Quality Improvement

 Quality
• Key Concepts in
Quality  Quality management

 Quality Control

 Quality Assurance

 Quality improvement / process

improvement

 Quality Audit

 Evidence based process improvement

 What is Quality?

ISO 8402-1986 KQMH Institute of Medicine

Quality is "the Totality of features and The six dimensions of
characteristics of the quality in health care: are
totality of features
Kenyan healthcare cited as Safety,
and characteristics
system that relates to Effectiveness, Patient-
of a product or its ability to satisfy a centeredness, timeliness,
service that bears stated or implied efficiency and equity
its ability to satisfy health need (IOM, 2001)
stated or implied (Ministry of Health,
needs” 2014)
 Common terms in Quality
• Quality • Quality control: Quality Assurance:
Management: A Concerned with Refers to all activities
set of
checking and that contribute to
improvement defining, designing,
reviewing work
and assessment assessing, monitoring,
techniques and that has been
and improving the
tools to improve done (product or
quality of healthcare.
the overall end service), e.g. Focuses on ensuring
performance of exit interviews, strict adherence to a
systems client satisfaction set of processes for
including quality surveys, service
assurance inspection, testing delivery/production
techniques. and sampling. (e.g. SOPs, Guidelines)
to minimize defects or
variations in the final
products or services
 Common terms in Quality…..
• Quality
• Self Assessment: “A
Improvement: A cyclic, Quality Audit: The systematic
systematic comprehensive, examination of a quality
approach to the systematic, and system carried out by an
processes of regular review of an internal or external quality
work that looks organization’s auditor or an audit team.
to remove waste, activities and results Typically performed at
loss, rework, against a model of predefined time intervals and
frustration, etc., business excellence ensure that the institution
(E.g. the total has clearly defined internal
in order to make
quality management
the processes of system monitoring
models of the
work more quality awards)
procedures linked to effective
effective, culminating in action
efficient, and planned
appropriate improvement
actions. ”
 Dimensions of quality in
healthcare
Efficiency: The
• Technical
• Effectiveness ratio of the
performance:
: The degree outputs of services
The degree to
to the associated
which the tasks to which the
costs of producing
carried out by the desired results those services
health workers
(outcome) of (use of minimum
and facility meets
expectations of care are met effort/resource to
(ability to achieve desired
the technical
outcome)
quality achieve
(compliance with desired
standards, etc.)
outcome
 Dimensions of quality in
healthcare…..
• Safety: The degree to • Interpersonal relationships:
which the risks of Trust, respect, confidentiality,
courtesy, responsiveness,
injury, infection or empathy, effective listening,
other harmful side communication between
effects are minimized providers and clients
• Choice: When • Access to healthcare: The
degree to which healthcare
appropriate, client services are unrestricted to
choice of provider, geographical, economic,
insurance plan or cultural, social, organizational
treatment or linguistic barriers
 Dimensions of Quality in Healthcare…..
Patient centeredness: Putting • Physical Infrastructure
the client first. The client as a
and comfort: Physical
co-producer of the desired
health outcome at individual, appearance of the
family and community levels. facility and cleanliness,
Continuity of care: Delivery of comfort, privacy and
care by one care provider other aspects that are
throughout the course of care important to the clients
(where appropriate) and
appropriate and timely
referral and communication
between providers
 Healthcare
Approaches used in
Quality Management In Healthcare
• Common Quality Management Approaches
Implemented in the Kenyan Healthcare System

1. Collaboratives
2. Six Sigma / Lean Six Sigma
3. Standard-Based Management and Recognition (SBMR) - implemented in
Reproductive Health
4. Benchmarking
5. Performance Improvement Approach (PIA) – Human Technology
 Approaches used in
Quality Management In Healthcare….
6. Client Oriented, Provider Efficient (COPE)

7. Quality Assurance (Constitutes Defining Quality, Quality

Monitoring and Quality Improvement – The Quality
Assurance Triangle)
8. PDCA Cycle

9. 5S–CQI (KAIZEN)

10. Donabedian’s Structure–Process–Outcome

11. Total Quality Management (TQM) approach

 General Steps of Quality Management
• Identify: Determine what to improve
– Setting Standards/ Defining Quality
– Determine a Quality gap

