that is regularly

referred to and revised.

Strengthen Quality Assurance Skills

and Critical Management Systems

QA activities are an important part of

management and may occasionally be

reformulated into a total quality

management system. In general,

however, QA efforts will focus more

narrowly on three critical management

systems: supervision, training, and

management information systems.

Special effort should be made to

strengthen these systems as a QA

program develops.

Organizations should develop

supervision systems that not only

evaluate and manage activities, but

also support health workers through a

process of professional growth. In the

long term, this approach can lead to

self-managed, self-directed individual

and collective work. While this may

seem difficult, it is necessary since

many health providers in developing

countries work at the periphery without

daily supervision. Supervisors can take

the lead in QA efforts by providing an

example of participatory leadership

and problem-solving skills;

Over time, health workers can initiate

quality improvement activities.

Methods for self-management and

concurrent QA such as health worker

and supervisor self-assessments and

other job aids can be introduced by the

supervisor to improve performance.

The training system should incorporate

competency-based training for specific

routine tasks, including service

delivery, counseling, and health

education, as well as for management

support services. Besides improving

training in skill areas essential for high-

quality services, the training capacity

should be developed and expanded to

include such QA skills as problem

solving, evaluation, and teamwork.

It is also important to revise the

management information system so

that it serves as an effective QA

monitoring system. This can be done

early or late in the QA process, when

57 | P a g e


managers and staff have an idea of

what information they need and how to

use it more effectively. Resistance to

change in this area may be easier to

manage after the QA program has

achieved some initial successes.

What Is A Standard?

The term standard is used very often

but its meaning is not understood by

most people. A Standard is a statement

of expected level of quality. It states

clearly the inputs required delivering a

service, how things should be done

(process) and what the output or

outcome should be. When we compare

what is expected in the standards to

what we do, we shall be able to

identify any quality gaps and then

make plans to improve upon it.

Types of Standards

In carrying out any health activity there

are three stages that are followed. We

need inputs (resources), we should also

define clearly how things are going to

be done (processes) and know what

results to expect (outcome).

Standards must therefore be set for

each of the three areas.

Input Standards

Input or structure standards define the

resources that must be supplied for the

activities to be carried out e.g., the

physical structure, people, equipment

and materials. For example to provide

outpatient services we need a building

with a number of rooms for

consultation, treatment, laboratory

etc. We also need trained nurses,

medical assistants or doctors and

equipment like thermometers,

weighing scales, sphygmomanometers

Process Standards

Process standards describe the tasks or

steps that must be carried out until the

activity is completed. In the example

of outpatient services, the steps

include, registration, recording of

temperature and weight, consultation

and collection of drugs.

Output/ Outcome Standards Output/

Outcome standards describe the

outputs or results of the activities

carried out. For example - the number

of patients seen at the OPD. There are

a number of standards that have been

developed by the Ghana Health Service

and some of us have been trained in

their use. A few examples are:

Integrated Management of Childhood

Illness (IMCI) case management

guidelines Malaria case management

guidelines Tuberculosis case

management guidelines Reproductive

health policy and standards and

guidelines.

Uses of Standards The use of standards

will ensure quality care and reduce the

differences in managing patients among

prescribers. It will also get value for

money.

Standards are used to: Define quality

Determine, inputs, processes and

outcomes, and Develop indicators to

58 | P a g e


monitor quality. Let's examine an

example of standards for antenatal

care using the three (3) areas namely,

input, process and outcome as

illustration Input standards These are

measured in terms of quality of

physical structure, equipment, supplies

and staff. Physical structure the

antenatal clinic should have a

reception and waiting area with

adequate seating for women. A

separate examination room for history

and examination. Equipment and

supplies Standing scale with Height

measure Sphygmomanometer Maternal

health records Fetoscope Dipstick for

urinalysis Measuring tape Examination

table Immunization equipments

Laboratory for basic tests Drugs- Folic

acid, Iron, anti-malarials

Process standards: These are written

out in the: National Reproductive

Health Policy, Standards and Protocols

Laboratory standard operating

procedures; and Medical records

procedures. Output/ Outcome

standards Pregnant women will attend

at least four times during pregnancy.

Ninety percent (90%) of women

attending antenatal clinic will report

satisfaction with care given (client

survey).

How Do Staff Get To Know About

Standards? When standards have been

developed, staff should be made aware

of them so that they can be used to

improve quality of care. There are

several methods that can be used

depending on what has been

developed. They include: Training of

health workers (in service and on the

job training) Launching of the standard

Seminars/ conferences developing job

aids Support supervision. When

standards have been well

communicated, the health worker

knows the standards; he/she accepts

them and changes his or her practice

accordingly.

Standards define what level of quality

we should be expecting. It states the

inputs required delivering a service,

how things should be done (processes)

and what the outcome should be.

Standards enable us develop indicators

so that the level of quality can be

measured and monitored.

MONITORING AND SUPERVISION

What Is Monitoring? In order to assess

whether we are making any

improvement in quality of service

delivery, we need to do regular

monitoring. It is important for us to

understand what is meant by the term

'monitoring'. Monitoring is the

collection, analysis and interpretation

of data in order to assess whether we

are making any progress towards

achieving our set targets or improving

quality. Data for monitoring quality

may be from the routine data that we

collect in the facilities and in the

communities, for example OPD

attendance and immunization

59 | P a g e


coverage. It may also be data that is

collected from time to time to follow

our performance on selected

indicators, for example patient waiting

time, drug availability.

Another aspect of quality monitoring is

to check if we are keeping to

standards, protocols or guidelines. For

example a health centre may compare

the treatment of Malaria with agreed

standards of treatment. What is the

Importance of Monitoring Quality of

Care? Monitoring helps us to identify

gaps in quality of our health care

delivery. It provides lessons to learn

from as we progress with our

implementation. It tells us if we are

making progress in improving quality of

care. Monitoring therefore helps us to

identify problems with the

implementation of our plans so as to

take the necessary steps in order to

achieve our targets.

Methods for Monitoring Quality of

Care

There are many methods of monitoring

quality. The common ones include:

Review of routine health information.

For example, Health Management

Information System data on OPD

attendance, In-patient admissions and

deaths, Immunisation coverage. Client

satisfaction surveys. Patients

complaints system. Critical incidents -

Adverse events. Mystery clients

Supervision We shall now discuss each

of these quality-monitoring methods.

Client Satisfaction Survey

This is a good way of getting the

clients' views on our services. It tells us

what the client's expect from our

health services. By telling us their

expectations and making suggestions,

clients are indirectly participating in

the decision making process of the

facility. It promotes services that are

sensitive to the needs of the client.

Preparation for the survey: It is

important to prepare very well before

starting any client satisfaction survey.

The quality assurance team should:

Identify the objective of the survey.

We need to be clear about what we

want to achieve at the end of the

survey. It is only when we get our

objectives right that we can know the

relevant data to collect. Develop your

questionnaire. There is currently an

existing questionnaire on satisfaction,

which is widely used by health

facilities. You may have to translate

the questionnaire into the local

language. This should be done and

agreed upon before the interviews are

conducted. Determine the number of

people to be interviewed (sample size).

It is recommended that a minimum of

50 clients are interviewed in a clinic or

health centre survey. Select and train

the interviewers on how to conduct the

interviews. The interviewers should not

be known to the clients.

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When do we collect the data?

Information should be collected from

clients when they are about to leave

the facility. This is called the EXIT

interview.

How do we collect the data?

