Quality Improvement Application

Quality Improvement In Hospitals
1Introduction:
Quality Improvement is a formal approach to the analysis of performance and
systematic efforts to improve it. There are numerous models used;
 FADE
 PDSA
 Six Sigma (DMAIC)
 CQI (Continuous Quality Improvement).
 TQM (Total Quality Management).
These models are all means to get at the same thing: Improvement. They are
forms of ongoing effort to make performance better.
 In industry, quality efforts focus on topics like product failures or work-related

injuries.
 In administration, one can think of increasing efficiency or reducing re-work.
 In medical practice, the focus is on reducing medical errors and needless
morbidity and mortality.
In Healthcare, the definition of quality can be complex and controversial because of the
different views of people with a stake in good Healthcare. A few different stakeholders
and what does each of these stakeholders want?
Providers Payers
Employers Patients
The decisions around the conflicts between what these stakeholders want often
determine if a QI project will be a success.
Hospitals are very important for humans. Every day any one can visit it. Care and
awareness from every individual in the hospital is very important. And also the nurses
and doctors must be qualified .Failing hospitals cause Death of people. We must
improve quality of them to achieve the customer satisfaction and happiness and
improve human health care.
1
1-Problems in hospitals:
(1.1) Long waiting time:-

One of the most serious problems that the waiting time of patients is very long. They
are waiting without any care. Because in the variation in patients arrival time and
lack of nurses, there are critical cases that can not stand any waiting time like heart
problems, breathing problems and bleeding. Which if they waited more time they
would come to death.
(1.2) Lack of doctors:-

As well as a shortage of nurses, the emergency service suffered from a lack of
senior doctors. That during night there were no senior doctors, middle grade cover
at all the night, also many critical problems occur at night such as breathing
problems.
(1.3)Resuscitation:-
Resuscitation is a key part of any medical service provision, the lack of suction
equipment on trolleys for patients with breathing problems is a very critical problem.
Junior doctor and also inspectors were sleeping during the night as patients had
stopped breathing.
(1.4)Cleanness:-
In public hospitals cleaning is not very sufficient, beds are not clean and there are
flies in the operation rooms and also polluted blood.
(1.5)Parking problems:-
Parking is not very large. And not designed very well, it must be designed for every
category of people. Such as handicapped people, and easy for leaving it.
Handicapped must park at the beginning of the park. To make matters worse the
pay machine does not accept debit or credit cards so if a person does not have
enough cash they have to worry about how they are going to get the car out of the
car park.
2
2-Questionnaire
 Patient:-
How long do you wait?
o Less than 10 min

o 10 min-30 min
o 30 min-45 min
o 45 min-1 hr
o More than 1 hr
When do you arrive?
o 1 hr-30 min early

o 10min-30min early
o On time
o 15 min-30 min late
o 30 min-45 min late
How many doctors are available?
o 1
o 2
o 3
o 4
o 5
o 6
How do you consider the overall cleanliness?
o Excellent
o Good
o Adequate
o Poor
o Very poor
3
Do you have a car?
o Yes
o No
Do you find a place in the parking?
o Yes easily
o Sometimes
o No never
How do you consider the care received?
o Excellent
o Good
o Adequate
o Poor
o Very Poor
How do you consider the information received?
o Excellent
o Good
o Adequate
o Poor
o Very poor
Indicate your degree of satisfaction with:
Response time:
o Very satisfied
o Satisfied
o Neither satisfied or dissatisfied
o Dissatisfied
o Strongly dissatisfied
4
 Employees:-
Do you have a car ?
o Yes
o No
Do you find a place in the parking?
o Yes easily
o Sometimes
o No never
How many rooms are available?
o 3
o 4
o 5
o 6
o 7
o More than 7
How many workers are available?
o 2
o 3
o 4
o 5
o 6
o More than 6
How do you consider the quality of care offered by the department?
o Excellent
o Good
o Adequate
o Poor
o Very poor
What is your degree of personal satisfaction with the work done?
o Very satisfied
o Satisfied
o Neither satisfied or dissatisfied
o Dissatisfied
o Strongly dissatisfied
5
 Sample Medical History Questionnaire:
Name:-
Date of Birth: - Sex:-
Address:-
Emergency Contact: - Phone:-
 Please circle “YES” or “NO” and provide additional details where requested on
all three sides of this form.
1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?