• Analyse: Understand the problem

– Finding causes of quality gaps
• Develop hypothesis about what changes can improve the problem / close the quality
gap
– Taking action to close the quality gap
• Test and implement
– Taking action to close the quality gap
• Assess the achieved outcome and compare with desired outcome
 Introduction to A3
• What is A3?
 A tool that documents the PDCA problem solving cycle
 A3s serve as mechanisms for managers to mentor others in root-
cause analysis and scientific thinking
 A3 management is a system based on building structured
opportunities for people to learn in the manner that comes most
naturally to them:
o through experience,
o by learning from mistakes
o through plan-based trial and error
A3 Template
 Why Use A3
• It helps build problem –solving skills using root cause analysis
• A consistent approach to solving problems using the PDCA
cycle
• Keeps things simple and brief
• A3 is the international designation for paper size (11”x17”)
• Less space encourages simplification
• A way of structuring thinking
• A communication tool for workers to report problems and
improvement suggestions to management
• A way for quality improvement teams to structure and
“discipline” the improvement process
 The PDCA cycle
• Plan-Do-Check-Adjust
(PDCA) Cycle
The PDCA cycle is a scientific
method and approach for
problem solving

At the core of all quality

systems

The foundation for A3

 A3 Terms
Problem or Symptom: an issue or pain in a process that
causes dissatisfaction or an undesirable result.

Root Cause: The foundational reason a problem exists. If

this is solved, the problem will go away. Solving
symptoms does not make problems go away. Problems
must be solved at the root.

Solution: An action that is taken to resolve a problem or a

symptom or a foundational root cause.
 A3 Terms….
 Proposed Countermeasures: The term ”Countermeasures” is used
instead of “Solution.” Rather than saying a problem is “solved.”
– Countermeasures are temporary responses to specific problems
that will serve until a better approach is found or conditions
change.

 Implementation Plan: What are the main actions and outcomes

for executing the plan?
– This includes the 4Ws and IH, What, When, Where, Who and
How
A3 & PDCA
 Elements of A3
• Part I-Planning
 Common Snares for Part (I)
 Instead of a problem, a solution is listed
 There is no analysis of current state, no process walk, no
picture of a process map, or findings of an assessment
 No current state metric is identified
 Not involving stakeholders in identifying the problem
 The problem does not impact the customer
 The problem is dependent on other groups changing
rather than leading to change the A3 owner can impact
 The A3 owner has made themselves the customer (this
typically is stated, as “I’m not getting what I need.”)
 The scope of the project is either too broad or too narrow
 Elements of A3….
Part II-Analysis
 The analysis portion of the A3
• For beginners, the Analysis portion of the A3 is often skipped because people
move right to counter measures. As the problem solving skills get stronger,
people see the value in spending time exploring and confirming root causes
before implementing solutions
 The analysis portion of the A3 is where we explore possible root causes to the
problem

 Tools like the Fishbone Diagram and the 5 Whys can be displayed on the A3
 A Fishbone Diagram is used to brainstorm root causes- the head of the Fishbone
is the problem and the possible root causes are listed on the “bone”

 The 5Whys is the method of asking “why” until getting to the root cause
 5 Whys Example
The patient was late in theatre, it caused a delay. Why?

There was a long wait for a trolley. Why?

A replacement trolley had to be found. Why?

The original trolley's safety rail was worn and had

eventually broken. Why?

It had not been regularly checked for wear. Why?

The root cause - there is no equipment maintenance schedule

Example of a Fishbone Diagram
 Common Snares of Part (II) of the A3

 No analysis tools such as Fishbone Diagram or the 5 Whys

are used

 No root cause is conducted ( often occurs when a

solution is listed as the problem)

 The root causes start with “lack of… for example, “lack of
training,” which is another way of listing solutions
 Elements of A3….
• Part III- Countermeasures and Implementation
 Common Snares of Part (III) of the A3
 Someone’s pet solution is picked for implementation

 There is no agreement or involvement with workers from

the process regarding the counter measures

 Countermeasures were not discussed and agreed on by

stakeholders

 The countermeasures reduce work in one function, but

increase the workload for another function
 Elements of A3….
• Part IV-Follow up
 Common Snares of Part (IV) of the A3
 There is no follow-up and therefore the solution does
not stick

 The A3 is not shared- there is no communication

 The countermeasures are not checked- lost opportunity

to fine tune and adjust
 Next session-OFIs
1. Brainstorming
2. RCA
3. Value stream mapping (VSM)v
 QIT-Activity
• A3 projects -: Identify major challenges/problems in scm
affecting your facility(about 3-4)-must be achievable

• Project 101-: pick one of the major

challenges/problems in scm , follow the A3 steps until a
countermeasure/solution is found