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Dear Readers,
Welcome to the October issue of SiteNews! We hope you have found the resources on the site to be helpful. For those of you who are first-timers this issue includes a quick overview of the new products uploaded and the feedback about the site.
We have decided to feature the products on Quality in this issue and hence we highlight a particularly effective available product on Quality Strategy worksheet for continually improving quality of services and checklist as the featured product of this month, a template to design the action plan, which will give you an idea on how to modify the present working system to achieve the quality of services on a sustainable basis. Also we have featured all the products on Quality for your easy reference.
This month we feature International Eye Foundation in the Collaborating Partner section.
In an eye hospital, refractive error service is the main source of income and hence in The Way it Works section, we present Estimation of Refractive Error Service for the Service Area Population tool (automated Excel sheet). This tool will help you to calculate potential for refraction services, Gross revenue and net revenue from sale of spectacles.
In addition to all our regular columns this issue provides you with an article Quality management in Eye Care that spotlights the integral part of Quality in any Organization.
Hope this issue will impart the resources which are worth to be read. Looking forward to come up with more resources in future.
Wish you a productive reading!

Happy reading!
Regards,
Vision 2020 e-resource team
The Issue Features...
Strategy worksheet for continually improving quality of services and checklist
Vol. 1 No.10 October 2004
•   Vision2020 e-resource
•   The Way it Works
•   Featured Product
•   Collaborating partner
•   Management Article

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As part of developing new products we have come up with the Ophthalmic Nursing Manual which could be used as a reference manual for the nurses.

Also we want to feature this issue as a Quality issue with the introduction of all the products on Quality that is available on our site.

To access all the products on Quality, go to the homepage of the site www.v2020eresource.org and enter your user name and password on the boxes provided at the end. This will take you to the Resource bank page where you will find the key areas and management processes. Or Please click on the following link to go directly to the Resource Bank page: Resource Bank - Simple Search

Checkmark the Quality box on the management processes and click Submit. The resources under this category of check will be listed down in 8 pages, with 36 products. You can find an Abstract, Guideline, Refer to friends, See Product, Write a Review and Place your vote for each product. Some of the most excellent products under this category are listed below:
  1. Quality Cataract Series (7 Modules)
  2. Quality Assurance Modules
  3. Articles on Quality
  4. Strategy Worksheet for continually improving the Quality of Services


All these materials are useful as a tool for building up the quality in your work. We are expecting your usage of the materials and the feedback.

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Introducing the Estimate Market Potential for Refractive Error Service Tool - A new tool that makes it possible to know the potential for an eye hospital in terms of estimating the magnitude of refraction services in a given service area population.

Eye hospitals are heavily dependent on the Refractive Services since this makes up the large part of their Service Delivery. The tool Estimating Refractive Error Services in the Service area population will be a boon to all those particularly planning to start the refraction services for a particular service area.

This tool will help to know the estimated annual demand/revenue of spectacles we need to estimate potential spectacle users in the service area population. This tool also helps you to calculate potential for refraction services, Gross revenue and net revenue from sale of spectacles. There is a User Manual which provides a layman a perspective on how to effectively use this tool or one has the option of the PowerPoint Broadcast to provide a Tutorial for complete understanding of the tool.

How to start the search:
You can access the tool on Estimating Refractive Error Services in the Service area population through these series of steps:
  1. Go to the homepage of the site by pasting the website address: http://www.v2020eresource.org/
  2. Click on the Resource Bank link provided at the Menu bar of the homepage.
  3. After the Resource Bank Page has loaded, please click on the Disease Strategies box.
  4. Check mark the Refractive Error Services box
  5. Check mark the Planning box on the Management Processes section and then click Submit at the bottom.
  6. You will be taken to a page which shows you the materials listed for this selection process
  7. In that page you can find the Estimating Refractive Error Services in the Service area population as the third and last product.
  8. You will find an Abstract and Guideline for the product and also the See Product link to see the full product.
  9. Also you will find the User Manual and Tutorial for the product.
  10. You can refer this product to your friend, Write a review to us and also vote the product about its usage.


Find the Product:
Have a look at the Excel Sheet by clicking here: Estimating Refractive Error Services in the Service area population. It gives you details on the Estimated Refractive Errors & uptake, Total number of potential Spectacles users, Estimated annual demand, Estimated revenue to make things more clear. More over you can provide your comments and suggestions by clicking on the Comments & Suggestions in Worksheet 1 of the Excel document.

You can download the User Manual and also have a look at the Tutorial we have prepared for this.

