HEALTH CARE SYSTEM

PERFORMANCE
By: Masheal Alsouhih
Amjad Almutairi
Supervised by:
Dr.Hanan Algorashi
 Learning Objectives:
1. Provide an overview of Healthcare performance and it types
2. Discuss the importance of health care performance measurements.
3. Define the concepts of quality health care ,Total quality management,
quality improvement, Continues quality improvement, quality
assurance and clinical effectiveness
4. Explain the model of quality and six sigma model
5. Explain the methodology used to assess quality
 Outline:
1. Introduction
2. Healthcare performance measurements and its types.
3. The importance of healthcare performance measurements.
4. Quality health care ,TQM ,IQ,CQI, QA and clinical effectiveness
5. Models of quality and Six Sigma
6. Methods of Quality Assessment
 INTRODUCTION
Healthcare performance measurements
are aggregated, quantified and analyzed
data on a particular healthcare-related
activity. Their purpose is to identify
opportunities for reducing costs,
improving quality of care and
increasing efficiency of care delivery. ...
Quality and efficiency of patient care.
These measurement initiatives are typically
developed and operated with the active
involvement of the physicians and hospital
staff whose performance is being measured
— as well as government and other third-
party agencies — to ensure that the
measures are meaningful, and the data are
accurate.
Types of healthcare performance measurements
include:

1- Quality and efficiency of patient care

2- Cost of healthcare services
3- Disparities in performance
4- Care outcomes
There are many reasons why healthcare performance
measurements are important to healthcare
institutions and society in general:

● Good health is more important to people than most other

goods or services . Society has a strong collective interest in
assuring that the healthcare system works to ensure people
lead healthy lives as much as possible.
● Governments and individuals spend a lot on
healthcare. Not only do people collectively and individually
spend significant dollars on healthcare (and/or healthcare
insurance), these costs have risen quickly over time compared
to other economy sectors.
● People want to make informed decisions about their

healthcare. Objective performance measures help people make

better healthcare decisions because they can compare “apples

to apples” and seek the best care.

● Governmental bodies can make better healthcare

polices. Performance measurements provide solid background

data for legislative policy discussions about healthcare

programs and investments — indicating where improvements in

laws and mandates can be made.

Performance measurements provide one of the best ways to
spearhead overall health system and hospital improvements
by providing solid data on the current state of efficiencies
and effectiveness, including:
1- Evaluating and measuring that a facility or individual meets
established benchmarks.

2- Identifying gaps in care — especially where performance is

low, and remediation is needed.
3-Recognizing and rewarding above-standard performance — and
using these examples to create best practices.

4-Securing ongoing data to monitor information about changes in

quality of care over time.
 Prioritizing healthcare performance
measurements – which are more important?

1. Length of stay
Measures the length of time between a patient's admittance and discharge.
This metric gives an institution hard data over time on care efficiency.
2. Readmission rates
Tracks the percentage of patients that are re-admitted within 30 days of
their discharge. Hospitals are able to quantify the quality of care patients
received. A large percentage of readmissions may mean that patients are
receiving substandard care and providers are overlooking complications or
relevant patient data.
3. HCAHPS – patient satisfaction
The Hospital Consumer Assessment of Healthcare Providers and Systems
(HCAHPS) survey provides an extensive measurement of patient satisfaction
— from care quality to facility cleanliness
4- Mortality rates
How many patients die during a hospital stay before being discharged?
This measurement indicates how well an institution can stabilize a
patient's condition following surgery or another procedure.
5- Bed utilization rate (or bed occupation rate)
Measures how many hospital beds are being used at any given time. If
there are too many hospital beds available, a hospital many lose money
because staffing and maintenance costs remain relatively constant — no
matter the number of patients.
6- Hospital incidents
Measures the consequences from unexpected side effects of hospital
procedures. The metric is an important indicator of whether a hospital
has the procedures in place to give high-quality care without triggering
an incident.
7- Average cost per discharge
Helps hospitals understand where there may be overspending and where
they can make the most profit. Hospitals gain useful data, so they can
better analyze which patient care costs best improved patient outcomes.
8- Operating margin
Gauges the institution’s revenues after subtracting all operating costs —
though typically, most hospitals do not have a positive margin. If a
facility cannot maintain close to break even or better, the ability to enlist
staff and provide quality patient services may suffer.
9- Bad debt
Bad debt is revenue not received — all or in part — for patient care.
However, lack of payment is only considered bad debt if there has been
an event in a patient's life, such as unemployment, that keeps them from
paying for care.
Quality health care
Quality Health Care
Quality: is the degree of excellence.

