INTRODUCTION
TO
Continuous Quality
Improvement
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Continuous Quality Improvement in the Hospital
1
Activity 1:
Group yourselves into six (6)
1) Choose your leader
2) Choose your group name
3) Make your group cheer
4) In a sheet of paper write the name of your
group, group leader, and members together
with the respective ward
Group Name
Name
Group Leader
Group Members
Ward Assignment
Activity 2:
Think of your organization….
Medical Center
Think of your respective ward….
V Luna
1) Write three (3) words that BEST describe
your ward
2) Write three (3) words that LEAST
describe about your ward
Activity 3:
Think of your organization ….. V Luna Medical
Center
Think of your ward…..
What do you like most about your ward.
Write three (3) of them.
2) What do you like least about your ward.
Write three (3) of them.
1)
METACARDS ……
HISTORY OF CQI
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Quality in 21st Century
➢ As
we move into the 21st century, TQM
has developed in many countries into
holistic frameworks, aimed at helping
organizations achieve excellent
performance, particularly in customer and
business results.
➢ In
Europe, a widely adopted framework is
the so-called “Business Excellence” or
“Excellence” Model, promoted by the
European Foundation for Quality
Management (EFQM), and in the UK by
British Quality Foundation (BQF).
7
BENCHMARKING
“ Learning from the BEST in the World”
• Before
• Now
Japan
Germany
•
No. 1 in making
CAMERA
Japan
Switzerland
•
No. 1 in making
WATCHES
Japan
U. S. A.
•
No. 1 in
ELECTRONICS
Turning point in TQM is during the
year 2000 when the Institute of
Medicine released a report on
1999 entitled “To Err is Human”
“To Err is Human” Report
44,000-98,000 deaths per year due to preventable
medical errors- exceeding even that of deaths
caused by motor vehicle accident, AIDS and
breast cancer
Medical error- failure of planned action to be
completed as intended or the use of planned
error
“To Err is Human” Report
Common medical errors are:
◦ Adverse drug events
◦ Improper transfusions
◦ Surgical injuries and wrong site injuries
◦ Suicides
◦ Restraint-related injuries or death
◦ Falls
◦ Burns
◦ Pressure ulcers
◦ Mistaken patient identities
“To Err is Human” Report
Unit most likely to occur in:
◦ Intensive care units
◦ Operating room
◦ emergency department
Types of error
Diagnostic
◦ Error or delay in diagnosis
◦ Failure to employ indicated tests
◦ Use of outmoded tests or therapy
◦ Failure to act on results of monitoring or
testing
Treatment Error
◦ Error in the performance of an operation,
procedure, or test
◦ Error in administering the treatment
◦ Error in the dose or method of using a
drug
◦ Avoidable delay in treatment or in
responding to an abnormal test
Inappropriate (not indicated) care
Quality Assurance vs. Quality Improvement
Quality Assurance
Quality Improvement
Individual focused
Systems focused
Perfection myth
Fallibility recognized
Solo practitioners
Teamwork
Peer review ignored
Peer review valued
Errors seen as opportunities for
learning
Errors punished
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Quality Assurance
-The
planned
and
systematic
activities
implemented in a quality system so that quality
requirements for a product or service will be
fulfilled.
-“ Quality Assurance is the defining of professional
practice through well written standards and the
use of those
standards as a basis for
evaluation on
improvement of client care”
(Maker 1998)
-
Quality Assurance Approaches
General Approaches:
1. Credentialing- formal recognition of professional or technical
competenced and attainment of minimum standards by a
person or agency (Hinsyak 1981)
2. Licensure- is a contract between the profession and the state,
in which the profession is granted control over entry into or
exits from the profession and over quality of professional
practice.
3. Accreditation- an organization may established
standards to inspect or evaluate a physical structure,
organizational structure, personal qualification and/or
outcomes of care.
4. Certification – usually a voluntary process within the
profession. A persons educational achievements,
experience and performance on examinations are used
to determine the qualification for functioning in an
identified specialty area.
Quality Assurance
Specific Approaches:
1.Peer Review-designed to monitor client specific
aspects of care appropriate for certain levels of
care. Major tool used is the audit.
2. Utilization Review- activities are directed towards
assuring that care is actually needed and that the
cost appropriate for the level of care provided.
Includes the development of explicit criteria that
serves as indicators of the need for services and
length of services. Types are: Introspective,
Concurrent and Retrospective.
3. Client satisfaction
4. Incident Review- during patient hospitalization unusual
incident may occur which have bearing on the course of
care
5.Risk Management- a program that is developed in
eliminating or controlling healthcare situations that has
the potential to endanger or create risk to client.
REGULATORY MANDATE
DEPARTMENT OF HEALTH
AO 2006-0002
Establishment of the Continuous Quality
Improvement (CQI) Program
and Committee in DOH Hospitals
PHILIPPINE HEALTH INSURANCE
CORPORATION
The Philhealth Benchbook
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DEPARTMENT OF HEALTH
ADMINISTRATIVE ORDER 2006-0002
Establishment of the Continuous Quality
Improvement (CQI) Program
and Committee in DOH Hospitals
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Congruent with the requirements of hospital licensure and the intent of Departmen Order
Nos. 310-J s. 2001 and 172-C s. 2003 on “The Creation of the DOH Steering Committee
and Technical Working Group for the Establishment of CQI Program for the Health
Regulation Cluster and DOH Hospitals” and its amendment respectively, to consistently