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This section features products which our voters have ranked highly. This month we are featuring Quality Assurance in Cataract Surgery. Currently our site contains all the modules of the Quality Assurance Series.
  1. Quality Assurance in Cataract Surgery
  2. Quality Assurance in Refractive Errors
  3. Quality Assurance in management of Microbial Keratitis
  4. Quality Assurance in management of primary Open Angle Glaucoma
  5. Quality Assurance in management of Primary Angle Closure Glaucoma

Quality Assurance in Cataract Surgery

Abstract:
This book deals with the diagnosis, how the cataract surgery is done, preoperative medication, anaesthesia, surgery procedure, phacoemulsification technique, and postoperative care with the IOL In-patient Record. Apart from this there are appendices on pre-operative evaluation, preoperative preparation and anesthesia, intra-operative considerations, postoperative management and pediatric cataract.

Guideline:
This module helps ophthalmologists working in private practice, group practice, private eye clinics, charitable eye hospitals, government eye care facilities, Administrators of eye care/ cataract surgery programmes, traditional healers and allied ophthalmic personnel when they have an attitude to adopt or adapt some of the strategies in addition to knowledge and skills gained from ophthalmological training and standard textbooks

Have a look at the product: Quality Assurance in Cataract Surgery This is a priced publication of Aravind. Visit our website http://www.aravind.org/publications/new/index.htm to order the product.

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International Eye Foundation:

We are delighted to collaborate with other resource centres and eye care websites. In this issue we wish to feature one of our collaborating partners: International Eye Foundation. Founded in 1961 by corneal transplant pioneer, Dr. John Harry King, Jr., IEF is a US based donor-supported non-profit foundation dedicated to helping people see by expanding eye care services for those in need, supporting programs targeting avoidable blindness - cataract, trachoma, river blindness, and childhood blindness, providing affordable ophthalmic supplies, equipment, and medicines, enhancing financial self-sufficiency of eye care providers to reduce dependence on aid.

Aravind and IEF:
Aravind and IEF are working together in the field of Eye Care to find strategies that work towards the elimination of global blindness. The development of this site is made through with the funding from IEF for the Capacity Building Project of Laico. With the encouragement from the effective partner we are trying out ways to collaborate with other Resource Centres and also in the development of newer resources for the site. Moreover IEF is the major partner for the setting up of Vision Centre at Theni - Ambasamuthiram, to create permanent access to the rural communities to increase the uptake of eye care services. IEF and Aravind continue to expand the range of activities which provide mutual strengthening of the organizations. Hence we place our deep appreciation in strengthening the relationship.

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Quality Management in Eye Care


Mr. R.Muralikrishnan, Faculty, Lions Aravind Institute of Community Ophthalmology


Be it an eye hospital or a multi-specialty hospital or any other organization none can deny that 'Quality' is an integral part of the natural order of doing business.

Putting forth the simple question; What is Quality? The answers can be in many angles. Some say it is more related to the benefits, some say value for money, others for service and delivery. Everyone (not only customers) has his/her own opinion(s) and that is the biggest hurdle in delivering quality. As providers (individuals/ institutions) we try to define quality based on our own perception and try to deliver "Quality" services on the criteria, which we view to influence "High Quality". In fact the real quality is the other way round. Any organization that tries to incorporate 'Quality' as an indispensable aspect of the delivery system should undergo a paradigm shift; Quality is what the customers' value. It is "their" perception that matters in assuring quality and not "ours".

Customers view quality in two major dimensions. Theoretically, these dimensions are called as Product Quality and Service Quality. Customers express satisfaction knowingly or unknowingly in these two dimensions. Explaining what these dimensions mean in the words of a layman: Product Quality is "What a customer gets" and Service Quality is "How a customer gets". The quality of the product that is being consumed is what is termed as Product Quality. The quality of service that accompanies the product is the Service Quality.

In service industries like hospitals, they do delivery products, which are called as 'Service'. The so-called product in a hospital can be what a patient comes to buy. Obviously the medical care. This does not mean that medical care can be termed literally as a product but is more of a parallel drawn. This accompanied by what is called, as other services are the two dimensions where patients rate quality knowingly or unknowingly. Moreover, the ratings are subjective to what is called as the expectations. Quality vis--vis expectations stems from different factors like previous self and other's experiences, image and good will of the organization in the community, money the customer pays, economic status, education etc. Thus quality as being rated on the so-called expectations enlightens the aspect that Quality starts with the understanding of the customer expectations. In other words, Quality starts with Marketing.

Furthermore, on both of these dimension patients have their own criteria on which quality is being rated. One major challenge faced while trying to deliver quality is the mismatch in the perception between the provider and the customer. This is what is being reflected upon in the introductory part of this article.

So, any organization trying to manage quality needs to measure what are the criteria regarded by "their customers". The usage of the words "their customers" has more of a marketing overtone. It refers to which specific segment of the customers is an organization targeting to. Applying the same concept to quality management in hospital scenario, the perception of the patients regarding the criteria on which they rate quality needs to be elucidated. These criteria differ from segment to segment of patients. The more clear the criteria are, the more focussed can be the quality delivery and not in a sort of 'babe-in-woods' approach of delivering quality on what we (providers) feel is right. When the direction is not known, it is like being in a 'maze'.