Quality of care the degree to which health services for individual

and population increase and are consistent with current
professional knowledge.

Quality of care is predicted on positive outcomes, customer

satisfaction and cost efficiency.
Quality health care
Quality health care can be defined in many ways but
there is growing acknowledgement that quality health
services should be:
• Effective – providing evidence-based healthcare
services to those who need them
• Safe – avoiding harm to people for whom the care is
intended
• People-centred – providing care that responds to
individual preferences, needs and values.
To realize the benefits of quality health care, health services
must be:
Timely – reducing waiting times and sometimes harmful
delays
Equitable – providing care that does not vary in quality on
account of gender, ethnicity, geographic location, and socio-
economic status;
Integrated – providing care that makes available the full
range of health services throughout the life course;
Efficient – maximizing the benefit of available resources
and avoiding waste.
Is Quality Costly?

Poor quality is costly

Non-conformance-----Cost to fix it
Conformance -----Cost to evaluate
and improve
COMPARATIVE COST OF QUALITY

● Defect prevention : $1

● Inspection & testing to catch and correct

Defects. Cost of Correcting errors while
patient is still at healthcare facility. $10

● Customer is dissatisfied with the service.

Cost of getting patient to come back
from home : $100
● What is Clinical Effectiveness

● Clinical effectiveness is a collection of activities and tools, based

on research and measurement that are used to improve the
quality of healthcare. The activities include, but are not limited
to, guidelines, audit, research and evaluation.
QUALITY ASSURANCE

● Refer to the organizations effort to provide services

according to acceptable professional standard and
in a manner acceptable to the clients.

● Is a process of checking to see whether a services

being developed is meeting specified requirements.
Total Quality Management
Total Quality Management

Is holistic ,organization- wide approach

to maintaining and improving quality.

TQM has been identified as a structured system for

involving an entire organization in a continuous quality
improvement process target to meet and exceed customer
expectation
TQM CHARACTERISTICS
Four core characteristics of total quality
management are :
• Prevention
• Leadership
• Customer Satisfaction
• Adaptability
 Quality assurance Quality improvement

• Detection oriented • Preventive oriented.

• Narrow focus • Cross- functional.
• Responsibility of few • Responsibility of all
• Leader as director.
• Leader as empowered
• Reactive
• Proactive
• Externally directed
• Internally directed
• Retrospective
• Prospective
• Who focused ( negative) Is a
• Why focused. Is integrated activity
separate activity
CONTINUES QUALITY IMPROVEMENT
(CQI)
● Is the process used to improve quality and
performance, that focuses not only on fixing
problems , but also searching continually for
methods to improve and make more cost effective
the delivery of services.
Concepts of Continuous Quality
Improvement
1-Quality can be defined by how well we meet the needs of
those we serve.

2-Most problems are in process not people.

3-Unintended variation in processes can lead to unwanted

variation in outcomes.

4-Continual improvement can be achieved through serial

experimentation.
Principles of QI
1-QI work as systems and processes.
2-Focus on patients .
3-Focus on being part of the team .
4-Focus on use of the data .
CONTINUOUS QUALITY
IMPROVEMENT
- Deming introduced (Focus-PDCA) the plan, do, check, act cycle.

-This cycle preceded by asking three questions to define the problems

and focus on the quality improvement process:
• Application to pain management
Ask the 3 questions to improve the care of miss Kelly she is in pain
1 What are we trying to accomplish?
2 How will we know that a change is an improvement?
3 What changes can we make that will result in improvement?
1. Plan: Creating an action-plan for team members to
implement. Creating an action plan requires identifying
all the necessary tactical steps, assigning
accountability or responsibility for each step, and
creating a timeline for completion.

2. Do: Implement the planned change, completing the steps in

the action plan and holding people accountable for
assigned steps and time lines.
3-Check: Check the results to see whether the
improvement efforts truly made a difference.