These are the measures that should be

taken when conducting exit interviews.

Spread data collection over two weeks

or over a period of 10 days. (5 per day

from Monday to Friday) Select patients

randomly. You will have to decide

whether you will select every 3rd

person or 4th person or 5th person in

that order. Number your questionnaires

in consecutive order. (1,2,3,4,5) Before

interviewing the client, introduce

yourself and seek his consent. Explain

briefly why you are carrying out the

survey (to help improve on services for

clients) Let the same person interview

the clients to ensure that questions are

asked the same way. The interviewer

should not be in uniform. Do not

influence the client's responses.

Data Analysis and Report Writing.

After gathering the information from

the clients, you analyse and present

your findings using a simple data entry

form. For example assuming that 25 out

of 50 clients interviewed said that they

were seen in less than 1 hour then the

% of Clients seen within 1 hour is:

25/50 x 100 =50% The % obtained for all

the indicators are displayed graphically

for interpretation.

Clients Complaints System This is

another way clients can inform you

about the services that are being

provided without doing a survey.

There are several complaints system

but the most common and simple ones

are: 1. The use of

complaints/suggestions box. 2. The use

of client complaints desk.

Complaints /Suggestions

A complaint box as the name suggests,

involves placing a clearly labelled box

at an open place e.g. the reception.

Attached to the box is a pen and paper,

which clients will use to write down

their complaints and suggestions. There

should be a person responsible for

emptying the box, analyzing the

complaints and reporting on findings

regularly to management for action.

When using the complaint box, the

following should be noted:

1. It should be possible to not identify

those who make the complaints; else it

would scare off clients or patients who

would like to complain about the

quality of services.

2. Prompt investigations should be

carried out and feedback given to

clients who provide their address.

3. Staff should not sit by the box.

There are some problems that relate to

the use of the complaints box. Among

them are the following:

1. The box may not be opened for very

long periods.

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2. People may write about things that

are not related to the quality of

service.

3. They may also use it to make

accusations against health workers.

4. It is not useful in an area where a

large number of the clients are

illiterates.

Client Information and Complaints

Desk

A client Information and Complaint

Desk/Centre is normally located at a

place that is accessible to clients. A

well-trained staff with good

interpersonal skills should be in charge

of the desk. She or he is responsible for

giving the necessary information and

direction to clients, listening to their

complaints, documenting them and

following up on complaints. Most often

complainants have the opportunity of

receiving feedback on the spot. Some

of the complaints may need further

investigation. It is important that feed-

back is given to the complainant after

investigations have been conducted and

where the facility is in the wrong,

apology should be rendered. The

records of the complaints should be

reviewed regularly and feedback given

to management and staff.

Records Review: This is the collection

and analysis of information from

existing records and reports. The

routine data we collect from the Health

Management Information System (HMIS)

is an important source of information

for monitoring quality. We should take

interest in analyzing the data and use it

to improve quality in our facilities. For

example, analyzing trends in

immunization coverage can show us

whether we are meeting our set target.

We can also review patient records to

see if prescribers are complying with

standards, protocols and guidelines.

Review of Adverse Incidences

Adverse incidences are unusual

incidents that occur in the course of

duty at the work place e.g. a person

collapsing after an injection, adverse

events following immunization. Such an

event should be well documented and

thoroughly reviewed immediately after

it has occurred with a view to putting

in measures to prevent similar

occurrences in the future. The process

involves a systematic review of all

records on the incident. If you are

unable to undertake the review, you

should consult your supervisor to

support you do it.

Mystery Client

In this approach, the institution

engages the services of an individual

called the mystery client who visits the

health facility and pretends to be

receiving health care services in the

facility. Without attracting attention,

he or she observes, assesses and at

times experiences the quality of

services rendered by the staff to

clients. The mystery client then reports

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his or her findings to the institution for

analysis. The nature of the task of the

mystery client requires that he or she

must be confident, accurate and

reliable. He or she must also have good

memory in order to reproduce what

was observed and experienced in an

unbiased manner after the process.

Supervision

Supervision is a process of guiding,

helping and teaching health workers at

their workplace to perform better. It

involves a two-way communication

between the one supervising

(supervisor) and the one being

supervised (supervisee). Adequate

preparation should be made in terms of

planning and budgeting before the

visits. At the end of the visit, the

supervisor should make time to discuss

with staff their findings and agree on

what actions to take to improve on

performance. A report must be written

by the supervisor and feedback sent to

the staff.

There are various types of supervision

and three are described below:

1. Facilitative Supervision: It is also

called supportive supervision because

the supervisor does not see himself as

an inspector looking over the shoulders

of his subordinates for faults. Instead,

he sees himself as part of the quality

team guiding the staff to identify their

weaknesses and gaps in quality of

service delivery. Together with the

supervisee, they develop appropriate

solutions to improve on their

performance.

2. Inspectorate type: The supervision

here focuses on finding faults and has

minimal interaction. It therefore leaves

little or no learning experience to the

one being supervised.

Self- assessment or peer-based

supervision: This is where the

supervisor's role is indirect. It is the

type of supervision where staff

belonging to the same team or

professional group sets up a system

whereby they meet regularly to discuss

their own performance with little or no

external role. Monitoring is the way to

determine how much progress we are

making towards achieving our set

objectives. In this chapter, we have

come to understand that quality

monitoring involves the collection,

analysis and interpretation of data to

know where we are in quality of our

service delivery. Data for monitoring

quality may be obtained from routine

HMIS data, reports or periodic data

from surveys i.e. patient satisfaction

surveys. We have also discussed the

various types of supervision. We have

also learnt about other methods for

monitoring quality. As we implement

quality assurance, let us remember to

use the data we collect to improve the

quality of our services, which is one of

the five principles of quality.

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TOOLS FOR MONITORING

Indicators

You need to use Indicators to make

monitoring meaningful. An indicator

can be defined simply as the yardstick

by which you measure progress.

Indicators are derived from standards.

Depending on what you set out to do,

you may select indicators that will help

you measure them. We can categorize

Indicators for monitoring quality into

Client and Professional perspectives.

Client-defined indicators are those

derived from the clients expectations

and professional indicators are those

derived from professional standards.

Indicators for Monitoring Quality on

Patient Satisfaction (OPD)

1. Proportion of patients seen promptly

2. Proportion of patients seen without

an unnecessary delay

3. Proportion of patients examined by

the Doctor

4. Proportion of patients told about the

diagnosis

5. Proportion of patients given

instructions about how to take their

treatment

6. Proportion of patients told whether

or not to return

7. Proportion of patients having

privacy during consultation

8. Proportion of patients receiving all

drugs prescribed

9. Proportion of patients perceiving

staff attitude to be very good

10. Proportion of patients perceiving

clinic to be clean

11. Proportion of patients seeking

emergency treatment in the past 6

months who were seen promptly

12. Proportion of patients feeling very

satisfied with their visit

13. Proportion of thirty (30) essential

drugs in stock.

Examples of routine indicators:

Number of OPD attendance? Percentage

of children under 1 year who have

completed their Immunization

coverage? Number of injection abscess?

Percentage drug availability? Number of

supervised deliveries ? Number of drugs

prescribed for a patient In addition to

the above, the QA team can also use

indicators that look at how we manage

patients. We have standard guidelines

for the management of diseases like

Malaria and Diarrhoea in children under

5 years. Indicators that have been

developed from these guidelines

include: Proportion of children weighed

at OPD ? Proportion of children whose

temperatures were taken? Proportion

of children who were diagnosed as

having Malaria and prescribed oral

chloroquineor artesunate-amodiaquine.