deliver and continuously improve the quality of health care to our people, there is a need
to institutionalize and establish the Continuing Quality Improvement.
22
WHAT IS CQI
“CONTINUOUS QUALITY IMPROVEMENT (CQI)
IS A PROCESS THROUGH WHICH THE LEVEL
OF QUALITY IS DEFINED, PURSUED, ACHIEVED
AND CONTINUOUSLY IMPROVED THROUGH
THE ESTABLISHMENT OF FORMAL
MECHANISM/ SYSTEMS AND STRUCTURE
WITHIN THE ORGANIZATION”
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CONTINUOUS QUALITY IMPROVEMENT
DESCRIBES THE OVERALL EFFORT OF
THE HOSPITAL ORGANIZATION TO
ACHIEVE THE MOST EFFECTIVE CARE
WITH THE AVAILABLE RESOURCES AND
WITHOUT COMPROMISING QUALITY
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DIFFERENT PERSPECTIVE OF
QUALITY
1. CLINICAL QUALITY
2. SERVICE QUALITY
3. CULTURAL QUALITY
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CUSTOMERS
INTERNAL – WORKING WITHIN ORGANIZATION
CO-WORKERS, PATIENTS, CONSUMERS
EXTERNAL – FAMILIES OF PATIENTS, CUSTOMERS,
SUPPLIERS, GOVERNMENT AGENCIES
FOCUS -ACHIEVE HIGHER LEVELS OF CUSTOMER
SATISFACTION
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GOALS
TO ENSURE THAT ALL CONSUMERS RECEIVE
THE HIGHEST QUALITY AND MOST COST
EFFECTIVE HEALTH SERVICES AVAILABLE
THROUGH THE DEVELOPMENT AND
MAINTENANCE OF A QUALIFIED, DIVERSE AND
ACCESSIBLE MULTIDISCIPLINARY NETWORK,
CARE AND SERVICE ORGANIZATIONS
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OBJECTIVES
1. TO ENSURE ESTABLISHMENT AND
INSTITUTIONALIZATION OF CQI PROGRAM IN
MANAGING QUALITY IN HEALTH CARE IN ALL
DOH LICENSED HOSPITALS
2. TO PROVIDE TRAINING AND OTHER FORMS
OF TECHNICAL ASSISTANCE RELATIVE TO
QUALITY IMPROVEMENT TO ALL HOSPITAL
STAFF
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FRAMEWORK
ONGOING CYCLE OF MONITORING PERFORMANCE
AND FEEDBACK TO IMPROVE OUTCOME
QUALITY IMPROVEMENT TOOLS – ALIGNED WITH
MISSION, VISION
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PRINCIPLES OF CQI
1. ALL WORK IS SERVICE TO OTHERS
– OUR CUSTOMERS
2. QUALITY IS ACHIEVED BY IDENTIFYING AND
CONSISTENTLY MEETING THE NEEDS,
REQUIREMENTS AND EXPECTATIONS OF OUR
CUSTOMERS
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PRINCIPLES OF CQI
3.
ALL WORKS IS PART OF A PROCESS THAT
SERVES CUSTOMERS AND IS ORGANIZED
AROUND THE NEEDS FIRST.
4.
QUALITY SERVICE IS THE RESULT OF
TEAMWORK ORGANIZED AROUND A PROCESS
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PRINCIPLES OF CQI
5.
PART OF DAILY WORK IS TO IMPROVE
PROCESSES BY REDUCING VARIATION
6.
USE OF DATA AND MEASUREMENT IS KEY TO
IMPROVING PROCESSES AND OUTCOMES
7.
MANAGEMENT COMMITMENT TO QUALITY
PRINCIPLES AND PRACTICES IS ESSENTIAL
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COMPONENTS OF CQI
1.
LEADERSHIP AND MANAGEMENT
2.
QUALITY IMPROVEMENT
3.
RISK MANAGEMENT
4.
SYSTEM OF DOCUMENTATION AND REPORTING
5.
RESOURCE MANAGEMENT
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IMPLEMENTING MECHANISM
HOSPITAL CQI COMMITTEE
COMPOSITION:
CHAIR: CHIEF OF MEDICAL PROFESSIONAL
SERVICES
VICE CHAIR:
ADMINISTRATIVE OFFICER
CORE MEMBERS:
CHIEF NURSE
HOSPITAL TRAINING OFFICER
DEPARTMENT HEADS/SUPERVISORS
MEDICAL STAFF REPRESENTATIVE OR
PRESIDENT OF THE MEDICAL STAFF ORGANIZATION
MEDICAL RESIDENTS REPRESENTATIVE OR
PRESIDENT OF THE MEDICAL RESIDENTS ORG.
FINANCE OFFICERS
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FUNCTIONS OF CQI COMMITTEE
1.
2.
3.
4.
5.
DEVELOP A GENERAL FRAMEWORK OF THEIR
CQI PROGRAM
RECOMMEND INTERNAL POLICY DIRECTIONS
TO HOSPITAL MANAGEMENT
OVERSEE THE CQI ANNUAL PLANNING
ACTIVITIES AND QA PROGRAM IN THE
HOSPITAL
RECOMMEND IMPLEMENTING GUIDELINES &
STRATEGIES WITHIN THE HOSPITALS
EXERCISE OVERALL SUPERVISION,
TECHNICAL MANAGEMENT & COORDINATION
OF THE PROGRAM AMONG THE DIFFERENT
HOSPITALS UNITS
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FUNCTIONS OF CQI COMMITTEE
6.
7.
8.
9.
OVERSEE THE IMPLEMENTATIONOF QA ACTIVITIES
SUCH AS THE USE OF CPG AND TREATMENT
PROTOCOLS
RESOLVE ISSUES RELATED TO THE
IMPLEMENTATION OF THE PROGRAM
PROVIDE PERIODIC FEEDBACK TO THE CHIEF OF
HOSPITALS AND SEMI-ANNUAL REPORTS TO THE
FIELD IMPLEMENTATION AND COORDINATION TEAM
FOR LUZON AND NCR, VISAYAS AND MINDANAO,
COPY FURNISHED POLICY STANDARDS
DEVELOPMENT TEAM FOR SERVICE DELIVERY
IMPLEMENTATION OF THE PHIC BENCHBOOK ON
QUALITY ASSURANCE
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Continuous Quality Improvement in the Hospital
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CQI COMMITTEE DELIVERABLES
1.
CQI PROGRAM INCLUDING INTERNAL HOSPITAL
POLICIES & GUIDELINES BASED ON THE
RECOMMMENDED FRAMEWORK DISCUSSED
PREVIOUSLY
2.
ANNUAL CONTINUING QUALITY IMPROVEMENT
(CQI) PLANS AND ACTIVITIES
3.
ANNUAL TRAINING PROGRAM ON CONTINUING
QUALITY IMPROVEMENT (CQI) AND TOTAL
QUALITY MANAGEMENT (TQM) FOR THE
HOSPITAL STAFF
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CQI COMMITTEE DELIVERABLES
4.
PERIODIC REPORTS TO THE CHIEF OF
HOSPITALS AND SEMI-ANNUAL
ACCOMPLISHMENT REPORT SUBMITTED TO THE
FIELD IMPLEMENTATION AND COORDINATION
TEAM FOR LUZON AND NCR, VISAYAS AND
MINDANAO, COPY FURNISHED POLICY
STANDARDS DEVELOPMENT TEAM FOR SERVICE
DELIVERY
5.
INVENTORY OF POLICIES AND SOPs
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PHILHEALTH BENCHBOOK
RA 7875 Section 1 National Health
Insurance Act of 1995
Section 2 Guiding Principles
IRR Title V Section 50 – Accreditation and
Quality Assurance
of the NHIP
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In view of this, starting January 1, 2007, Philhealth shall require all
hospitals applying for accreditation, to have a Continuous Quality
Improvement (CQI) Program as described in Part III of the Philhealth
Benchbook. Likewise, accredited government hospitals are advised to
refer to DOH Administrative Order No. 2006-0002 for additional guidance.
41
SOURCE: PHIC Benchbook, 2004
42
43
IMPROVING PERFORMANCE CRITERIA
7.1 The organization has a planned systematic
organization-wide approach to process design and
performance measurement, assessment and