4-Act : Act on those results , distribute new policies to

key individuals, and Inform and educate all involved.
 HAPU PREVENTION
- Committee formation
-Prevent harm from HAPU - Identify best practice
-Raise awareness. - Audit Design
- Standardized practice - Develop action plan
- Leadership
- Committee agreement

-Audit documented care

- Observe practice
Implement standard intervention -Report incidents
Implement high risk intervention investigation
Implement action plan - Sharing findings
- Review action plan
 FOCUS METHODOLOGY
● F: focus on improvement idea , in this step asks the questions
what is the problem , data are obtained to support the
hypotheses that an opportunity for improvement exist.
● O: organize a team that knows the process.
● C: clarify what is happening in the current process.
● U: understand the degree of change needed.
● S: solutions, select a solution for improvement.
 MODELS OF QUALITY
Donabedians quality framework (1980) of structure, process and outcomes

● Quality measured by three aspects of:

● Structure standards: focus on the internal characteristics of organization and
its personal , these standards regulate the environment to ensure quality and
answer the question, is the structure in place that will allow quality to exist?

● (E.X ) nursing department provides in-service and opportunities for staff

and development.
 PROCESS STANDARD

● Focusing on whether the activities within an organization are being

appropriately conducted, these standards targeted behaviour,
activities, interventions, and the sequences of care giving events.

● (E.X) A nursing assessment will be done for each clients within

24 hours of initial client contact.
 Outcome standard
● Is the results of all the health care providers `activities , outcome
measure evaluate the effectiveness of nursing activities by
answering such question as, Did the patient recover?

● Outcome standard s address indicators such as physical and

mental health , social and physical function , health attitude,
knowledge, and behaviour ,utilization of resources and customer
satisfaction
S P O
What percentages of children have
received their immunizations?

Are there enough hospital beds to meet

the community’s demand in the event
of a catastrophe?

How many of my diabetics are receiving

yearly foot exams?

How many of my smoking patients

have successfully quit?
 Six Sigma
is another model for improvement. The term comes from
the use in statistics of the Greek Letter (sigma) to
denote Standard Deviation from the mean. 6 sigma is
equivalent to 3.4 defects or errors per million.

The method contains five steps: define, measure,

analyze, improve, and control (DMAIC).
1. In the define step, questions are asked about key
customer requirements and key processes to support those
requirements.
2. The measure step, key processes are identified, and data
are collected.
The analyze step, data are converted to
information. Causes of process variation are
identified.
The improve stage generates solutions and
measures process changes.
The control stage, Monitoring to evaluate ongoing
performance is done as part of this stage (Lee et al.,
2005).
METHODS OF QUALITY ASSESSMENT
A) Chart audit :
1. Prospective : a determination is

made before care begins.

2. Retrospective: Means that an audit

of the chart is done after discharge .

3. Concurrent: means ongoing at the

time of the client encounter

METHODS OF QUALITY ASSESSMENT
A. Observation.
B. Checklist
C. Statistical tools as run
charts, histogram, scatter
diagram, and praetor charts.
D. Non statistical tools: as
fishbone diagram or cause and
effect diagrams.
TOOLS OF CONTINUOUS QUALITY IMPROVEMENT

1. Benchmarking can involve comparisons of products, processes,

methods, and strategies.
2. Brainstorming is a simple group technique to stimulate creative
thinking, either to discover potential causes of a problem or potential
solutions. Such as Test strategy
3. Cause and effect.
4. Decision making.
5. Petro chart
6. The Histogram is a simple method to graphically represent
collected data and allow simple visual analysis of that data.
7. LEAN
 Cause and effect.
 Cause and Effect Diagram
 Identifies causesof problems
 Sorts ideas into categories
 Methods

 Machines (equipment)

 Manpower (people)

 Materials

 Measurement

 Environment
Pareto Charts
1. Visual depiction of significance and cumulative
accountability
2. Data driven
• Analysis of frequency of causes
• Prioritization/focuses attention on most significant
 Pareto Charts
80/20 Rule
Law of the vital few
Principle of factor sparsity

For many events, roughly 80% of the

effects come from 20% of the causes
(unequal distribution)

Most things in life are not distributed

evenly
LEAN
1. Maximize customer value while minimizing waste
2. Seven Forms of Waste
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Foster, Richard W.; Hughes, Edward F.X.; Boerstler, Heidi; O' Brien, James L.;
O'Connor, Edward J, January 01, 2010). Keys for Successful Implementation of
Total Quality Management in Hospitals