? Proportion of children who were

diagnosed as having diarrhoea and

given ORS.

Tools for Collecting Data and Use of

Information

Before you set out to collect data for

monitoring the progress of your QA, you

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need to agree on how you are going to

collect the data. The common tools

used for data collection during

monitoring are? Checklist?

Observational guide? Questionnaires? A

combination of all the 3.

Checklist

Checklist contains the important

information you will need to collect to

assist you monitor quality in your

facility. It lists out the important points

that should guide you to ask the

necessary questions and make the

required observations.

Observational Guide

It is a list of key points that will guide

you to observe the important activities

that you need to take note of. We can

use this method to assess staff attitude

at the OPD by observing how patients

are handled by health staff at the

various points during OPD consultation.

We can also use observational guide to

assess how sick children are managed

at the OPD by sitting in the consulting

room and quietly observing the process

of consultation using for instance, a

sample observation guide at appendix

1C. The rating scale provided with the

guide gives the result of observation a

numerical value.

Questionnaire

A questionnaire is a useful tool

containing questions on key issues that

you want to know about. There are

several types of questionnaires. A few

of them are stated below: Structured

questionnaire: This provides possible

answers for the one being interviewed

to choose from. ? Open-ended

questionnaire: The one being

interviewed is encouraged to come out

with his or her own answers. ? Semi-

structured questionnaire: This

combines both structured and open

ended.

Dissemination of Information on

Quality Assurance

The importance of gathering

information about quality is to improve

our services. People are more likely to

use the information when they

understand it, hence the need for

creative ways to disseminate it. It is

important to discuss your findings first

with management before presenting

them to the general staff body and the

community.

Find below some guidelines for

dissemination:

Findings from monitoring should be

presented in a very clear manner so

that staff can easily understand.

Findings should be presented as

absolute figures; proportions or

percentages; pictorial form e.g. line

graph, bar chart, pie chart and

histograms. ? Always remember that

after initial discussion of your findings

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with management, you would have to

follow it up with a written report so

that they can take action where

necessary. ? Findings should be

displayed on staff notice boards. ?

Always remember to hold staff durbars

to inform them about your findings. ?

The findings and the proposed solutions

should be shared with clients and the

community. The use of audiovisual

equipments like the video will make

your message clearer.

QUALITY IMPROVEMENT

Quality Assurance Cycle

The QA cycle is a guide that can be

followed to continuously improve

quality of our health services. It has

different stages and by going through

them, the QA team can follow the

cycle to assess, monitor and improve

the quality of care we give to the

clients. You can start from any stage of

the cycle but have to complete it once

you start. Just be simple, practical and

creative in your approach.

Steps in the quality assurance cycle

what then are the main steps in the QA

Cycle and how can they be used to

improve quality?

Plan for Quality

We do planning in our everyday lives

and in our facilities also. It is equally

important to plan for QA. Planning for

quality is not an individual task but

should be done by the whole QA team.

It is the task of this team to carefully

plan activities that will facilitate the

implementation of QA activities in your

facility. A budget should be prepared

with the plans so that resources are

committed for quality assurance. The

activities should be well organized,

systematically carried out and properly

coordinated.

Review Standards

We need standards to check whether

our activities meet client and

professional expectations. Standards

are usually set at the national level but

can be adapted for the lower levels.

Protocols and Guidelines can also help

us to improve the quality of our

services. Make a list of some of the

guidelines and protocols available at

your facility.

Communicate Standards

Communication plays a very important

role in QA. Whatever decision the team

takes must be well understood by all

members and properly communicated

to other staff. It is important to

communicate these standards set by

the facility to all members of staff. For

example all prescribers in the facility

should know about existing guidelines

and protocols and comply accordingly.

Each facility has its own effective way

to communicate information to the

staff. Examples include meetings and

durbars. What other examples do you

have?

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Monitor the Use of Standards Once

we have our standards, protocols and

guidelines in place, we then monitor to

see whether we are adhering to them

or not. For example, we can always

check to see whether the temperature

is taken and recorded for malaria

cases. The main aim of monitoring is to

check whether or not we are complying

with standards.

Identify and Prioritize Problems

In our facilities, some of the problem

areas are related to patient

satisfaction, poor prescription habits,

infection control practices etc. Since

we cannot solve all the problems at the

same time, there will be the need to

prioritize. We can determine the

priority problem areas as well as

opportunities for improvement. It may

be helpful to first select the simple

ones that we have resources to solve.

Once we see results of our activities,

we are encouraged to do more.

Define the Problem

Once the problem areas have been

identified, we try to define them. We

state them as problems. What does this

mean? Consider the following two

statements about the state of the clinic

compound: ? The compound is dirty

because patients litter the place and

the few laborers are lazy ? 45% of

patients complain the compound is very

dirty. In the above example the actual

problem is the very dirty compound.

The size of the problem is that 45% of

patients complain about it. A good

problem statement does not assign

reason or blames people. The second

statement obviously better defines the

problem.

Analyze the Problem

Every problem has got its underlying

causes. We therefore analyze to find

the root causes to the problem. Simple

methods for problem analysis include

Brainstorming, But Why and Tree

diagram.

The root cause of the problem in this

case is the absence of dustbins. The

situation may differ in your work place.

There is therefore the need to carefully

analyze the problem in order to get to

the root cause. In brainstorming, the

QA team freely talks about the problem

until they discover the root causes. The

problem can also be presented as a

tree with its causes representing the

roots

Suggest/Develop Solutions

After analyzing the problem, the team

should suggest ways of correcting the

problem. Again, this can be done

through brainstorming to gather a lot of

possible solutions. You can also find out

how other facilities have addressed

similar problems. Some problems are

easy to solve while others are difficult.

The solution you choose should be

practicable and within your available

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resources (money, material and human)

once you get to the root causes, it

becomes easy to suggest possible

solution. Usually the root causes and

the suggested solutions are like the two

sides of a coin. In the above example,

the suggested solution is to provide

dustbins.

Implement Solution. First develop

action plan. The action plan spells out

the activities to be undertaken based

on the solutions, persons responsible,

time frame for each activity, resources

required, expected output and how

monitored. It is helpful to assign people

to specific tasks even though we all

work on the problem as a team. The

person responsible should be clear

about the task and the time to report

to the team. Remember the saying that

everybody's business is nobody's

business. Always remember to make

people responsible!

Example of an Action Plan Clinic:

Aboabo Health Center Problem: 15%

patients complained the clinic is not

very clean.

Objective: To reduce the proportion of

patients who complain that the clinic is

not very clean from 15% to 10% by the

end of December 2004.

Period of implementation: July-

December 2004

The action plan should be implemented

within an agreed time period. During

the implementation period indicators

should be monitored to see if we are

achieving our goal before the final

evaluation. A Gantt chart may be of

help in the monitoring of activities.

Evaluate.

At the end of the agreed period we

check to see whether we have achieved

our goal. In the above example, we find

out in December 2004 whether we have

succeeded to reduce the proportion of

patients who complain that the clinic is

not very clean from 15% to 10%. In so

doing we improve the quality of state

of cleanliness from the patient's view

substantially. You will have to conduct

another patient satisfaction survey and

compare results to see how far you

have improved. Then the cycle

continues.

IMPLEMENTING QUALITY ASSURANCE

IN A FACILITY

Steps in the Implementation of QA in

A Facility

To effectively implement a QA system

in a facility, there are certain basic

steps to be considered. Some of these

steps can be carried out at the same

time. It will be helpful to review each

step periodically to ensure that the

implementation process is continuous.