improvement. (CORE)
7.3 Management is primarily responsible for developing,
communicating, and implementing a comprehensive
quality improvement program throughout the
organization and delegating responsibilities to
appropriate personnel for its day-to-day implementation.
7.4 All service units and staff are responsible for, and
demonstrate involvement in performance improvement
that results in better services for internal and external
clients
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IMPROVING PERFORMANCE
7.5 Managers and staff evaluate the effectiveness of the
quality improvement program and take action to
address any improvements required.
7.6 The organization provides better care and service as a
result of continuous quality improvement activities
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46
SOURCE: PHIC Benchbook, 2004
PLAN-DO-CHECK-ACT CYCLE
47
SOURCE: PHIC Benchbook, 2004
PDCA TECHNIQUE
Plan
Documentation
Do
Performance
Improvement
Program
Evaluation
Act
8/4/2021
Action
Check
SOURCE: PHIC Benchbook, 200448
Continuous Quality Improvement in the Hospital
PDCA TECHNIQUE
Also known as the “Deming Cycle or
“Control Cycle, it is a systematic
approach to problem solving by utilising
the various tools of the QC Circles.
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PDCA TECHNIQUE
A P
2
C D
A P
3
C D
A P
1
C DA P
1
C D
A P
Current
1
Situation
C D
“Ningas
Cogon”
A P
4
C D
A P
5
C D
Be consistent for the
long haul.
Don’t give up.
Keep at it.
“Even if you have
problems, just
continue.”
A P
1
C D
SOURCE: Phil. TQM Foundation, Inc50
PHIC BENCHBOOK SELF-ASSESSMENT AND
SURVEY TOOL
7. IMPROVING PERFORMANCE
Goal: The organization continuously and systematically improves its
performance by invariably doing the right thing the right way the first
time and meeting the needs of its internal & external clients
CODE
7.1x1
core
STANDARDS
INDICATOR
The organization has a
planned systematic
organization-wide
approach to process
design & performance
measurement,
assessment and
improvement
Presence of quality
improvement
program
CORE
EVIDENCE
Document Review
1. Policy creating the QI
Program
2. Proof of meetings or
similar documents of QA
Committee activities
3. Policies & procedures on
performance
measurement &
improvement
SECTION
Document
review
Leadership
interview
Interview
Validation of QI activities
thru interview of pertinent
staff including frontliners
and Committee members
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51
PHIC BENCHBOOK SELF-ASSESSMENT AND
SURVEY TOOL
7. IMPROVING PERFORMANCE
Goal: The organization continuously and systematically improves its
performance by invariably doing the right thing the right way the first
time and meeting the needs of its internal & external clients
CODE
7.3x1
STANDARDS
Management is
primarily responsible
for developing,
communicating and
implementing a
comprehensive quality
improvement program
throughout the
organization and
delegating
responsibilities to
appropriate personnel
for its day-to-day
implementation
8/4/2021
INDICATOR
EVIDENCE
Proof that the
Document Review
management is
1. Memoranda/orders
primarily
creating the QI
responsible for
team/Quality Circle
developing,
2. Minutes of meetings/
communicating &
extracts of minutes
implementing a
relating to concerned topic,
comprehensive
documentation of activities
quality
3. Monitoring reports on CPG
improvement
use or similar QI activities
program
4. Designation of a point
throughout the
person for the QA program
organization and
delegating
Interview
responsibilities to Validation the activities by
appropriate
asking the management team
personnel for its
or officer involved in QA
day-to-day
program
Continuous Quality Improvement in the Hospital
implementation
SECTION
Document
review
Leadership
interview
52
PHIC BENCHBOOK SELF-ASSESSMENT AND
SURVEY TOOL
7. IMPROVING PERFORMANCE
Goal: The organization continuously and systematically improves its
performance by invariably doing the right thing the right way the first
time and meeting the needs of its internal & external clients
CODE
7.4x1
STANDARDS
All service units and
staff staff are
responsible for, and
demonstrate
involvement in,
performance
improvement that
results in better
services in internal &
external clients
8/4/2021
INDICATOR
EVIDENCE
Proof that all
service units and
staff are
responsible for,
and demonstrate
involvement in
perfomance
improvement
that results in
better services
for internal &
external clients
Document Review
1. Policies or issuances on
CQI program
2. QA/CQI manual
3. Patient satisfaction survey
results/ratings
4. Staff staisfaction survey
SECTION
Document
review
ER
OPD
Wards
Interview
Validation the activities thru
interview of any staff
including the frontliners,
patients, external clients
Continuous Quality Improvement in the Hospital
53
PHIC BENCHBOOK SELF-ASSESSMENT AND
SURVEY TOOL
7. IMPROVING PERFORMANCE
Goal: The organization continuously and systematically improves its
performance by invariably doing the right thing the right way the first
time and meeting the needs of its internal & external clients
CODE
STANDARDS
INDICATOR
EVIDENCE
7.5x1
Managers and staff
evaluate the
effectiveness of the
quality improvement
program and take
action to address any
improvements required
Proof of
evaluation of the
quality
improvement
program
Document Review
1. Minutes or extracts of
minutes of the
management or Executive
Committee meetings
2. Memoranda, policies,
orders emanating from the
evaluation of QI programs/
activities
3. Monitoring and evaluation
reports
Document
review
7.6x1
core
The organization
provides better care
service as a result of
continuous quality
improvement activites
Presence of
patient
satisfaction
survey
CORE
Document Review
1. Patient satisfaction survey
results
2. Patient satisfaction survey
questionnaire (may check
on the domains and items)
Document
review
Continuous Quality Improvement in the Hospital
Continuous Quality Improvement in the Hospital
