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Sanil Joseph,
Quality is being used as a competitive weapon in the contemporary business world; healthcare is also not saved from its crutches. In fact, quality in healthcare is not just a competitive weapon but quite an inevitable aspect of medical care as it is dealing with the matter of life and death. Customers are becoming better informed and more demanding day by day. Patient satisfaction cannot be achieved by mere perfection in the clinical procedures. Effectively meeting the ever changing expectations of the patients in terms of the non clinical aspects is the greatest challenge of today. This article is an attempt to provide a birds eye view of the different concepts of quality assurance in health care.
Health services exist to meet the health needs of clients, the delivery of health services therefore should be designed to meet those needs. A focus on the client examines how and whether each step in a process is relevant to meeting client needs and eliminates steps that do not ultimately lead to client satisfaction or desired client outcomes. This focus on the client can be achieved by gathering information about the clients and then designing services to cater to the needs that are discovered. Client-focused organizations meet client needs and expectations, thereby providing higher quality care. This encourages clients to return when they need additional care and to recommend the services to others. Focus on Systems and Processes Quality management views all work in the form of processes and systems. Systems are the arrangement of organizations, people, materials, and procedures that together are associated with a particular function or outcome. A system consists of inputs, processes, and outputs/outcomes. A process is defined as "a sequence of steps through which inputs from suppliers are converted into outputs for customers." All processes are directed at achieving one goal or output from the system that encompasses the processes. Focus on Measurement In quality assurance, data are used to analyze processes, identify problems, test solutions, and measure performance. Data are important because they ensure objectivity. For example, the collection and analysis of data allow us to develop and test hypotheses. Comparing data from before and after a change can allow us to verify that the changes have actually led to improvements. Focus on Teamwork A team is "a high-performing task group whose members are interdependent and share a common performance objective" (Francis and Young 1992). Teams are important for Quality Assurance (QA) for several reasons. First, processes consist of interdependent steps that are executed by different people, so the group working within a process will understand it better than any one person. Including key people in the improvement of a process often involves clarifying and incorporating the insights and needs of clients into healthcare delivery. The participation of major stakeholders improves the ideas generated, builds consensus about changes, and reduces resistance to change. Moreover, mutual support and cooperation arise from working together on a project, leading to increased commitment to improvement. Such an atmosphere of support discourages blaming others for problems. Finally, the accomplishments of a team often increase the members self-confidence. This empowers staff to work towards the goal of quality by motivating them to contribute their knowledge and skills to improve organizational and individual performance. Dimensions of Quality The application of medical science and technology in a particular way maximizes its benefits to health without correspondingly increasing its risks. The degree of quality is, therefore, the extent to which the care provided is expected to achieve the most favorable balance of risks and benefits (Avedis Donabedian 1982). The most comprehensive and perhaps the simplest definition of quality is that used by advocates of total quality management (W. Edwards Deming 1982): Doing the right thing right, right away. Experts generally recognize several distinct dimensions of quality that vary in importance depending on the context in which a QA effort takes place. The following nine dimensions of quality have been developed from the technical literature on quality and synthesize ideas from various QA experts. Together, they provide a useful framework that helps health teams to define, analyze, and measure the extent to which they are meeting program standards for clinical care and for management services that support service delivery. While all of these dimensions are relevant to developing country settings, not all nine deserve equal weight in every program. Each should be defined according to the local context and specific programs. Technical performance: The degree to which the tasks carried out by health workers and facilities meet expectations of technical quality (i.e., adhere to standards) Access to services: The degree to which healthcare services are unrestricted by geographic, economic, social, organizational, or linguistic barriers Effectiveness of care: degree to which desired results (outcomes) of care are achieved Efficiency of service delivery: The ratio of the outputs of services to the associated costs of producing those services Interpersonal relations: Trust, respect, confidentiality, courtesy, responsiveness, empathy, effective listening, and communication between providers and clients Continuity of services:Delivery of care by the same healthcare provider throughout the course of care (when appropriate) and appropriate