Quality control Meaning of Quality Webster’s Dictionary degree of … of a thing American Society for Quality totality of features and characteristics that … … Consumer’s and producer’s perspective Copyright 2006 John Wiley & Sons, Inc. 3-2 Meaning of Quality: Consumer’s Perspective Fitness for use how well product or service does what it is supposed to Quality of design designing quality characteristics into a product or service A Mercedes and a Ford are equally “fit for use,” but with different design dimensions Copyright 2006 John Wiley & Sons, Inc. 3-3 Dimensions of Quality: Service Time and timeliness Completeness Courtesy Consistency Accessibility and convenience Accuracy Responsiveness Copyright 2006 John Wiley & Sons, Inc. 3-4 Quality in healthcare “Quality is the extent to which health services for individuals and populations increase the likelihood of … … … and are consistent with … … .” Institute of Medicine Medical injuries • 44,000 to 98,000 deaths every year • More people die from medical errors than from breast cancer, AIDS, or traffic accidents • Direct health care cost of medical errors 9-15 billion/year “Applying Quality Improvement Tools to Disorders Identified in Newborn Screening”, Marc S. Williams, MD, Director Intermountain Clinical Genetics Institute How good is our quality of healthcare? • Until recent reforms, only 50% of Americans receive recommended preventive care • Patients with acute illness – 70% received recommended treatments – 30% received contraindicated treatments • Patients with chronic illness – 60% received recommended treatments – 20% received contraindicated treatments Schuster et al. “How good is the quality of healthcare in the United States?” Milbank Quarterly 76:517-63, 1998 Factors affecting quality in healthcare • Overutilization • Under utilization • Avoidable complications Cost of Quality • Cost of Achieving Good Quality – Prevention costs – Appraisal costs • Cost of Poor Quality – Internal failure costs – External failure costs Copyright 2006 John Wiley & Sons, Inc. 3-9 Prevention Costs • Quality planning costs • Product-design costs • Process costs • Training costs • Information costs Copyright 2006 John Wiley & Sons, Inc. 3-10 Appraisal Costs • Inspection and testing • Test equipment costs • Operator costs Copyright 2006 John Wiley & Sons, Inc. 3-11 Internal Failure Costs • Scrap costs • Rework costs • Process failure costs • Process downtime costs • Price-downgrading costs Copyright 2006 John Wiley & Sons, Inc. 3-12 External Failure Costs • Customer complaint costs • Product return costs • Warranty claims costs • Product liability costs • Lost sales costs Copyright 2006 John Wiley & Sons, Inc. 3-13 Quality–Cost Relationship • Cost of quality – Cost of poor quality • 20 to 35% of revenues – Cost of achieving good quality • 3 to 4% of revenues – Profitability • In the long run, quality is free Copyright 2006 John Wiley & Sons, Inc. 3-14 Video • UCSF Medical Center opens robotic pharmacy (4:17) Quality Management and Productivity • Productivity – ratio of output to input • Yield: a measure of productivity Yield= or Y=(I)(%G)+(I)(1-%G)(%R) Copyright 2006 John Wiley & Sons, Inc. 3-16 Product Cost Product Cost where: Kd = direct manufacturing cost per unit I = input Kr = rework cost per unit R = reworked units Y = yield Copyright 2006 John Wiley & Sons, Inc. 3-17 Product Yield for Multistage Processes Y= where: I = input of items to the production process that will result in finished products gi = good-quality, work-in-process products at stage i Copyright 2006 John Wiley & Sons, Inc. 3-18 Deming’s 14 Points 1. 2. 3. 4. 5. Create … of purpose Adopt philosophy of … Cease mass … Select a few suppliers based on … Constantly improve … and … Copyright 2006 John Wiley & Sons, Inc. 3-19 Deming’s 14 Points (cont.) 6. 7. 8. 9. 10. Institute worker … Instill … among supervisors Eliminate ... among employees Eliminate … between departments Eliminate … Copyright 2006 John Wiley & Sons, Inc. 3-20 Deming’s 14 Point 11. Remove numerical … 12. Enhance worker … 13. Institute … training and education programs 14. Develop a commitment from top management to implement above 13 points Copyright 2006 John Wiley & Sons, Inc. 3-21 Total Quality Management (TQM) • Steps 1. Measure patient wants and provider needs 2. Design process that will meet and even exceed patient expectation 3. Design a process that is fail proof or fail safe Monitor results and using results to improve system 4. Benchmark system by comparisons to peers Deming Wheel: PDCA Cycle Copyright 2006 John Wiley & Sons, Inc. 4. Act 1. Plan Institutionalize improvement; continue cycle. Identify problem and develop plan for improvement. 3. Study/Check 2. Do Assess plan; is it working? Implement plan on a test basis. 3-23 Continuous Quality Improvement • Continues process of improvement after PDSA cycle • Objective – Increase patients’ and clinicians’ satisfaction – Achieve higher quality – Reduce cost and waste – Increase productivity Continuous Quality Improvement • Steps 1. 2. 3. 4. 5. 6. 7. 