SECTION
54
PHIC BENCHBOOK SELF-ASSESSMENT AND
SURVEY TOOL
7. IMPROVING PERFORMANCE
Goal: The organization continuously and systematically improves its
performance by invariably doing the right thing the right way the first
time and meeting the needs of its internal & external clients
CODE
7.6x2
STANDARDS
The organization
provides better care
service as a result of
continuous quality
improvement activites
8/4/2021
INDICATOR
EVIDENCE
Proof of better
patient outcomes
Document Review
1. Documentation of better
outcomes for patients as a
result of CQI activities e.g.
declining trends of
nosocomial infection,
increase in patient
satisfaction ratings, in OBincrease in trend of trial
labor vs CS, increase use
of component blood vs
fresh whole blood, etc.
Continuous Quality Improvement in the Hospital
SECTION
Document
review
55
PHIC BENCHBOOK SELF-ASSESSMENT AND
SURVEY TOOL
7. IMPROVING PERFORMANCE
Goal: The organization continuously and systematically improves its
performance by invariably doing the right thing the right way the first
time and meeting the needs of its internal & external clients
CODE
STANDARDS
INDICATOR
EVIDENCE
7.7 x1
Quality improvement
activities respect the
confidentiality of data
regarding patients, staff
and other care
providers.
Proof that QI
activities respect
the
confidentiality of
data regarding
patients, staff
and other care
provider
Document Review
1. Policies and procedures on
confidentiality of records.
8/4/2021
2. QA/CQI manual
SECTION
Document
review
Leadership
interview
3. Reports related to QI
activities
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56
JOINT COMMISSION INTERNATIONAL
SECTION 1: PATIENT-CENTERED STANDARDS
Access to Care and Continuity of Care
Patient and Family Rights
Assessment of Patients
Care of Patients
Anesthesia and Surgical Care
Medication Management and Use
Patient and Family Education
SECTION 2: HEALTH CARE ORGANIZATION
MANAGEMENT STANDARDS
Quality Improvement and Patient Safety
Prevention and Control of Infections
Governance, Leadership, and Direction
Facility Management and Safety
Staff Qualifications and Education
Management of Communication and Information
TRENT ACCREDITATION (UK)
Scheme Benefits
❑ Assures the quality of service to patients, staff, commissioners
and providers
❑ Provides a benchmark of standards
❑ Provides quality monitoring information
❑ Facilitates the development of people and organizations
❑ Creates a dynamic environment for change
❑ Provides networking opportunities
❑ Overseas contacts
Core Elements
❑ Peer review
❑ Pre-survey visits
❑ Accreditation awards by an I
❑ Mentoring for the organization if
independent Board
desired
❑ Newsletter
❑ Continuous process of
❑ Training events for participants and development
surveyors in the scheme and
networking opportunities
AUSTRALIAN COUNCIL ON
HEALTHCARE STANDARDS (ACHS)
❑ An independent, not-for-profit organization dedicated to
improving quality in health care.
❑ ACHSl delivers accreditation and quality improvement
programs to health care organisations throughout the
world. The standards and program are based on the
internationally recognised ACHS standards and program,
which are accredited by the International Society for
Quality in Health Care (ISQua)..
❑ Australia's leading health care assessment and
accreditation provider
❑ Mission: To improve the quality and safety of health care
QUALITY HEALTH NEW ZEALAND
Vision: Recognized as a national and international leader in the
provision of standards setting, performance assessment
and recognition of achievement in Health and Disability
Services.
Mission: Inspire a commitment to continuous quality improvement
in Health and Disability Services.
EQUIP4 STANDARDS
ACCREDITATION CANADA
❑Accreditation Canada is a not-for-profit, independent
organization.
❑Provides national and international health care
organizations with a voluntary, external peer review to
assess the quality of their services based on standards of
excellence.
Vision
The leader in raising the bar for health quality
Mission
Driving quality in health services through accreditation
Quality of care
And
Patient safety
62
QUALITY DEFINED
“FIT FOR USE”
- JURAN
DEGREE TO WHICH A SET OF INHERENT
CHARACTERISTICS FULFILS
REQUIREMENT
ISO 9000
“DOING IT RIGHT THE FIRST TIME ALL
THE TIME”
CROSBY
Continuous Quality Improvement in the Hospital
63
The QUALITY GRID
- What you do +
+
How you do it
Right
Right
Right
Wrong
Wrong
Wrong
Right
Wrong
things
things
-
things
things
Continuous Quality Improvement in the Hospital
64
QUALITY OF CARE
THE DEGREE TO WHICH THE
PROCESS OF CARE INCREASES
THE PROBABILITY OF
OUTCOMES DESIRED AND
REDUCES THE PROBABILITY OF
UNDESIRED OUTCOMES, GIVEN
STATE OF MEDICAL
KNOWLEDGE
US OFFICE OF TECHNOLOGY ASSESSMENT (1988)
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65
PATIENT-CENTERED CARE
CARE THAT IS RESPECTFUL OF AND
RESPONSIVE TO INDIVIDUAL PATIENTS
PREFERENCES, NEEDS AND VALUES
AND (ENSURES) THAT PATIENT VALUES
GUIDE ALL CLINICAL DECISIONS
INSTITUTE OF MEDICINE, 2001
Continuous Quality Improvement in the Hospital
66
SIX MAJOR AIMS:
HEALTHCARE SHOULD BE
SAFE
EFFECTIVE
PATIENT-CENTERED
TIMELY
EFFICIENT
EQUITABLE
COMMITTEE OF QUALITY OF HEALTHCARE IN
AMERICA (2003)
Continuous Quality Improvement in the Hospital
67
VIDEO
GINNY’s STORY
8/4/2021
Continuous Quality Improvement in the Hospital
68
A Patient Safety Solution is any
system design or intervention that
has demonstrated the ability to
prevent or mitigate patient harm
stemming from the processes of
health care.
Dr. Y P Bhatia, HMA, Pattaya, Thailand, August, 2007
69
INSTITUTE OF MEDICINE, USA
“ Experts estimate that as many as
98,000 people die in any given year from
medical errors that occur in hospitals.”
“ More people die annually from
medication errors alone than from
workplace injuries.”
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Errors occur when our actions do not
agree with our Intentions even
though we are capable of carrying