and timely referral and communication between providers Safety: The degree to which the risks of injury, infection, or other harmful side effects are minimized Physical infrastructure and comfort: The physical appearance of the facility, cleanliness, comfort, privacy, and other aspects that are important to clients Choice: As appropriate and feasible, client choice of provider, insurance plan, or treatment. Measuring Quality Measuring quality consists of quantifying the current level of performance according to expected standards. It is the systematic identification of the current level of quality the facility or system is achieving. The QA approach to Measuring Quality is inextricably linked with defining quality, since the indicators for quality measurement are derived from the specific definition or standard under scrutiny. Quality cannot be measured without a clear definition or standard. Likewise, measuring quality leads directly to the identification of areas for improvement or enhancementthe first step in improving quality. Successful improvement ultimately contributes to attaining quality care, the goal of quality assurance. QA activities that are part of measuring quality include quality assessment, quality monitoring, and external evaluation of quality. Quality assessment is the measurement of the quality of healthcare services. Quality assessment measures the difference between expected and actual performance to identify opportunities for improvement. Performance standards can be established for most dimensions of quality, such as technical competence, effectiveness, efficiency, safety, and coverage. Where standards are explicit, quality assessment measures the level of performance according to those standards. For dimensions of quality where standards are more difficult to identify, such as continuity of care or accessibility, quality assessment describes the current level of performance with the objective of improving it. Quality assessment is often an initial step in a larger QA process which may include providing feedback to health workers on performance, training and motivating staff to undertake quality improvements, and designing solutions to bridge quality gaps. Quality Improvement Approaches Rapid Team Problem Solving. Rapid team problem solving is an approach in which a series of small incremental changes in a system is testedand possibly implementedto improve quality. This approach entails many small to medium size tests of individual changes in similar systems. Like individual problem solving, this approach could be used in any setting, although it generally requires that teams have some experience in problem solving and/or seek a mentor to help implement this approach quickly. This approach to quality improvement is less rigorous in the time and resources required than the next two approaches because it largely relies on existing data and group intuition, thereby minimizing lengthy data collection procedures. Rapid team problem solving may involve cause analysis, but implemented in a less rigorous fashion than in systematic problem solving. Teams are ad hoc (temporary) and disband once the desired level of improvement has been achieved. Systematic Team Problem Solving. Systematic team problem solving is often used for complex or recurring problems that require a detailed analysis; it frequently results in significant changes to a system or process. The mainstay of this approach is a detailed study of the causes of problems and then developing solutions accordingly. This detailed analysis usually involves data collection and therefore often requires considerable time and resources. While systematic team problem solving can be used in any setting, due to its in-depth nature, it is most appropriate when the ad hoc team can work together over a period of time. Typically, such teams disband once sufficient improvement objectives are reached. Continuous Improvement of Quality (Performance Improvement & Benchmarking) Performance Improvement Performance Improvement (PI) is a methodology for improving the quality of institutional and individual performance. PI grew out of the realization that poor job performance seldom is due solely to the performers lack of skills and knowledge, but usually to other factors in the system. PI is often used interchangeably with Human Performance Technology (HPT). The International Society for Performance Improvement defines HPT/PI as "a set of methods and procedures, and a strategy for solving problems, for realizing opportunities related to the performance of people. It can be applied to individuals, processes, and organizations. It is, in reality, a systematic combination of three fundamental processes: performance analysis, cause analysis, and intervention selection." PI has attracted much attention lately in the international development community, due largely to the enthusiasm of the USAID Office of Population, which is encouraging cooperating agencies to adopt PI. There are many similarities and some differences between PI and Quality Improvement (QI). Although PI and QI arise from different beginnings, both take a systems view. Both methodologies are continually evolving, and that there is no discrete boundary between them. Benchmarking Benchmarking is a process for finding, adapting, and applying best practices. The term "benchmarking" was first used by the Xerox Corporation of Rochester, New York in the 1970s to describe "the continuous process of measuring products, services, and practices against the companys toughest competitors or those companies renowned as industry leaders." Benchmarking typically