Quality Improvement in Hospitals

Submitted by:
Akram G. Ghabbour
Certified Quality Manager (American Society for Quality)

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Performance Indicators

system performance
indicators .
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) (External Factors Stakeholders
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Statistical Tool..
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Accreditation Programs


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Standards
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Patients' family rights, organization ethics
Patient care, emergency care, baby friendly hospital
Nursing services
Safety :
- environmental safety
- clinical safety
- infection control
- sterilization
- employee health program
Medical support services

- pharmacy
- laboratory
- blood bank
- radiology
Management of hospitals
- Housekeeping
- laundry
- kitchen
Accreditation tools:
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Standard

Hospitals have a specified list of procedures for

Not

Partially

Fully

met(0)

met(1)

met(2)

which consent is required from patients or other

authorized person and the list includes:
- surgery and invasive procedure
- anesthesia
- use of blood
- - research
Count
Score
Total


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Monitoring System:
Developing a monitoring system for quality is a long and tedious
process. It will consist of a series of interdependent steps including:
1. identify key aspects of care in public facilities that are worth
monitoring.
2. identify indicators and important clinical criteria for monitoring the
important aspects of care;
3. establish thresholds (levels, trends, patterns) when possible that will
trigger evaluation of the care;
4. develop data collection methodology: identify data elements and
sources of data;
5. develop automated modules essential for quality improvement program,
such as infection control, drug use, utilization data, and discharge
summary;
6. develop routine reporting system;
7. monitor the important aspects of care by collecting and organizing the
data for each indicator;

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TQM
Teamwork
- accreditation programs
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six six sigma
DMAIC sigma
DMAIC
Define, Measure, Analyze, Improve, Control DMAIC refers to a datadriven quality strategy for improving processes, and is an integral part of
the company's Six Sigma Quality Initiative. DMAIC is an acronym for five
interconnected phases: Define Measure, Analyze, Improve, and Control.
Each step in the cyclical DMAIC Process is required to ensure the
best possible results. The process steps are:
Define the Customer, their Critical to Quality (CTQ) issues, and the
Core Business Process involved.
Define who customers are, what their requirements are for
products and services, and what their expectations are
Define project boundaries the stop and start of the process
Define the process to be improved by mapping the process flow
Measure the performance of the Core Business Process
involved.
Develop a data collection plan for the process
Collect data from many sources to determine types of defects and
metrics
Compare to customer survey results to determine shortfall

Analyze the data collected and process map to determine root

causes of defects and opportunities for improvement.
Identify gaps between current performance and goal performance
Prioritize opportunities to improve
Identify sources of variation
Improve the target process by designing creative solutions to
fix and prevent problems.
Create innovate solutions using technology and discipline
Develop and deploy implementation plan
Control the improvements to keep the process on the new course.
Prevent reverting back to the "old way"
Require the development, documentation and implementation of
an ongoing monitoring plan
Institutionalize the improvements through the modification of
systems and structures (staffing, training, incentives)

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Environmental scanning

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.1 Set Mandate top management


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Sustain Improvement Results

.2 leadership :
Set Culture
Customer Focus
Rely on Data
Rely on Teams
participation
.3 Allocate Funds


.4 Gather Data and Select Problems


Corrective action
Preventive action
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 .5 Assign teams to problems

. facilitator

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.6 Implementation

) DEMING WHEEL(PDCA-Plan-D0-Check-Act
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prioritization matrix
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Process
Flow Charts

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brainstorming affinity diagrams ... fish bone diagram



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Monitoring system
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milestones .
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.10 Spread Improvement

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Impact of improvement efforts

Project

Reduced

Client

Market

Care

Employee

Cost

Satisfaction

Share

Outcomes

Work life

Clinic Enhancement

%30

%70

%60

Outdoor clinics
Purchases

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Tools
Brainstorming
Affinity Diagram
Pareto Diagram
Control charts
SIPOC Supplier-Input-Process-Output-Customer
QFD Quality Function Deployment
Balanced score card
Bench marking
Process charts
PDCA Plan Do Check Act
SPC Statistical Process Control
Five s
Cause and effect
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documentation
system standards processes
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auditing system .
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empowered employees

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