out the task.
Dr. Y P Bhatia, HMA, Pattaya, Thailand, August, 2007
8/4/2021
Continuous Quality Improvement in the Hospital
71
But Why are We Talking About
Errors Today???
Dr. Y P Bhatia, HMA, Pattaya, Thailand, August, 2007
72
8/4/2021
Continuous Quality Improvement in the Hospital
… because
➢ 999,936
deaths occur annually in the USA, here are some
of the statistics and death rate estimates from various
reports:
➢ 42% of people believed they had personally experienced
a medical mistake (NPSF survey)
➢ 44,000 to 98,000 deaths annually from medical errors
(Institute of Medicine)
➢ 225,000 deaths annually from medical errors including
106,000 deaths due to "non-error adverse events of
medications" (Starfield)
➢ 180,000 deaths annually from medication errors and
adverse reactions (Holland)
➢ 20,000 annually to 88,000 deaths annually from
nosocomial infections
➢ 2.9 to 3.7 percent of hospitalizations leading to adverse
medication reactions
➢ 7,391 deaths resulted from medication errors (Institute of
Medicine)
➢ 2.4 to 3.6 percent of hospital admissions were due to
(prescription) medication events (Australian study)
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SENTINEL EVENT EXPERIENCE IN THE US
Of 4064 sentinel events reviewed by the Joint
Commission, January 1995 through December
2006:
531
520
488
385
302
224
153
138
Events of wrong site surgery
Inpatient suicides
125 Perinatal death/injury
94 Transfusion-related
events
Operative/ Post op complications
85 Infection-related events
Events relating to medication errors 72 Deaths following
elopement
Deaths related to delay in treatment 66 Fires
Patient Falls
67 Anesthesia-related
events
Deaths of patients in restraints
51 Retained foreign objects
Assault/Rape/Homicide
763 “other”
= 4064
SOURCE: JCI SINGAPORE PRACTICUM
74
Surgical sponge that was left
in a patient, identified by the
radio-opaque thread inside
the sponge.
X-ray of a retained clamp
that the surgical team
forgot to remove.
75
Retained laparotomy pad,
Mount Sinai Medical
Center, New York, 1998.
Retained laparotomy pad,
Jacobi Hospital,
Bronx, New York, 1996
76
X-ray of a retained clamp that
the surgical team forgot to
remove.
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X-ray of a surgical scissor
blade that broke off that the
surgical team didn’t notice.
Continuous Quality Improvement in the Hospital
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$280G award took guts: DOCS LEFT SURGICAL TOOL IN WOMAN’S ABDOMEN
January 13, 2006
By Laurel J. Sweet
Boston Herald
A Belmont woman living as a man was awarded $280,000 yesterday by a jury that found two doctors
negligent for leaving a nearly foot-long surgical instrument in her abdomen while wrapping up a
hernia operation at St. Elizabeth’s Hospital.
“I was pretty mortified,” Alex Mitchell, 38, told the Herald of the Adept-Med FISH, a metal-spined
device resembling a blue flounder that swam around in her torso for four months.
The FISH shields organs during suturing, but is supposed to be pulled out at the last minute. When it
showed up on an X-ray, after Mitchell’s pain and vomiting had been written off as gallstones and
ovarian cysts, the FISH had floated more than a foot from her incision.
“The first time I went to the emergency room, I thought I was having a heart attack,” she said.
Mitchell’s attorney, William J. Thompson of Lubin & Meyer, apparently hit a squeamish nerve when he
reminded jurors, “This could happen to any one of us.”
Thompson later called the judgment “fair compensation for what Alex Mitchell has been through. This
is the system working.”
Mitchell, a transgender shift supervisor for CVS, ran into health problems after having her stomach
stapled in 1999. Just 5 feet, 2 inches tall, her weight has since plummeted to 170 from 310 pounds.
The Suffolk Superior Court panel deliberated only briefly before finding that Dr. Kathaleen Porter and
Dr. Aqueel Siddiqui erred in not accounting for the FISH’s whereabouts after the Jan. 12, 2001,
operation.
But because Siddiqui, now a vascular surgeon, was only a third-year surgical resident at the time, the
jury put it on Porter, the attending surgeon, to foot the bill for Mitchell’s compensation.
“We didn’t have to be here today,” Mitchell said. “I’m not looking for them to lose their licenses. But,
they have never taken responsibility for what they did wrong.”
http://www.lubinandmeyer.com/cases/fish.html
MAN WINS $3.2M FOR LOST TESTICLE
Published by The Boston Herald, October 24, 1997
A 26-year-old Franklin man has won a $3.2 million jury award in a medical
malpractice case that charged a misdiagnosis cost him a testicle.
A Worcester Superior Court jury on Wednesday awarded Robert Rappa $2
million, plus interest, after finding that he was misdiagnosed when he
went to the emergency room at Milford-Whitinsville Hospital in
November 1991.
Rappa's lawyer, Celine Boyle at the Boston law firm of Lubin & Meyer
claimed [the doctor] failed to perform the proper tests...and sent him
home with pain medication and antibiotics.
While a man can perform sexually with only one testicle, the condition
may interfere with his ability to have children, Boyle said.
"It can affect your ability to procreate and it is disfiguring," she said. "It
can also give you performance anxiety."
She said Rappa is one of six siblings but is the only boy in the family and
very much wants to have children of his own, particularly to carry on the
family name.f
http://www.lubinandmeyer.com/cases/news_wins.html
The 2007 International Patient
Safety Goals
“The IPSGs represent proactive strategies to
reduce risk of medical error and reflect good
practices proposed by leading patient safety
experts”
 Joint Commission International (JCI) introduced the
IPSGs in 2006
 During 2007, JCI rolled out the IPSGs as part of the
survey process.
 Beginning 1 January 2007, hospitals accredited by
JCI will be required to display compliance with the
following ISPGs