Relating specifically to Quality Management in eye care delivery systems (immaterial whether it is high volume or low volume), it is important to understand the two dimensions of quality in eye care delivery.
  1. Product Quality: Though eye care services are intangible, the visual outcome (the better visual acuity for the patients with no or low postoperative complications and infection rates) vis--vis quality of vision restored can be the 'product' that the patients expect. The patients rate the quality of visual outcome as a manifestation of clinical quality. However, this is not possible in all kinds of eye diseases but to a majority of them. The end 'product', what a patient looks for in an eye hospital can range from good quality of visual acuity, appropriate glass prescription, rehabilitation etc. depending upon the eye problem of the patient.
  2. Service Quality: The other aspects accompanying the so-called 'Product' like waiting time, cleanliness, behaviour of staff, clear information, supportive services, etc. to name a few is called as Service Quality. In brief, all the "How-the-customer-gets" aspects are considered as criteria on which patients make their rating. It is a clich to say that hospital's quality means only Clinical Quality. Today, patients are concerned more about the 'accompaniments' than just the medical care.

Keys to Quality Management
Understanding the dimensions of quality, it is also essential to understand a few broad keys for quality management. Though there are a lot of meticulous details to manage quality, these are but a few vital keys in managing quality.

Shared Vision for Quality
The initiative for any quality management programme is a good 'vision' for quality. The top management should be first convinced that quality has to form a part of the system. It is not just enough if the top management has a vision for quality. All the employees at all levels should possess this. Right from the Administrator to the Ophthalmologist to the Sweeper should share a common vision for quality. It becomes the responsibility of the top management to communicate and reinforce continuously on the vision. The vision can even be reflected in the day-to-day decision-making. The whole team should be aligned towards the 'common vision'. A clearly defined vision should be a feeling that accompanies every employee while executing his or her job. A vision is like a lighthouse to take the right path and help in better decision-making.

A vision for quality in a eye hospital should essentially take into account the development of a patient-oriented system. Alignment of the staff should be towards delivering a patient-centered process. Vision should encompass both the product quality (good visual outcome, appropriate prescription, safe medication, less complications, less infection, etc.) and the service quality (behaviour of the staff, clear information, cleanliness, etc.). Managing these aspects in a systematic and regular fashion helps in having a better 'Quality'. A vision as a lighthouse should fall in place before the quality initiative.

Quality Teams
With the presence of the vision, it needs to be translated into a feasible action. When the top management fulfills the visionary role, it is the intentionally created quality teams (not groups) who fulfill the executive role. The team should comprise of representatives of the top management (Chief Medical Officer, Administrator, Nursing Superintendent, etc.) and the appropriate staff. Depending upon the needs, the quality teams may have process (diagnostic, surgical, admissions, discharge, patient flow, etc.) improvement teams, quality improvement teams (infection control teams, surgery complications review teams, etc.), quality circles (small teams in each department for continuous improvement) etc. Participation of all the staff is a major impetus for making quality happen. Design for Quality

Standards of performance of activity or activities for all prime jobs of clinical and non-clinical aspects need to be set. These standards of performances are the targets and form what is called as 'Design for Quality'. Standardized clinical examination, surgical protocols, standards of cleanliness, standard of attitude of staff, etc needs to be developed for each key result area (where patients' expectations rise). For e.g., a patient who has come for a cataract surgery will expect good examination, good preoperative and postoperative, less complications, no infection, clear information, clean beds & rooms etc. Similarly for every activity in an eye hospital, there will be key result areas and standards of performance need to be set for moving ahead. The whole structure, process and outcome need to be tuned to this 'Design for Quality'. The costs associated with quality called the cost of 'Providing Quality' and 'Not Providing Quality' can be measured only with this 'Design for Quality'.

To keep up to the requirements of this design, training for all staff forms an important component while managing quality. "Quality staff" to provide quality service is the expected outcome of these trainings.

Continuous Improvement
Quality is a never-ending story. Measuring, monitoring, controlling and reviewing processes and activities are the heartbeats of continuous quality improvement. Process improvement, technology up gradation, human resources development, etc. adds to the continuous journey. Quality can never be achieved in a day because "Quality is what the Customer Values" and what the customer values changes from time to time, period-to-period and person-to-person.

References
  1. Whiteley,Richard .C, "The Customer Driven Company-Moving from Talk to Action" ; Addison-Wesley Publishing Company Inc.
  2. Thulasiraj R.D. and Muralikrishnan R., "Measuring Patient Satisfaction-Designing an Instrument"; Illumination, Vol.3, No.2, April to June, 1996,pg.6
  3. Oakland, John, "Total Quality Management-The Route to Improving Performance"; Butterworth Peinemann Publications, 2nd edition.