The steps involve the need to:

1. Form a multidisciplinary quality

action team

2. Create awareness among staff

3. Review present state quality

4. Develop/adapt written guidelines

5. Carry out QA training

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6. Apply skills to continuously improve

your performance

7. Share results periodically with other

staff and clients 8. Hold regular QA

meetings to plan and review

performance

Form a Multidisciplinary QA Team

Teamwork is key to successful QA

implementation at the facility level.

Each member of staff has a special role

to play just as a rainbow has many

colors. The team should be

multidisciplinary eg. Pharmacy,

laboratory, Nurses, Records etc be

represented. There is the need to

ensure that the members are

committed to work. The team shall be

responsible for the implementation of

QA at the facility.

Create Awareness among Staff

It is important that every member of

staff (from the lowest to the highest)

understands and appreciates the QA

concept. A system to create awareness

include staff durbars, departmental

meetings etc. Awareness creation

should continue until quality becomes

part of normal routine work.

Review the Present State of Quality

Performance

At the facility. Before you can take any

meaningful step to improve quality,

you need to know your present state of

quality performance in your institution.

How can this be achieved? You can get

information from normal routine

records, results of patient satisfaction

survey etc. You then determine where

you want to focus and improve

performance.

Develop Written Guidelines /

Standards

The team at this time looks at how to

improve quality according to approved

standards and guidelines. Existing

guidelines can be obtained from

National or Regional levels. They can

be adapted or new ones developed.

The most important thing is that all the

standards and guidelines are

communicated to staff.

Conduct Training For QA Team And

Other Staff.

A start up training is conducted for QA

team members. This training will cover

broad areas on QA principles; setting

up process and overall strategies in QA

management. The team should be

confident enough to initiate QA process

in the facility after the training.

Subsequently, there will be the need to

train other members of staff. There

should also be a system for systematic

and continuous education.

Apply Skills To Improve QA.

At this point, the QA team should be in

the position to apply the knowledge

and skills acquired to confidently

initiate the QA program in the facility.

It is usually advisable to start small

with indicators which are easy to

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monitor and see results e.g. Patient

satisfaction survey. You may then

expand to other areas based on what

the team decides.

Share QA Results With Other Staff

and Patients.

It is important to share the results of

QA performance with other members of

staff. This will help to create more

awareness, increase commitment and

deepen sense of ownership among

staff. For example, Performance can be

presented using bar charts at staff

durbar. Other creative ways can be

explored to disseminate information to

clients eg using patient information

desk.

Hold Regular QA Review Meetings

Once you have initiated the process of

implementing QA in your institution,

there is the need to meet regularly and

review your performance as a team.

You can achieve this by holding regular

QA meetings. Keep minutes of meetings

for reference and may be used to

develop action plan . Remember to

appoint a Chairman and a Secretary.

The role of the Health Care Manager

in QA

The Health Care Manager plays a

central role in the successful

implementation of the QA program.

There is the need for the manager to

personally show interest and inspire

other staff. The manager may play

some of the following roles among

others: Lead the staff to cultivate

Quality culture in the facility. Ensure

that the QA Team meets as scheduled.

Provide logistics to implement QA in

the institution Encourage training to

develop staff Develop incentive system

and strategies to motivate staff. ? ? ? ? ?

It is of no use to receive training in QA

and not putting into practice.

Management commitment is very

important for successful QA

implementation.

What the Leadership stands for I always

want to improve my services even with

the little resources I have. I always look

for creative ways to improve my

services through teamwork. Above all I

always make sure my services meet

professional standards and to the very

best taste of my clients. I always aim at

excellence. QA

MANAGING CHANGE IN QUALITY

ASSURANCE

Types of Change in an Organization

Various types of change can occur in a

health facility or organization. Change

can be described as being imposed

when there is a directive to initiate

change from somewhere else. An

example is when the Director General

directs institutions to implement QA. A

health facility on its own can initiate

change by reorganizing the way things

are done or puts in place measures to

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improve its performance. An example is

the management and staff of a facility

decides to initiate change in order to

establish a QA program.

Change can be described as necessary

when an organization whose survival is

being threatened by circumstances,

undergoes major changes to ensure its

survival. An example is the

privatization of a public health facility

that is performing poorly.

Reactions to Change People react to

change in different ways.

These include? Those who will welcome

change? Those who will be indifferent

to change? Those who will oppose

change

Reasons Why People Welcome

Change? Some people welcome change

because: ? They want to be free from

the boredom of their work. Possibly,

they feel they are being marginally

utilized and thus are looking out for

more challenging opportunities. ? They

expect to enjoy better conditions of

service? They expect the fall of

someone's “kingdom”. This occurs at

the workplace when some staff feel

others have undue advantages over

them in terms of access to resources

and privileges and the change is likely

to affect the privileged negatively?

They expect recognition from the

change- and opportunity to be involved

more in the organization's activities.

Reasons People Are Indifferent To

Change People are indifferent to

change because; ? They have heard of

it all, being said before, and it never

happened? They see that systems and

cultures are entrenched for such long

periods- the organization hardly

undergoes any change

Reasons Why People Oppose Change

People resist change because? They

want to guard their own interests. The

change threatens to deprive them of

their position and privileges ? There is

misunderstanding and lack of trust.

This occurs when the reasons for the

change, the implications and benefits

are not explained to them? They may

have to acquire new skills and

behaviors which they may find difficult

to learn.

Strategies for Managing Change in QA

the under listed/following strategies

can be used to manage change in your

facility. ? Share ideas and discuss the

need for change with all staff who will

be involved in the change process. This

calls for frequent dialogues through

staff durbars, meetings, group

discussions etc.? Use methods aimed at

effecting changes in attitudes, values

and skills eg conferences, study tours

to sites of best QA practice to

introduce and clarify new concepts and

share experiences.

Ways to Minimize Resistance When

Implementing Change The following is

suggestions as to how you can minimize

resistance to the implementation of QA

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in your facility. ? Show strong

commitment and leadership? Involve all

staff- do not leave it to a privileged

few? Provide data for the need to

change to all staff? Communicate the

change message effectively and

continuously, listen and act upon

concerns from the staff? Allay fears of

staff- use consultations, discussions

workshops etc? Look for consensus

decisions, encourage those likely to be

affected to suggest solutions? Do not

initiate too many activities at a time?

Be transparent? Encourage innovations?

Involve staff in standards setting?

Monitor performance and provide

feedback to staff.

CHANGE MANAGEMENT

Principle OF QUALITY :

Improvement Requires Change

Every system is perfectly designed to

achieve exactly the results it gets

To improve the system, change the

system…

Principle #2:

Less is more

You cannot destroy productivity

When changing the system,

keep it simple

Understanding Change in the Hospital

Atmosphere

Change = not just doing

something different, but

engineering something different

at least one step in at

least one process

Hospital Atmosphere = hospitals

tend to be viscous, complex

systems with default levels of

performance change engineered

to improve performance can be a

foreign concept - or even overtly

resisted.