E.V. Kessler, Implementing International Patient Safety Goals ,Hospital
Management Asia 2008
80
The 2007 International Patient
Safety Goals
Goal: Identify Patients Correctly
 Goal: Improve Effective Communication
 Goal: Improve the Safety of High-alert
Medications
 Goal: Eliminate Wrong-site, Wrongpatient, Wrong-procedure Surgery
 Goal: Reduce the Risk of Health Care–
acquired Infections
 Goal: Reduce the Risk of Patient Harm
Resulting from Falls

E.V. Kessler, Implementing International Patient Safety Goals ,Hospital
Management Asia 2008
81
VIDEO
TIME OUT
8/4/2021
Continuous Quality Improvement in the Hospital
82
LET US DO QUALITY NOT ONLY FOR:
REGULATORY COMPLIANCE
TO AVOID MALPRACTICE SUIT
TO SUSTAIN BUSINESS GROWTH
BUT LET US DO QUALITY BECAUSE:
OUR PATIENTS DESERVE THE BEST
QUALITY OF CARE WE
CAN DELIVER
83
Conceptual
framework
of cqi
84
8/4/2021
Continuous Quality Improvement in the Hospital
CONTINUOUS QUALITY
IMPROVEMENT
STRUCTURED ORGANIZATIONAL PROCESS
FOR INVOLVING PERSONNEL IN PLANNING
AND EXECUTING A CONTINUOUS FLOW OF
IMPROVEMENTS TO PROVIDE
QUALITYHEALTHCARE
THAT MEETS OR EXCEEDS EXPECTATIONS.
C.P Mc LAUGHLIN and
A.D. KALUZNY
8/4/2021
Continuous Quality Improvement in the Hospital
85
Customer
satisfaction
measurement
86
8/4/2021
Continuous Quality Improvement in the Hospital
SATISFACTION
➢ READINESS TO REPURCHASE
➢ WILLINGNESS TO RECOMMEND US
➢ WILLINGNESS TO PAY OUR PRICE
WITHOUT HAGGLING OR SEEKING A
LOWER- COST PRICE
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87
CUSTOMER SATISFACTION…
END STATE RESULTING FROM HAVING
CONSUMED A PRODUCT OR A SERVICE
ISO 9000
THE EVALUATION RENDERED THAT
THE EXPERIENCE WAS AT LEAST AS
GOOD AS IT WAS SUPPOSED TO BE.
H.K. HUNT 1977
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SATISFIED CUSTOMERS CAN BE
EXPECTED TO:
• REMAIN AS CUSTOMER LONGER
• SPREAD POSITIVE WORD OF MOUTH
• INCREASE SHARE OF SPENDING WITH
THE ORGANIZATION THAT BEST SATISFIES
THEM
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89
AND THEREFORE IMPROVED
CUSTOMER SATISFACTION WILL:
➢INCREASE ORGANIZATIONAL
PROFITABILITY
➢ IMPROVE CUSTOMER RETENTION
➢ IMPROVE MARKET SHARE
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Continuous Quality Improvement in the Hospital
90
Performance
improvement
teams
91
8/4/2021
Continuous Quality Improvement in the Hospital
WHO WILL DO CONTINUOUS
QUALITY IMPROVEMENT?
CONTINUOUS IMPROVEMENT
NEEDS TO BE CARRIED OUT BY
COHESIVE, DISCRETE,
IDENTIFIABLE GROUPS OR
TEAMS.
TEAM WORK AND MULTISKILLING
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TEAMS IN HEALTHCARE
HEALTHCARE CARE IS DELIVERED BY
TEAMS
MULTI – DISCIPLINARY
MULTI – SPECIALTY
PATIENT – CENTERED
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TEAMS IN HEALTHCARE
Composition
Healthcare providers
Administrative non clinical staff
Multiple disciplines
Focusing on a patient or group of patients
with similar healthcare needs
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CLINICAL MICROSYSTEM AS A TEAM
A group of people who work together on a
regular basis to provide care to discrete
sub-populations of patients. It has clinical
and business aims, linked processes, and
a shared information environment and it
produces outcomes.
Nelson E.C. et al
Microsystems in Healthcare
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VALUE OF TEAMS
➢ Teams can build a more complete picture of
a process or situation
➢ Mutual support and cooperation leads to
increased commitment to quality
improvement
➢ Team accomplishments builds the
confidence of individual members
➢ When people help design a solution they
embrace rather than resist it
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96
THE QUALITY OF OUR
SERVICE IN THE END IS
DETERMINED BY OUR
FRONT LINE EMPLOYEES
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DO WE ALWAYS NEED A TEAM?
PROBLEM SOLVING APPROACH
• INDIVIDUAL PROBLEM SOLVING
• RAPID TEAM PROBLEM SOLVING
• SYSTEMATIC TEAM PROBLEM SOLVING
• PROCESS IMPROVEMENT TEAM