NO YES (list)
_____________________________________________
2. Do you take any prescribed medication on a permanent or semi-permanent basis
(steroids, anti-inflammatory, antibiotics, insulin, etc.)?
NO YES (list..And..Give..Reason)
_______________________________________________
3. Have you ever had an epileptic seizure?
NO YES
_______________________________________________
4. Have you ever been told by a doctor that you have epilepsy?
NO YES (list..Any..Medication)
________________________________________________
5. Have you ever been treated for diabetes?
NO YES (list..Any..Medication)
________________________________________________
6.Have.you.ever.been.told.by.a.doctor.that.you.were.anemic?
NO YES When?
What.treatment?
_______________________________________________
7. Have you ever been told by a doctor that you have sickle cell anemia?
NO YES
_______________________________________________
6
8. Do you have or have you ever had high blood pressure?
NO YES (list any medication)

________________________________________________
9. Do you have, or have you ever had, the following diseases?
Heart disease (heart murmur, rheumatic fever, other)
NO YES(give name and date)

_________________________________________________
Lung disease (pneumonia, other)
NO ( give name and date)

YES
_________________________________________________
Kidney disease (infections, other)
NO ( give name and date)

YES
________________________________________________
Liver disease (mononucleosis, hepatitis, other)
NO YES (give name and date)

_________________________________________________
10. Have you ever been told by a doctor that you have asthma?
NO YES (list any medication)

________________________________________________
11. Do you have or have you ever had a hernia or “rupture”?
NO YES (if so, has it been repaired?)
________________________________________________
12. Have you been “knocked out” or become unconscious in the past three years?
NO YES (if so, describe and give date)

_______________________________________________
13. Have you had a concussion or other head injury in the past three years?
NO YES (if so, describe and give date)
________________________________________________
14. Have you stayed overnight in a hospital due to a head injury?
NO YES (if so, list date)
7
15. Have you ever had a neck injury involving bones, nerves, or disks that disabled you for a
week or longer?
NO YES Type of injury Dates

________________________________________________________________________
16. Do you wear glasses or contacts during competition?
NO YES
________________________________________________________________________
17. Do you wear any of the following dental appliances?
NO YES (Circle those that apply)

Permanent bridge Braces .Removable retainer Permanent retainer
Removable partial plate Full plate Permanent crown or jacket
________________________________________________________________________
18. Have you had a broken bone (fracture) in the past two years?
NO YES
What bone? Right or left? Dates
19. Have you had a shoulder injury in the past two years that disabled you for a week or
longer (dislocation, separation, etc.)?
NO YES
Type of injury? Right or left? Dates
20. Have you ever had shoulder surgery?
NO YES
What was done and why? Right or left? Dates
21. Have you ever injured your back?
NO YES Type of injury? Dates

________________________________________________________________________
22. Do you have back pain?
NO YES (Circle any that apply)

Seldom Occasionally Frequently With Heavy Lifting
________________________________________________________________________
8
23. Have you injured your knee in the past two years?
NO YES
________________________________________________________________________
24. Have you been told by a doctor or athletic trainer that you injured the cartilage in your
knee?
NO YES Right or left? Dates
________________________________________________________________________
26. Have you ever had knee surgery?
NO YES What was done and why?
Right or left? Dates