A Common Strategy Which Commonly

Fails:

Experts design a comprehensive

protocol using EBM over several

months

Protocol is presented as a

finished, stand alone product

Customization of protocol is

discouraged

Compliance depends on vigilance

and hard work

Monitoring for success or failure

is the exception to the rule (with

failures coming to light after

patients are harmed)

Flawed implementation leads to

repetitive efforts down the road

High-Reliability Strategies Commonly

Succeed:

Build a “decision aide” or

reminder into the system

Make the desired action the

default action (not doing the

desired action requires opting

out)

Build redundancy into

responsibilities (e.g. if one

person in the chain overlooks it,

someone else will catch it)

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Schedule steps to occur at

known intervals or events

Standardize a process so that

deviation feels weird

Take advantage of work habits or

reliable patterns of behavior

Build at least one - if not more -

of these high-reliability

strategies into any changed

process.

Change engineered to drive

improvement depends on…

Workplace Culture: personnel

must be receptive to change

Awareness: administrative and

medical staffs must care about

performance and support its

improvement through change

Evidence: local experts must

identify which research to translate

into practice

Experience: a skilled team must

choose, implement, and follow up

changes to ensure:

1) improvement efforts are ongoing

and yielding better performance

2) Productivity is preserved

AWARENESS OF THE LOCAL

PERFORMANCE GAP

Patient

Medical Staff

Administrative Support

EXPERIENCE WITH SIMILAR

IMPROVEMENT EFFORTS

Hospitalist Quality Officer

Multidisciplinary Team Members

Success Stories From Other Institutions

EVIDENCE TO TRANSLATE INTO

PRACTICE

“Bedside” Teaching

Didactic Teaching Sessions

Local Expertise in Disease Literature

WORKPLACE CULTURE READY TO

ACCEPT CHANGE

Task Load

Culture of Improvement

Culture of Negative Expectations

CONCEPTS ON TEAM MEMEBERSHIP

AND LEADERSHIP

Three types of team members…

1) Team Leader

2) Team Facilitator

3) Process Owners (members with

operational, hands-on fundamental

knowledge of the process)

Team Leader…

schedules and chairs team

meetings

sets the agenda (printed at each

meeting)

records team activities (working

documents in binder)

reports to management (Steering

Team)

often a member of Steering

Team

Team Facilitator…

owns the team process (enforces

ground rules)

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technical expert on QI theory

and tools

assists Team Leader

teaches while doing, within team

Process Owners…

chosen for fundamental

knowledge

will help implement

should become leaders (so

choose wisely)

Team Ground Rules…

All team members and opinions

are equal

Team members will speak freely

and in turn

– We will listen attentively

to others

– Each must be heard

– No one may dominate

Problems will be discussed,

analyzed, or attacked (not

people)

All agreements are kept unless

renegotiated

Once we agree, we will speak

with "One Voice" (especially

after leaving the meeting)

Honesty before cohesiveness

Consensus vs. democracy: each

gets his say, not his way

Silence equals agreement

Members will attend regularly

Meetings will start and end on

time

Hospitals have two dynamic levels

impacting performance:

1) Processes

tasks performed in series or in

parallel, impacting patient care and

potentially patient outcomes

all those affecting relevant aspects of

patient care

clinical decision making, order

writing, admission intake,

medication delivery, direct patient

care, discharge planning, PCP

communication, discharge follow-

up, etc

2) Personnel

skilled people with hearts and

minds, with variable levels of

attention, time, and expertise

– anybody who touches the patient or a

relevant process in the system

departments, physicians, clerks,

pharmacy, nursing, RT,

PT/OT/ST, care technicians,

phlebotomist, patient transport,

administration

What?

– is the right thing to do?

– will make the system more

effective?

Six Sigma Teams in Hospitals

Six Sigma teams are composed of

groups of individuals who bring

authority, knowledge, skills, abilities

and personal attributes to the project.

Interdepartmental teams are groups of

people with the skills needed to deliver

the value desired. Processes are

designed by the team to create the

value in an effective and efficient

manner. Management must see to it

that the needed skills exist in the

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organization. It is also management’s

job to see that they remove barriers to

cooperation.

PROCESS IMPROVEMENT TEAMS

Process improvement teams focus on

improving one or more important

characteristics of a process, e.g.,

quality, cost, cycle time, etc. The

focus is on an entire process, rather

than on a particular aspect of the

process. A process is an integrated

chain of activities that add value. A

process can be identified by its

beginning and ending states.

Process improvement teams work on

both incremental improvement KAIZEN)

and radical change (breakthrough). The

team is composed of members who

work with the process on a routine

basis. Team members typically report

to different bosses, and their positions

can be on different levels of the

organization’s hierarchy.

Process improvement projects must be

approved by the process owner, usually

a senior leader in the organization.

Process improvement teams must be

chartered and authorized to pursue

process improvement.

WORK GROUPS

Work groups focus on improvement

within a particular work area. The work

area is usually contained within a single

department or unit. The process owner

is usually the department manager.

Team members are usually at the same

level within the organization’s

hierarchy and they usually report to

one boss.

Work group members are trained in the

use of quality control techniques and

supported by management. The idea is

that all workers have an important

contribution to make to the quality

effort and the work group is one

mechanism for allowing them the

opportunity to make their contribution.

Quality circles

Quality circles (circles) are local groups

of employees who work to continuously

improve those processes under their

direct control. Here are some necessary

steps that must be completed before

circles can succeed:

Management from the top level to the

supervisory level must have a clear idea

of their organization’s purpose.

Everyone in the organization must be

committed to helping the organization

achieve its purpose.

Senior leadership must have an

effective organization for dealing with

company-wide issues such as quality,

cost, cycle time, etc. (e.g., the cross-

functional form discussed earlier).

Attention must be focused on processes

rather than on internal politics and

reporting relationships.

Personnel involved must be trained in

cooperation skills (e.g., team work,

group dynamics, and communication

and presentation skills). This applies to

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area supervisors and managers, not just

circle members.

Personnel involved must be trained in

problem-solving skills (e.g., the

traditional QC tools, the 7Mtools,

brainstorming, etc.).

Circle participation must be

encouraged by local management.

Merely grafting quality circles onto a

traditional command-and-control

hierarchy won’t work.

Reasons why work groups

fail

1. The quality circle in an American

Arm was isolated, not part of a

company-wide quality control effort. As

a result, circles were usually unable to

deal successfully with problems

involving other areas of the company.

There were no resources in other areas

to draw upon.

2. Key management personnel moved

about too frequently and circles were

not provided with consistent leadership

and management support.

3. Employees transferred in and out of

circle work areas too frequently.

Without stability in the membership,

circles never developed into effective

groups. Building effective teams takes

time.

Self-managed teams are away to

reintegrate work and flatten the

management hierarchy. If properly

implemented and managed, the result

can be improved quality and

productivity. If poorly implemented

and managed, the result can be added

problems.

Self-managed teams are often given

some of the responsibilities that, in

traditional organizations, are reserved

to management. This includes the

authority to plan and schedule work,

hiring, performance assessment, etc.

While difficult to implement

successfully, the result is a leaner,

more efficient organization, higher

employee morale, and better quality.

Several preconditions are necessary to

assure success:

1. Communicate and listen Encourage

two-way, honest, open, frequent

communication. The more informed

employees are, the more secure and

motivated they will be.

2. Train employees an empowering

culture is built on the bedrock of

continuing education in every form

imaginable. If an employee doesn’t

know what to do, how to do it right, or

most important, why it is done a

certain way and what difference it

makes, don’t expect him to feel or act

empowered.

3. Team employees No one has found a

technological alternative to

cooperation when it comes to building

a positive work climate. Teams make it

possible for people to participate in

decision-making and implementation

that directly affects them.

