QUALITY HEALTH CARE AND NURSING

Total Quality Management (TQM)

A comprehensive and structured approach to organizational management that seeks to improve the
quality of products and services through ongoing refinements in response to continuous feedback.

TOTAL
Implies that all members of the organization make consistent effort to achieve the objective of
customer delight through systematic efforts for improvement of the organization.
QUALITY
• “Quality is fitness for use.” (Juran)
• “Quality is conformance to requirements” (Crosby)

Quality of product or services is the ability to satisfy the needs and expectations of the customer.
• Quality of Care = Quality of the Process
• The degree to which health care increases the likelihood of desired health outcomes
• Consistent with the current professional knowledge

Characteristics of High-Quality Care

1. Safe
2. Effective
3. Efficient
4. Appropriate
5. Accessible
6. Patient-centered

Critical Issues on the Quality of Care

1. Individual and Organizational Competence
2. Continuity of Care
3. Information Management
4. Role of Evidenced-Based Medicine

Quality of Care
Patients = ultimate recipients of care
Provider Organizations = indirect beneficiaries

Provider Organizations
Internal and External Customers
– Staff and Employees
– Funders (Owners)
– Payors of Health Care (insurance companies)
– Contractors (housekeeping, security agencies)

Importance of Quality of Health Care

• The Hippocratic Oath Principle of “Primum Non Nocere’’ (First do no harm)
• Social and humanitarian motivation to use resources for the good of those in need
• Professionalism
• Survival
Where Quality of Health Care Starts
a) Selection of the most appropriate health intervention
b) Effective, efficient and timely application of the selected intervention

Assessing the Quality of Health Care

Components:
1. Structural
2. Process
3. Outcome

Quality is measured against a set of standards.

Quality Assurance Framework

If a service provider renders adequate performance in these dimensions and rates high on the cross
dimensional issues, the result is appropriate quality of care.

Dimensions of Quality Health Care

1. Safety
Avoidance of harm from care, whether by omission or commission as well as from the environment in
which it is carried out.
2. Effectiveness
Related to the extent to which a treatment, intervention or service achieves the desired outcome.
3. Appropriateness
Doing the right thing to the right patient in a timely manner
Ensure appropriateness of key medical interventions including compliance with selected clinical
pathways.
4. Consumer Participation
Develop mechanism to assess patient’s satisfaction level with service providers.
Provide opportunities for patients to participate in health service planning, delivery, monitoring and
evaluation.
5. Accessibility
Equitable access to health services on the basis of patient’s need, irrespective of geography, payment
group (indigent, paying etc.) ethnicity, age or gender
6. Efficiency
Ensures cost-efficiency through the implementation of case payments, select contracting and
monitoring of compliance with clinical pathways
Minimize inappropriate resource inputs and allocate resources to services which provide the greatest
benefit

Cross-Dimensional Issues
1. Competence
3 Levels of Competence:
A. Organizational Competence
Organization’s ability to assess its capacity to perform functions or procedures, or to supply a particular
service
B. Multidisciplinary Care Team Competence
Team’s ability to deliver optimum outcomes for patients.
Encourage a multidisciplinary team approach to health care delivery through clinical pathways and
accreditation standards.
C. Individual Competence
The individual health care provider’s skills, knowledge and attitudes
• Selection and recruitment of appropriate staff
• Skills assessment
• Peer review
• Continuing education
• Clinical supervision
• Credentialing
2. Information Management
Encourage to prioritize the development of information systems to promote and support appropriate
use of data for health care quality improvement.
3. Continuity of Care
Is achieved through admission and discharge planning, communication and coordination among health
care professionals, and linkages between hospital and community care providers.
4. Evidence-based Medicine, Clinical Practice Guidelines and Clinical Pathways
The conscientious, explicit and judicious use of current best evidence in making decisions about the care
of individual patient
Attempts to attain care improvement through the elimination of unnecessary diagnosis or treatment
• Clinical Practice Guidelines – aids in making appropriate decision for specific clinical
circumstances
• Clinical Pathway – sequential way of providing multidisciplinary clinical care for a particular type
of patient
5. Education and Training
Provision for a well-planned education program for all stakeholders.
Priorities for the development of clinical practice guidelines and other quality improvement activities.
6. Accreditation
Assessment of an organization’s compliance with set standards and evaluation of its commitment to
provide quality care and service.

Accrediting Agencies for Healthcare Organizations

Joint Commission International or JCI
Focuses on improving safety of patient care through:
1. Provision of accreditation and certification services
2. Advisory and educational services
• JCI Accredits:
- Hospitals
- Primary Care Organizations
- Ambulatory Care Organizations
- Home Care and Long Term Care
- Clinical Laboratories
- Clinical Care Programs
International Organization for Standardization (ISO)
- World’s largest developer of international standards
- Gives state of the art specifications for products, services and good practice, helping to make
the industry more efficient and effective.
Accrediting Agencies for Academic Institutions
PACUCOA – Philippine Association of Colleges and Universities Commission on Accreditation
- A private accrediting agency which gives formal recognition to an educational institution by attesting
that its academic program maintains excellent standards in its educational operations in the context of
its aims and objectives.
PAASCU – Philippine Accrediting Association of Schools, Colleges, and Universities
- A private, voluntary, non-profit and non-stock corporation that accredits academic programs which
meet standards of quality education.

Improving Quality of Care

Quality Control
3 Steps of the Quality Control Process
1. The criterion or standard is determined.
2. Information is collected to determine if the standard has been met.
3. Educational or corrective action is taken if the criterion has not been met.

• Steps in Auditing Quality Control

Audits Frequently Used in Quality Control

• Structure
• Process
• Outcome
Structure Audits
• Staffing ratios
• Staffing mix
• Emergency department wait times
• Availability of fire extinguishers in patient care areas
Process Audit
• Critical pathways
• Standardized clinical guidelines
Outcome Audit
• Mortality
• Morbidity
• Length of hospital stay

Hallmarks of Effective Quality Control Programs

1. Support from top level administration
2. Commitment by the administration in terms of fiscal and human resources
3. Quality goals reflect search for excellence rather than minimums
4. Process is ongoing (continuous)

Quality Assurance
• Prescribes preventive activities to ensure the quality of the finished product
• The activities evaluate whether the process of planning, execution, delivery and maintenance of
goods and services are being performed according to stated design.
Quality Improvement
Upgrading from previously accepted minimal performance standards
Total Quality Management
• Individual is the focal element on which production and service depend.
• Focus is on doing the right things, the right way, the first time, and problem-prevention
planning, not inspective and reactive problem solving.