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1. INDIVIDUAL PROBLEM SOLVING
➢ Individual decision making for a smaller
scale problem
➢ Able to identify problem and solution using
individual analysis
➢ Individual must have autonomy over situation
– not dependent on others for change
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2. RAPID TEAM PROBLEM SOLVING
➢ Ad hoc team approach to quality for a
more obvious problem
➢ Small incremental changes are tested
➢ Often use data that exists and team’s
knowledge and wisdom
➢ A mentor may be used for guidance
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3. SYSTEMATIC TEAM PROBLEM
SOLVING
➢ Ad hoc team approach to quality for more
complex or recurring problems
➢ Detailed analysis requires data collection
➢ Detailed analysis allows for more targeted
solution
➢ More time and resources needed for this
approach
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4. PROCESS IMPROVEMENT
➢Permanent team established to address a
core process or issue
➢ Most complex of four approaches
➢ Process improved over time through use of
data
➢ Requires continuous allocation of
resources to process improvement
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QUALITY CONTROL
CIRCLES
103
8/4/2021
Continuous Quality Improvement in the Hospital
CONCEPT OF QUALITY CONTROL CIRCLES
A Quality Control Circle (QCC) is a group
of 4-7 workers performing similar or
related tasks, who get together on a
regular basis, to discuss a topic or theme
affecting their work and workplace.
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CONCEPT OF QUALITY CONTROL CIRCLES
Other Small Group Activities (SGA’s) exist in
the form of
❖
❖
❖
❖
WORK GROUPS
AD HOC COMMITTEES
TASK FORCES
TEAMS
But –
They are NOT Quality Control Circles, in the
true sense of the world.
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PROBLEM SOLVING METHODOLOGY
PROBLEM IDENTIFICATION & PROBLEM PRIORITIZATION
UNDERSTANDING THE PRESENT SYSTEM
ANALYSIS of the ROOT CAUSES
Plan
SELECTION OF BEST ALTERNATIVE SOLUTIONS
PROJECT PRESENTATION
SOLUTION IMPLEMENTATION
Do
Project Evaluation
Check
STANDARDIZATION
SELF-EVALUATION & FUTURE PLANNING
Action
106
Quality Circle Practitioners Association of the Phils.
QC/TEAM APPROACH TO PROBLEM SOLVING
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Improvement in the Hospital
107
SOURCE: PHIC Benchbook, 2004
QC TOOLS
CONTINUOUS
IMPROVEMENT IS CARRIED
OUT THROUGH A NUMBER
OF BASIC QUALITY TOOLS
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CONTINUOUS QUALITY
IMPROVEMENT
7 BASIC TOOLS
1.
2.
3.
4.
5.
6.
7.
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CHECKSHEET
HISTOGRAM
PARETO DIAGRAM
GRAPH
CONTROL CHART
CAUSE AND EFFECT
SCATTER DIAGRAM
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109
HISTORICAL NOTES ON
7 QC TOOLS
CONCEPT BEHIND THE SEVEN BASIC
TOOLS CAME FROM KAORU ISHIKAWA,
A RENOWNED QUALITY EXPERT
FROM JAPAN (1968)
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ISHIKAWA - ADVOCATED USE OF SEVEN
TOOLS OF QUALITY CONTROL
PARETO CHART
– PRIORITIZE ACTION
CAUSE & EFFECT
(ISHIKAWA) DIAGRAM
– IDENTIFY CAUSES
STRATIFICATION
– SUBSET CAUSE
CHECK SHEETS
– COLLECT DATA
HISTOGRAM
– DISPLAY VARIATION
SCATTER DIAGRAM
– INVESTIGATE DUAL
FACTOR RELATIONSHIP
CONTROL CHARTS
– MONITOR PROCESS
VARIATION
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HOWEVER IT IS CLAIMED THAT
95% OF THE QC PROBLEM CAN BE
SOLVED USING THE 7 BASIC QC TOOLS
NO NEED FOR A HIGH LEVEL OF
KNOWLEDGE OF STATISTICS
CAN BE LEARNED AND APPLIED BY
SHOP FACTORY WORKERS EVEN KIDS
7 QC TOOLS IS A BASIC TOOL KIT
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THERE ARE OTHER TOOLS
SEVEN ADVANCED QC TOOLS
1.
2.
3.
4.
5.
6.
AFFINITY DIAGRAM
RELATION DIAGRAM
SYSTEM DIAGRAM
MATRIX DIAGRAM
MATRIX DATA ANALYSIS
PROCESS DECISION
PROGRAM CHART METHOD
7. ARROW DIAGRAM
7 ADVANCED QC TOOLS OR MANAGEMENT
TOOLS ARE FOR IDEAS
7 BASIC QC TOOLS ARE FOR NUMERICAL DATA
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AND MORE TOOLS:
As those used in Six Sigma and Lean