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4. Trust employees Support team

decisions even if they aren’t the

outcomes you had in mind. Trust teams

with information and allow them to

fail.

5. Feedback Find people doing things

right. Recognize efforts as well as

results by ending ways to frequently

and creatively say thank you. Share the

glory in every way possible. Give

frequent specific performance

feedback (good news as well as bad).

TEAM DYNAMICS

MANAGEMENT, INCLUDING

CONFLICT RESOLUTION

Conflict management is a duty shared

by the facilitator and the team leader.

The facilitator can assist the leader by

assuring that creative conflict is not

repressed, but encouraged. Explore the

underlying reasons for the conflict. If

‘‘personality disputes’’ are involved

that threaten to disrupt the team

meeting, arrange one-on-one meetings

between the parties and attend the

meetings to help mediate.

The first step in establishing an

effective group is to create a consensus

decision rule for the group, namely:

No judgment may be incorporated into

the group decision until it meets at

least tacit approval of every member of

the group.

This minimum condition for group

movement can be facilitated by

adopting the following behaviors:

Avoid arguing for your own position.

Present it as lucidly and logically as

possible, but be sensitive to and

consider seriously the reactions of the

group in any subsequent presentations

of the same point.

Avoid ‘‘win-lose’’ stalemates in the

discussion of opinions. Discard the

notion that someone must win and

someone must lose in the discussion;

when impasses occur, look for the next

most acceptable alternative for all the

parties involved.

Avoid changing your mind only to avoid

conflict and to reach agreement and

harmony. Withstand pressures to yield

which have no objective or logically

sound foundation. Strive for

enlightened flexibility; but avoid

outright capitulation.

Avoid conflict-reducing techniques such

as the majority vote, averaging,

bargaining, coin-flipping, trading out,

and the like. Treat differences of

opinion as indicative of an incomplete

sharing of relevant information on

someone’s part, either about task

issues, emotional data, or gut level

intuitions.

View differences of opinion as both

natural and helpful rather than as a

hindrance in decision-making.

Generally, the more ideas expressed,

the greater the likelihood of conflict

77 | P a g e


will be; but the richer the array of

resources will be as well.

View initial agreement as suspect.

Explore the reasons underlying

apparent agreements; make sure

people have arrived at the same

conclusions for either the same basic

reasons or for complementary reasons

before incorporating such opinions into

the group decision.

Avoid subtle forms of influence and

decision modification. E.g., when a

dissenting member finally agrees, don’t

feel that he must be rewarded by

having his own way on some subsequent

point.

Be willing to entertain the possibility

that your group can achieve all the

foregoing and actually excel at its task.

Avoid doom saying and negative

predictions for group potential.

Collectively, the above steps are

sometimes known as the ‘‘consensus

technique.’’ In tests it was found that

75% of the groups who were instructed

in this approach significantly

outperformed their best individual

resources.

Stages in group development

Groups of many different types tend to

evolve in similar ways. It often helps to

know that the process of building an

effective group is proceeding normally.

During the forming stage a group tends

to emphasize procedural matters.

Group interaction is very tentative and

polite. The leader dominates the

decision-making process and plays a

very important role in moving the group

forward.

The storming stage follows forming.

Conflict between members, and

between members and the leader, are

characteristic of this stage. Members

question authority as it relates to the

group objectives, structure, or

procedures. It is common for the group

to resist the attempts of its leader to

move them toward independence.

Members are trying to define their role

in the group.

It is important that the leader deal

with the conflict constructively. There

are several ways in which this may be

done:

Do not tighten control or try to force

members to conform to the procedures

or rules established during the forming

stage. If disputes over procedures

arise, guide the group toward new

procedures based on a group consensus.

Probe for the true reasons behind the

conflict and negotiate a more

acceptable solution. Serve as a

mediator between group members.

Directly confront counterproductive

behavior. Continue moving the group

toward independence from its leader.

During the norming stage the group

begins taking responsibility, or

ownership of its goals, procedures, and

behavior. The focus is on working

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together efficiently. Group norms are

enforced on the group by the group

itself.

The final stage is performing. Members

have developed a sense of pride in the

group, its accomplishments, and their

role in the group. Members are

confident in their ability to contribute

to the group and feel free to ask for or

give assistance.

Member roles and responsibilities

PRODUCTIVE GROUP ROLES

There are two basic types of roles

assumed by members of a group: task

roles and group maintenance roles.

Group task roles are those functions

concerned with facilitating and

coordinating the group’s efforts to

select, define, and solve a particular

problem.

Floundering- Review the plan. Develop

a plan for movement.

The expert - Talk to offending party in

private. Let the data do the talking

Insist on consensus decisions

Dominating participants - Structure

participation. Balance participation.

Act as gate-keeper

Reluctant participants- Structure

participation. Balance participation.

Act as gate-keeper

Using opinions instead of facts -Insist

on data. Use scientific method.

Attribution- (i.e., attributing

motives to people with whom we

disagree). Don’t guess atmotives. Use

scienti¢cmethod. Provide constructive

feedback

Ignoring some comments - Listen

actively.Train teamin listening

techniques. Speak to o¡ending party in

private.

Wanderlust -Follow a written agenda.

Restate the topic being discussed

Feuds - Talk to offending parties in

private. Develop or restate ground

rules.

Rushing things Provide constructive

feedback Insist on data. Use scienti¢c

method.

The development of task and

maintenance roles is a vital part of the

teambuilding process. Team building is

defined as the process by which a group

learns to function as a unit, rather than

as a collection of individuals.

Role ID- Group Maintenance

Encourager

Harmonizer

Compromiser

Gate-keeper

Standard setter

Observer/commentator

Follower

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Group task roles

Initiator- Proposes new ideas, tasks, or

goals; suggests procedures or ideas for

solving a problem or for organizing the

group.

Information seeker- Asks for relevant

facts related to the problem being

discussed.

Opinion seeker- Seeks clari¢cation of

values related to problemor suggestion.

Information giver- Provides useful

information about subject under

discussion.

Opinion giver- O¡ers his/her opinion of

suggestionsmade. Emphasis is on values

rather than facts.

Elaborator - Gives examples.

Coordinator- Shows relationship among

suggestions; points out issues and

alternatives.

Orientor- Relates direction of group to

agreed-upon goals.

Evaluator- Questions logic behind ideas,

usefulness of ideas, or suggestions.

Energizer- Attempts to keep the

groupmoving toward an action.

Procedure - technician Keeps group

from becoming distracted by

performing such tasks as distributing

materials, checking seating, etc.

Recorder - Serves as the group

memory.

COUNTERPRODUCTIVEGROUP ROLES

In addition to developing productive

group-oriented behavior, it is also

important to recognize and deal with

individual roles which may block the

building of a cohesive and effective

team. The leader’s role includes that of

process observer. In this capacity, the

leader monitors the atmosphere during

group meetings and the behavior of

individuals. The purpose is to identify

counterproductive behavior. Of course,

once identified, the leader must

tactfully and diplomatically provide

feedback to the group and its

members. The success of Six Sigma is,

to a great extent, dependent on the

performance of groups.

Aggressor- Expresses disapproval by

attacking the values, ideas, or feelings

of other. Shows jealousy or envy.

Blocker- Prevents progress by persisting

on issues that have been resolved;

resists attempts at consensus; opposes

without reason.

Recognition-seeker Calls attention to

himself/herself by boasting, relating

personal achievements, etc.

Confessor- Uses group setting as a

forum to air personal ideologies that

have little to do with group values or

goals.