focuses on innovation in managing a given work system or process, while the "benchmark" is the measure by which that system or process is judged to be successful or effective. Because benchmarking is a quality improvement approach focused on processes, the process of interest must be defined. This is partly why many benchmarking efforts are connected to larger business or strategic planning processes. However, benchmarking can be used as a stand-alone tool for developing a new service or improving an existing one. One of the important ideas to keep in mind is that benchmarking does not mean replicating someone elses process exactly, but rather seeking out aspects of a successful process that could improve your own work. There are many types of benchmarking: internal, competitive or external, generic process, etc. The main difference between types of benchmarking is the source of information about innovative processes. For example, an outpatient clinic manager seeking to improve client registration may wish to visit other hospital departments to identify "internal" innovations or visit outpatient clinics in other hospitals to find "external" sources of innovation. Talking with employees from a hotel known for its client focus and efficient check-in process may offer important lessons in client registration from a "generic process" point of view. Institutionalizing Quality Institutionalization is an ongoing process in which a set of activities, structures, and values becomes an integral and sustainable part of an organization. Quality assurance will be institutionalized when it is formally and philosophically incorporated into the structure and functioning of a health system (or organization), consistently implemented, and supported by a culture of quality, as reflected in organizational values and policies that advocate quality care. QA and improved quality of care require more than a technical approach of tools and methods. Sustained improvements often require a change in attitude and sense of ownership for the quality of services provided by an organization. Many supporting factors are required to integrate QA into the structure and function of an organization. These building blocks or essential elements of institutionalization can be broadly classified under the following heads:
An internal environment conducive to initiating, expanding, and sustaining QA is necessary to institutionalize QA. Such an enabling environment includes the following elements, each important individually, but also supportive of each other in a synergistic fashion:
The institutionalization of QA requires a clear delineation of oversight roles and responsibilities and accountability for the implementation of QA activities. The specific organizational structure for implementing QA can vary greatly from one organization to another, and will evolve over time as the QA program matures. There is no "correct" or "best" structure; an effective structure for QA may combine many forms, such as a QA unit, quality improvement teams at facilities, or an oversight committee. Whatever form the QA structure takes, institutionalization needs mechanisms to ensure oversight, coordination, delegation of roles and responsibilities, and accountability. As QA becomes more integrated into the job descriptions (roles and responsibilities) of staff throughout the organization, the type of oversight required shifts, as does its location. Routine management structures (such as a district management committee) may assume daily oversight of QA activities, and the role of the designated QA unit may become more focused on the development of standards. In other situations, early QA activities may be coordinated through a more umbrella-like structure as the program is taking shape. Accountability for results achieved and for the resources used to achieve those results is imperative. Essential Support Functions In addition to creating an internal environment that supports a culture of quality, provides resources and guidance for implementation, and has outlined clear roles and responsibilities for QA, those performing the day-to-day implementation of QA require more specific types of support. As the name implies, support functions provide "support" for the staff to undertake and sustain technical QA activities. The development of ongoing systems to ensure QA capacity building, communication of QA efforts, and rewarding quality work are critical for an organization to move beyond performing QA as isolated activities, to a state of continuously implemented QA, embedded in the organizational work ethic. There are many other support functions, such as logistics and financial management, but these three have particular importance in QA institutionalization. In sum, quality improvement is a continuous effort by all the members of an organization to meet and exceed the needs and expectations of the patients and other customers. The goal is to not merely meet standards of care or to see them as limits (ceilings) to which we strive, but to exceed these standards. Performance assessment or measurement (QA) is a necessary step but it is not the endit is the first step in a continuous cycle of improving quality. Quality is an institutional philosophy, a mind set and a way of life. It is a process of transforming the culture and creating a Quality Culture for the institution. Implementation of Quality Management is process oriented although there are some technical and professional know-how in this process. The emphasis should be on management of changes and teamwork. Rererences:
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