8. Select a process Study and document current process Seek ways to improve current process Design an improved process Implement new process Monitor and evaluate new process Document process if it succeeds and publicize it Restart in step 1 if improvement is not achieved Six Sigma • A process for developing and delivering … … products and services • Measure of how much a process deviates from … • … defects per million opportunities Copyright 2006 John Wiley & Sons, Inc. 3-26 Black Belts and Green Belts • …. – an executive responsible for project success • … – project leader • … … – a teacher and mentor for Black Belts • …… – project team members Copyright 2006 John Wiley & Sons, Inc. 3-27 Six Sigma: DMAIC DEFINE MEASURE ANALYZE 67,000 DPMO cost = 25% of sales Copyright 2006 John Wiley & Sons, Inc. IMPROVE CONTROL 3.4 DPMO 3-28 Video • Lean Six Sigma at AMC (5 min) Seven Basic Quality Tools Check Sheet Fishbone Diagram Run Chart Histogram Pareto Chart Scatter Diagram Flow Chart Copyright 2008 Health Administration Press. All rights reserved. 8-30 Histogram 20 15 10 5 0 1 2 6 13 10 16 19 17 12 16 2017 13 5 6 2 1 Copyright 2006 John Wiley & Sons, Inc. 3-31 Pareto Analysis CAUSE NUMBER OF DEFECTS Poor design Wrong part dimensions Defective parts Incorrect machine calibration Operator errors Defective material Surface abrasions Copyright 2006 John Wiley & Sons, Inc. 3-32 PERCENTAGE 80 16 12 7 4 3 3 64 % 13 10 6 3 2 2 125 100 % 70 (64) Pareto Chart Percent from each cause 60 50 40 30 20 10 (13) (10) (6) (3) 0 Copyright 2006 John Wiley & Sons, Inc. Causes of poor quality 3-33 (2) (2) Flow Chart Start/ Finish Copyright 2006 John Wiley & Sons, Inc. Operation Operation 3-34 Decision Operation Operation Operation Decision Start/ Finish Check Sheet COMPONENTS REPLACED BY LAB TIME PERIOD: 22 Feb to 27 Feb 2002 REPAIR TECHNICIAN: Bob TV SET MODEL 1013 Integrated Circuits Capacitors Resistors Transformers Commands CRT Copyright 2006 John Wiley & Sons, Inc. |||| |||| |||| |||| |||| |||| || || |||| | 3-35 Scatter Diagram Y Copyright 2006 John Wiley & Sons, Inc. X 3-36 Control Chart 24 UCL = 23.35 Number of defects 21 c = 12.67 18 15 12 9 6 LCL = 1.99 3 2 4 6 8 10 Sample number Copyright 2006 John Wiley & Sons, Inc. 3-37 12 14 16 Cause-and-Effect Diagram Measurement Faulty testing equipment Human Out of adjustment Poor supervision Incorrect specifications Tooling problems Lack of concentration Improper methods Old / worn Inadequate training Quality Problem Inaccurate temperature control Defective from vendor Poor process design Ineffective quality management Not to specifications Dust and Dirt Machines Materialhandling problems Environment Copyright 2006 John Wiley & Sons, Inc. Deficiencies in product design Process Materials 3-38 American Customer Satisfaction Index (ACSI) • Measures customer satisfaction • Established in 1994 • Web site: www.acsi.org – Examples (in 2003) • Amazon.com scored 88 (highest in service) • Dell scored of 78 (highest in computer industry) • Cadillac scored 87 (highest in car industry) Copyright 2006 John Wiley & Sons, Inc. 3-39 ISO 9000 • A set of procedures and policies for international quality certification of suppliers • Standards – ISO 9000:2000 • ISO 9001:2000 – Quality Management Systems— Requirements – standard to assess ability to achieve customer satisfaction • ISO 9004:2000 • Quality Management Systems—Fundamentals and Vocabulary • defines fundamental terms and definitions used in ISO 9000 family Copyright 2006 John Wiley & Sons, Inc. 3-40 – Quality Management Systems— Guidelines for Performance Improvements – guidance to a company for continual improvement of its quality-management system Implications of ISO 9000 for U.S. Companies • Many overseas companies will not do business with a supplier unless it has ISO 9000 certification Copyright 2006 John Wiley & Sons, Inc. 3-41 Case: North Shore University Hospital • Used 6-sigma in a project to reduce delays in bed -assignment turnaround time • Analysis showed delays in post-anesthesia care and emergency department results in inability to accept new patients – Staff incorrectly used bed-tracking system, resulting in delay in bed turnaround time • Mean turnaround time reduced from 226 min to 90 min Case: Cystic fibrosis • Highly variable approaches to care • Significantly different outcomes between centers • Competition limited • Collaboration limited • Little publicly available data for comparison “Applying Quality Improvement Tools to Disorders Identified in Newborn Screening”, Marc S. Williams, MD, Director Intermountain Clinical Genetics Institute Case: Cystic fibrosis • Cystic Fibrosis Foundation formed – Assessed status quo as unsatisfactory – Initial discussions were not fruitful – Brought in QI experts to teach QI • all participants needed to perform a project • Patients were engaged early and are a key component of the QI process “Applying Quality Improvement Tools to Disorders Identified in Newborn Screening”, Marc S. Williams, MD, Director Intermountain Clinical Genetics Institute Case: Cystic fibrosis • Demonstrated improvement was possible • Anonymous data sharing revealed high variability between centers – CFF had insisted on anonymizing data – Centers that were performing poorly insisted they needed to talk to high-performing centers to see how they were doing • Many site visits and exchanges “Applying Quality Improvement Tools to Disorders Identified in Newborn Screening”, Marc S. Williams, MD, Director Intermountain Clinical Genetics Institute Case: Cystic fibrosis • • • • Care improved in all centers All centers did some things well All centers did some things not so well Participation in the QI activities of the CFF is mandatory for accreditation as a CF center “Applying Quality Improvement Tools to Disorders Identified in Newborn Screening”, Marc S. Williams, MD, Director Intermountain Clinical Genetics Institute Reference • Russell and Taylor, Chapter 2