Playboy- Displays lack of commitment

to group’s work by cynicism, horseplay,

etc.

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Dominator- Asserts authority by

interrupting others, using flattery to

manipulate, claiming superior status.

Help-seeker Attempts to evoke

sympathy and/or assistance from other

members through ‘‘poor me’’ attitude.

Special-interest pleader asserts the

interests of a particular group. This

group’s interest matches his/her self-

interest.

FACILITATION TECHNIQUES

When to use an outside facilitator

It is not always necessary to have an

outside party facilitate a group or

team.

While facilitators can often be of

benefit, they may also add cost and the

use of facilitators should, therefore, be

carefully considered. The following

guidelines can be used to determine if

outside facilitation is needed

(Schuman, 1996):

Distrust or bias- In situations where

distrust or biasis apparent or

suspected, groups should make use of

an unbiased outsider to facilitate (and

perhaps convene) the group.

2. Intimidation The presence of an

outside facilitator can encourage the

participation of individuals who might

otherwise feel intimidated.

3. Rivalry- Rivalries between individuals

and organizations can be mitigated by

the presence of an outside facilitator.

4. Problem de¢nitionLIf the problem is

poorly de¢ned, or is de¢ned di¡erently

by multiple parties, an unbiased

listener and analyst can help construct

an integrated, shared understanding of

the problem.

5. Human limits- Bringing in a

facilitator to lead the group process

lets members focus on the problem at

hand, which can lead to better results.

6. Complexity or novelty-In a complex

or novel situation, a process expert can

help the group do a better job of

working together intellectually to solve

the problem.

7. Timelines-If a timely decision is

required, as in a crisis situation, the

use of a facilitator can speed the

group’s work.

8. Cost- A facilitator can help the group

reduce the cost of meeting a signi¢cant

barrier to collaboration.

Selecting a facilitator

Facilitators should possess four basic

capabilities (Schuman, 1996):

1. He or she should be able to

anticipate the complete problem-

solving and decision-making processes.

2. He or she should use procedures that

support both the group’s social and

cognitive process.

3. He or she should remain neutral

regarding content issues and values.

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4. He or she should respect the group’s

need to understand and learn from the

problem solving process.

Facilitation works best when the

facilitator:

Takes a strategic and comprehensive

view of the problem-solving and

decision-making processes and selects,

from a broad array, the speci¢c

methods that match the group’s needs

and the tasks at hand.

Supports the group’s social and

cognitive processes, freeing the group

members to focus their attention on

substantive issues.

Is trusted by all group members as a

neutral party who has no biases or

vested interest in the outcome.

Helps the group understand the

techniques being used and helps the

group improve its own problem-solving

processes.

Principles of team leadership

and facilitation

Human beings are social by nature.

People tend to seek out the company of

other people. This is a great strength of

our species, one that enabled us to rise

above and dominate beasts much larger

and stronger than ourselves. It is this

ability that allowed men to control

herds of livestock to hunt swift

antelope, and to protect themselves

against predators. However, as natural

as it is to belong to a group, there are

certain behaviors that can make the

group function more (or less)

effectively than their members acting

as individuals.

We will define a group as a collection

of individuals who share one or more

common characteristics. The

characteristic shared may be simple

geography, i.e., the individuals are

gathered together in the same place at

the same time.

Perhaps the group shares a common

ancestry, like a family.Modern society

consists of many different types of

groups. The first group we join is, of

course, our family. We also belong to

groups of friends, sporting teams,

churches, PTAs, and so on. The groups

differ in many ways. They have

different purposes, different time

frames, and involve varying numbers of

people. However, all effective groups

share certain common features. In their

work, Joining Together, Johnson and

Johnson (1999) list the following

characteristics of an effective group:

Group goals must be clearly

understood, be relevant to the needs of

group members, and evoke from every

member a high level of commitment to

their accomplishment.

Group members must communicate

their ideas and feelings accurately and

clearly. E¡ective, two-way

communication is the basis of all group

functioning and interaction among

group members.

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Participation and leadership must be

distributed among members. All should

participate, and all should be listened

to. As leadership needs arise, members

should all feel responsibility for

meeting them. The equalization of

participation and leadership makes

certain that all members will be

involved in the group’s work,

committed to implementing the group’s

decisions, and satis¢ed with their

membership. It also assures that the

resources of every member will be fully

utilized, and increases the cohesiveness

of the group.

Appropriate decision-making

proceduresmust be used £exibly if they

are to be matched with the needs of

the situation. There must be a balance

between the availability of time and

resources (such as member’s skills) and

the method of decision-making used for

making the decision. The most e¡ective

way of making a decision is usually by

consensus.

Consensus promotes distributed

participation, the equalization of

power, productive controversy,

cohesion, involvement, and

commitment.

Power and in£uence need to be

approximately equal throughout the

group. They should be based on

expertise, ability, and access to

information, not on authority.

Coalitions that help ful¢ll personal

goals should be formed among group

members on the basis of mutual

in£uence and interdependence.

Con£icts arising fromopposing ideas and

opinions (controversy) are to be

encouraged . Controversies promote

involvement in the group’s work,

quality, creativity in decision-making,

and commitment to implementing the

group’s decisions. Minority opinions

should be accepted and used.

Con£icts prompted by incompatible

needs or goals, by the scarcity of a

resource (money, power), and by

competitiveness must be negotiated in

a manner that is mutually satisfying

and does not weaken the cooperative

interdependence of group members.

Group cohesion needs to be high.

Cohesion is based on members liking

each other, each member’s desire to

continue as part of the group, the

satisfaction of members with their

group membership, and the level of

acceptance, support, and trust among

the members. Group norms supporting

psychological safety, individuality,

creativeness, con£icts of ideas, growth,

and change need to be encouraged.

Problem-solving adequacy should be

high. Problems must be resolved with

minimal energy and in a way that

eliminates them permanently.

Procedures should exist for sensing the

existence of problems, inventing and

implementing solutions, and evaluating

the effectiveness of the solutions.

When problems are dealt with

83 | P a g e


adequately, the problem-solving ability

of the group is increased, innovation is

encouraged, and group effectiveness is

improved.

The interpersonal effectiveness of

members needs to be high.

Interpersonal effectiveness is a

measure of how well the consequences

of your behavior match intentions.

These attributes of effective groups

apply regardless of the activity in

which the group is engaged. It really

doesn’t matter if the group is involved

in a study of air defense, or planning a

prom dance. The common element is

that there is a group of human beings

engaged in pursuit of group goals.

Facilitating the group task

process

Team activities can be divided into two

subjects: task-related and

maintenance-related. Task activities

involve the reason the team was

formed, its charter, and its explicit

goals.

The facilitator should be selected

before the team is formed and he or

she should assist in identifying

potential team members and leaders,

and in developing the team’s charter.

The facilitator also plays an important

role in helping the team develop

specific goals based on their charter.

Goal-setting is an art and it is not

unusual to find that team goals bear

little relationship to what management

actually had in mind when the team

was formed. Common problems are

goals that are too ambitious, goals that

are too limited and goals that assume a

cause and effect relationship without

proof. An example of the latter would

be a team chartered to reduce scrap

assuming that Part X had the highest

scrap loss (perhaps based on a week’s

worth of data) and setting as its goal

the reduction of scrap for that part.

The facilitator can provide a channel of

communication between the team and

management.

Facilitators can assist the team leader

in creating a realistic schedule for the

team to accomplish its goals.

Facilitators should assure that

adequate records are kept on the

team’s projects. Records should

provide information on the current

status of the project.