Process Mapping

Mistake-Proofing

Constraint Management

Interrelationship Digraphs

Process Flow

Force Field Analysis

Line Balancing

Multi-voting

Value Analysis

Sales and Operations
Planning, Stocking Strategy

Run Charts

Materials Management

Vendor Certification/
Scorecards/Lead-Time
Reduction

Shop Floor Controls

Kaizen

Supplier Communication

Order Management/Case
Teams
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114
THE PHILIPPPINE SOCIETY FOR QUALITY
IN HEALTHCARE WOULD LIKE TO
FOR YOUR TRUST IN US
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115
BIBLIOGRAPHY
1. Continuous Quality Improvement in Healthcare
Theory, Implementations and Applications
Third Edition
Curtis P. McLaughlin and Arnold D. Kalunzy
2. Customer Satisfaction Measurement Simplified
A Step-by-Step Guide for ISO 9001:2000 Certification
Terry G. Vavra
3. To Err is Human
Building A Safer Health System
Institute of Medicine
4. QA Monograph: A Modern Paradigm for Improving Healthcare Quality
Rashad Massoud, Karen Askov, Jolee Reinke, Lynne Miller Franco,
Thada Borstein, Elisa Knebel,and Catherine MacAulay
5. Total Quality Management Promotion Guide Book
Hitoshi Kume
Japan Standards Association
8/4/2021
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BIBLIOGRAPHY
6. 2008 Criteria for Performance Excellence
Malcolm Baldridge National Quality Award
7. Productivity and Quality Management: A Modular Programme
Part 1 Productivity and Quality Improvement: Concepts, Processes and
Techniques
Joseph Prokopenko and Klaus North
International Labour Office
Asian Productivity Organization
8. Statistical Quality Control Using Excel, 2nd Edition
Steven M. Zimmerman
Marjorie L. Icenogle
9. A3 Problem Solving for Healthcare
A Practical Method for Eliminating Waste
Cindy Jimmerson
10. Customer Satisfaction Tool Kit for ISO 9001:2000
Sheila Kessler
8/4/2021
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117
BIBLIOGRAPHY
11. Philippine National Standards ISO 9001: 2000
12. Quality Improvement in Healthcare
Quality Assurance Project
Bethesda, USA
13. BENCHBOOK on Performance Improvement of Health Services
Philippine Health Insurance Corporation
14. National Library of Healthcare Indicators
Health Plan and Network Edition
Joint Commission on Accreditation of Healthcare Organizations
15. Quality Improvement
Practical Applications for Medical Group Practice, 2nd Edition
Davis Balestracci, Jr., MS and Jeanine L. Barlow, MPH
16. Applied Tracer Methodology: Tips & Strategies for Continuous
Systems Improvement – Joint Commission Resources
17. Patient Safety and Quality Healthcare
March / April 2008 Issue Vol. 5 Issue no. 2
18. Joint Commission International Accreditation Standards for Hospitals
3rd Edition
8/4/2021
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118
BIBLIOGRAPHY
19. Module on Documentation and Records Management System TQM
Integration Program
20. Quality Improvement Activities
Training Manual for the Seminar Workshop
Philippine Council on Accreditation of Healthcare Organization
(PCAHO)
21. Quality Circle Management Workshop
Dr. Tan Kheok Juay
Principal Consultant
Spring Singapore
22. The Six Sigma memory Jogger
A Pocket Guide of Tools for Six Sigma Improvement Terms
Michael Brassard, Linda Finn, Danna Finn, Diane Ritter First Edition
GOAL/QPC
23. Seminar Workshop Quality Circles, QC Tools and Problem Solving
Philippine TQM Foundation
24. Seminar Workshop Customer Satisfaction Measurement
Philippine TQM Foundation
8/4/2021
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119
BIBLIOGRAPHY
25. PSQUA Compilation
Winners of the Annual Search for the Most Outstanding QA
Studies 2000-2002
24th Annual Quality Circle Regional Convention Quality Circle
Association of the Philippines
May 26-28 2004, Westin Philippine Plaza
26. Hospital Management Asia 2007 Sharing of Hospital Practices
27. Basic Tools – Lean Six Sigma – Greenbelt Training Alabang
Medical Clinic
8/4/2021
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REFERENCES
A Modern Paradigm for Improving Healthcare Quality – QA Monograph
http://en.wikipedia.org/wiki/Data
http://www.niu.edu/rcrportal/datamanagement/dctopic.html
http://www.isixsigma.com/library/content/c010422b.asp
Module on Data Collection and Data Integrity/ Lean Six Sigma Training
- Ms. Mary Ann Guilatco
8/4/2021
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