What is Quality?
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Dimensions of Quality
Effectiveness
Efficiency
Technical Competence
Safety
Accessibility
Interpersonal Relations
Continuity
Amenities
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Perspectives on Quality
Client / Family
Provider
Health Care
Administration
& Management
Community
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Definition of Quality
“The quality of technical care consists in the
application of medical science and technology in a way
that maximizes its benefits to health without
correspondingly increasing its risks. The degree of
quality is, therefore, the extent to which the care
provided is expected to achieve the most favorable
balance of risks and benefits.”
• Avedis Donabedian, M.D., 1980
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Definition of Quality
“Doing the right thing, right, the first time.
Doing it better the next time.”
• ODI Consulting
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Definition of Quality
“...proper performance (according to standards) of
interventions that are known to be safe, that are
affordable to the society in question, and have the
ability to produce an impact on mortality, morbidity,
disability, and malnutrition.”
• M.I. Roemer and C. Montoya Aguilar,
WHO, 1988
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Definition of Quality
“Quality is conformance to requirements or
specifications.”
• Phil Crosby, 1979
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Definition of Quality
“Quality is compliance with standards.”
• QA Project Contract, 1997
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Quality Definitions
•
•
•
•
Meet or exceed standards
User “fit”
User expectations
Technical accuracy
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What is Quality Assurance?
QA, QI, QM, TQM, CQI
Alphabet Soup
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Components of a System
Inputs
Processes
Outputs
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Outcomes
Effects
Impacts
Quality Assurance System
INPUTS
PROCESSES
OUTCOMES
• Client expectations
• Quality Design
• Staff performance
monitored
• Organizational structure
• Planning for quality
• Trained personnel
• Setting standards
• Compliance with
standards
• Budget
• Monitoring quality
• Increased efficiency
• Standards
• Supervision
• Culture of quality
• Political support
• Quality Improvement
• Organizational culture
• Accreditation
• Increased access
and utilization
• Satisfied clients
• Improved health
outcomes
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Standard Setting
SS
QA
PS
Problem Solving
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M
Monitoring
Quality Design
QD
QA
QI
Quality
Improvement
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QC
Quality
Control
Design
Organizational
Restructuring
Process Redesign
Quality Design
Planning
Standard Setting
Audit
Quality Assessment
Team-Based
Problem Solving
Management Action
Feedback
Individual Action
Improve
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Q?
Monitoring Systems
Supervision
Self Evaluation
Control
Definition of Quality Assurance
“Process of measuring quality, analyzing the
deficiencies discovered, and taking action to
improve performance followed by measuring
quality again to determine whether
improvement has been achieved. It is a
systematic, cyclical activity using standards of
measurement.”
• Dr. Heather Palmer, US expert
in ambulatory care
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Definition of Quality Assurance
“All the arrangements and activities that are
meant to safeguard, maintain, and promote
the quality of care.”
• Dr. Avedis Donabedian
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Definition of Quality Assurance
“Quality Assurance is that set of activities that
are carried out to set standards and to monitor
and improve performance so that the care
provided is as effective and as safe as
possible.”
• The Quality Assurance Project,
1993
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Definition of Quality Assurance
“A systematic process for closing the gap
between actual performance and desirable
outcomes…”
• Drs. Ruelas and Frenk
QA work in Mexico
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Definition of Quality Management
“...a systematic managerial transformation
designed to address the needs and
opportunities of all organizations as they try
to cope with increasing change, complexity
and tension within their environments.”
• Dr. Donald Berwick, Institute for
Healthcare Improvement
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Definition of Quality Improvement
“…an approach to the continuous study and
improvement of the processes of providing health
care services to meet the needs of patients and
others. Synonyms and near synonyms include
continuous quality improvement (CQI), continuous
improvement, performance improvement, and total
quality management. “
• Joint Commission on Accreditation
of Healthcare Organizations
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Continuous
Improvement
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Philip Crosby
• Quality is free - remove un-quality
things, which are all the actions that
involve not doing jobs right the first time
• People-focused interventions targeted
at zero defects
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Deming’s 14 Points of Management
• Create constancy of purpose toward quality
improvement
• Adopt a philosophy which expects good products and
services
• Cease dependence on inspection and build quality into
the product or service
• Don’t award business solely on the basis of price tag
• Improve constantly the system of production and
service
• Institute on-the-job training
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Deming’s 14 Points of Management
(cont’d.)
• Institute leadership with an aim to help people and
machines do better jobs
• Drive out fear
• Break down barriers between departments
• Eliminate slogans, exhortations and targets
• Eliminate number quotas and management by
objective, substitute leadership
• Remove barriers to pride of workmanship
• Institute education and self-improvement
• Take action to accomplish the transformation
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The Juran Trilogy®
Quality Planning
Quality Improvement
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Quality Control
Shewart Cycle
Act
Check
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Plan
Do
Principles of Managing Quality
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Principles of Managing Quality
Leadership
Client focus
Data
Team work
Systems/
process focus
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Leaders and Quality
“In our experience, no quality
improvement effort has ever been
successful without top management’s
involvement.”
J. M. Juran
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Specific Actions for Leaders
• Define the vision - communicate it and
model its attainment
• Approve financial investment in
improving quality
• Provide and approve time spent in
quality pursuits
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Specific Actions for Leaders
• Require training and learning about
quality - attend and present it yourself
• Reward quality - look for it, recognize it
• Tie reward systems to quality
• Serve on teams
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Specific Actions for Leaders
• Lead the quality effort
– communicate the plans for quality
assessment and improvement
– approve specific improvement projects
– receive / request reports of QI efforts
– “walk the talk”
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Two Major Theories of Client
Satisfaction With Health Care
Expectancy-value theory:
Satisfaction = Perceived care >
Expectations of care
Exchange theory:
Satisfaction = Value of care > Cost of care
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“In God we trust
All others please bring data”
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“Every system is perfectly
designed to achieve
exactly the results it
achieves”
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Stages of Team Development
Forming
Storming
Norming
Performing
Closing
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Components of a System
Inputs
Processes
Outputs
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Outcomes
Effects
Impacts