Records should be designed to make it

easy to prepare periodic status reports

for management. The facilitator should

arrange for clerical support with such

tasks as designing forms, scheduling

meetings, obtaining meeting rooms,

securing audio visual equipment and

office supplies, etc. tasks as designing

forms, scheduling meetings, obtaining

meeting rooms, securing audio visual

equipment and office supplies, etc.

Other activities where the facilitator’s

assistance is needed include:

Meeting management- Schedule the

meeting well ahead of time. Be sure

84 | P a g e


that key people are invited and that

they plan to attend. Prepare an agenda

and stick to it! Start on time. State the

purpose of the meeting clearly at the

outset. Take minutes. Summarize from

time-to-time. Actively solicit input

from those less talkative. Curtail the

overly talkative members. Manage

conflicts. Make assignments and

responsibilities explicit and specific.

End on time.

Communication-The idea that ‘‘the

quality department’’ can ‘‘assure’’ or

‘‘control’’ quality is now recognized as

an impossibility. To achieve quality the

facilitator must enlist the support and

cooperation of a large number of

people outside of the team. The

facilitator can relay written and verbal

communication between the team and

others in the organization. Verbal

communication is valuable even in the

era of instantaneous electronic

communication. A five minute phone

call can provide an opportunity to ask

questions and receive answers that

would take a week exchanging email

and faxes. Also, the team meeting is

just one communication forum, the

facilitator can assist team members in

communicating with one another

between meetings by arranging one-on-

one meetings, acting as a go-between,

etc.

Facilitating the group

maintenance process

Study the group process. The facilitator

is in a unique position to stand back

and observe the group at work. Are

some members dominating the group?

Do facial expressions and body

language suggest unspoken

disagreement with the team’s

direction? Are quiet members being

excluded from the discussion?

When these problems are observed, the

facilitator should provide feedback and

guidance to the team. Ask the quiet

members for their ideas and input. Ask

if anyone has a problem with the

team’s direction. Play devil’s advocate

to draw out those with unspoken

concerns.

TEAM PERFORMANCE EVALUATION

Evaluating team performance involves

the same principles as evaluating

performance in general. Before one can

determine how well the team’s task

has been done, a baseline must be

established and goals must be

identified. Records of progress should

be kept as the team pursues its goals.

Performance measures generally focus

on group tasks, rather than on internal

group issues. Typically, financial

performance measures show a payback

ratio of between 2:1 and 8:1 on team

projects. Some examples of tangible

performance measures are:

productivity

quality

cycle time

grievances

85 | P a g e


medical usage (e.g., sick days)

absenteeism

service

turnover

dismissals

counseling usage

Many intangibles can also be measured.

Some examples of intangibles

effected by teams are:

employee attitudes

customer attitudes

customer compliments

customer complaints

The performance of the team process

should also be measured. Project

failure rates should be carefully

monitored. A p chart can be used to

evaluate the causes of variation in the

proportion of team projects that

succeed.

Failure analysis should be rigorously

conducted.

Aubrey and Felkins (1988) list the

effectiveness measures shown below:

leaders trained

number of potential volunteers

number of actual volunteers

percent volunteering

projects started

projects dropped

projects completed/approved

projects completed/rejected

improved productivity

improved work environment

number of teams

inactive teams

improved work quality

improved service

net annual savings

TEAM RECOGNITION AND

REWARD

Recognition is a form of employee

motivation in which the company

identifies and thanks employees who

have made positive contributions to the

company’s success. In an ideal

company, motivation flows from the

employees’ pride of workmanship.

When employees are enabled by

management to do their jobs and

produce a product or service of

excellent quality, they will be

motivated.

The reason recognition systems are

important is not that they improve

work by providing incentives for

achievement. Rather, they make a

statement about what is important to

the company. Analyzing a company’s

employee recognition system provides a

86 | P a g e


powerful insight into the company’s

values in action.

These are the values that are actually

driving employee behavior. They are

not necessarily the same as

management’s stated values. For

example, a company that claims to

value customer satisfaction but

recognizes only sales achievements

probably does not have customer

satisfaction as one of its values in

action.

Public recognition is often better for

two reasons:

1. Some (but not all) people enjoy

being recognized in front of their

colleagues.

2. Public recognition communicates a

message to all employees about the

priorities and function of the

organization.

The form of recognition can range from

a pat on the back to a small gift to a

substantial amount of cash. When

substantial cash awards become an

established pattern, however, it signals

two potential problems:

1. It suggests that several top priorities

are competing for the employee’s

attention, so that a large cash award is

required to control the employee’s

choice.

2. Regular, large cash awards tend to

be viewed by the recipients as part of

the compensation structure, rather

than as a mechanism for recognizing

support of key corporate values.

Carder and Clark (1992) list the

following guidelines and observations

regarding recognition:

Recognition is not a method by which

management can manipulate

employees. If workers are not

performing certain kinds of tasks,

establishing a recognition program to

raise the priority of those tasks might

be inappropriate.

Recognition should not be used to get

workers to do something they are not

currently doing because of conflicting

messages from management. A more

effective approach is for management

to first examine the current system of

priorities. Only by working on the

system can management help resolve

the conflict.

Recognition is not compensation. In this

case, the award must represent a

significant portion of the employee’s

regular compensation to have

significant impact. Recognition and

compensation differ in a variety of

ways:

Compensation levels should be based

on long-term considerations such as the

employee’s tenure of service,

education, skills, and level of

responsibility. Recognition is based on

the speci¢c accomplishments of

individuals or groups.

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Recognition is £exible. It is virtually

impossible to reduce pay levels once

they are set, and it is di⁄cult and

expensive to change compensation

plans.

Recognition is more immediate. It can

be given in timely fashion and

therefore relate to speci¢c

accomplishments.

Recognition is personal. It represents a

direct and personal contact between

employee and manager. Recognition

should not be carried out in such a

manner that implies that people of

more importance (managers) are giving

something to people of less importance

(workers).

Positive reinforcement is not always a

good model for recognition. Just

because the manager is using a certain

behavioral criterion for providing

recognition, it doesn’t mean that the

recipient will perceive the same

relationship between behavior and

recognition.

Employees should not believe that

recognition is based primarily on luck.

An early sign of this is cynicism.

Employees will tell you that

management says one thing but does

another.

Recognition meets a basic human need.

Recognition, especially public recog

nition, meets the needs for belonging

and self-esteem. In this way,

recognition can play an important

function in the workplace. According to

Abraham Maslow’s theory, until these

needs for belonging and self-esteem

are satisfied, self-actualizing needs

such as pride in work, feelings of

accomplishment, personal growth, and

learning new skills will not come into

play.

Recognition programs should not create

winners and losers. Recognition

programs should not recognize one

group of individuals time after time

while never recognizing another group.

This creates a static ranking system,

with all of the problems discussed

earlier.

Recognition should be given for efforts,

not just for goal attainment.

According to Imai (1986), a manager

who understands that a wide variety of

behaviors are essential to the company

will be interested in criteria of

discipline, time management, skill

development, participation, morale,

and communication, as well as direct

revenue production. To be able to

effectively use recognition to achieve

business goals, managers must develop

the ability to measure and recognize

such process accomplishments.

Employee involvement is essential in

planning and executing a recognition

program. It is essential to engage in

extensive planning before instituting a

recognition program or before changing

a bad one. The perceptions and

expectations of employees must be

surveyed.

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Health Care Quality

Healthcare

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