________________________________________________________________________
27. Have you had a severe ankle sprain in the past two years?
NO YES
________________________________________________________________________
28. Do you have a pin, screw, or plate in your body?
NO YES Where in your body?
Dates
29. Do you have any other conditions that we should be aware of (i.e., ulcers, pregnancy,
food..Or..Insect..Allergies,.tendonitis,.etc.)?
NO YES (Specify and give details)
________________________________________________________________________
30. Please give the dates of your last tetanus and polio shots:
Tetanus Polio
The questions on this form have been answered completely and truthfully to the best of my
knowledge.
Signature of Athlete (or parent if athlete is a minor) Date
9
Selected problem
The most serious problem is the waiting time according to the questionnaire .
1- Quality tools
1.1 Histograms
10
1.2 Flow Chart
11
1.3 Fish bone diagram:
Machine Man Power

Lack of Doctors
Unreliable Software Technicians take long time gathering history
Patients late or early arrival
Increased Patient Wait Time

Untrained Technicians
Patients Bunching
Poor Scheduling system
Equipment availability
No Queuing System
Method Material
2 -Main Quality Indicators:

 Tests Performance
 No of Doctors
 No of technicians
 Training
 Technicians Behavior
 Equipment state
3 -Solutions:
 The clinic instituted a policy of seeing patients at the appointed time.
 The clinic formalized its training for technicians to reduce the variation in
exam times.
 The scheduling system itself is being restructured to anticipate the time
patients require completing vision tests before meeting with their doctors.
 The clinic also created a queuing system that limited the number of
patients entering the doctors' waiting area.
12
4 -Implementation:
 If patients came early, they were told the clinic had to see patients who were
scheduled before them. If patients came later than 20 minutes, their visit had to
be approved by their physician. Patients are gradually learning that they can't
game the system by arriving at a different time than their scheduled visit. This
makes it easier to predict what tests will be needed and at what time.
 A staff member created color-coded cards for each doctor. The number
allotted to each was based upon the number of patients he or she could see in
one hour. The cards were placed at a desk, which patients were allowed to pass
only when a card for his or her doctor was available.
 There are two appointment times: one for meeting with the technician to gather
the history and perform refraction and any additional tests and a second for the
time at which the patient will see the physician. Depending on the tests
required. The arrival time may be as little as five minutes and as much as 60
minutes before the exam. Because the clinic's software system does not allow
schedulers to put two different appointment times in for one patient, the
schedulers now have to call patients to notify them of their arrival time. But
practice leaders are hopeful that its next software program will automate the
process.
5 -Key Measures:
The data collection process focused on three measures, as defined below
 Technician time:
The goal is 10 minutes for each exam (the previous range was five to 21
minutes). The consultants determined that if the clinic could train the
technicians to complete both the history and the refraction in eight minutes
each, they could save the equivalent of one and one-half staff positions per
year. Because the clinic is growing, it would not lay off staff but would use any
extra staff to meet the needs of new physicians.
 Wait times:
"We met the benchmark for a complete
eye exam, which is one hour and 16
minutes," says prior. The average prior
to implementation was three minutes
more. The clinic expects to see greater
time savings when it fully implements
the new scheduling system.
13
 Bunching:
Doctors only see one or two patients waiting for their visit at any given time.
That doesn't mean more patients aren't waiting, as there can still be clusters of
patients after 11 am or 4 pm. In those cases, the clinic managers or patient
coordinator tries to assign patients to different doctors to smooth out the flow.
The goal is to pull patients through the system at the pace at which doctors can
see them, rather than push them through without regard for such timing.
6 -Conclusion:
Performance improvement in health care is a cyclical process. Healthcare
professionals are expected to look continuously for opportunities to improve the
quality of process, services, and outcomes.
Many improvement methodologies are applied and followed the model of

continuous performance monitoring, ongoing identification of improvement
opportunities and team based improvement process.
Remember that:
•Improving Healthcare quality is a responsibility.
•Measurement and improvement are possible.
•Identifying the root cause before making changes.
•Be creative in developing solutions.
14
7-References
The OECD Health Care Quality Indicators Project: history
by SMattke - 2006 - Cited by 19 - Related articles - All 4 versions Its Health

Care Quality Indicators (HCQI) Project is attempting to . Mattke S. Monitoring
and improving the technical quality of medical care: a new..
ntqhc.oxfordjournals.org/cgi/content/full/18/supple 1/1 - Similar
http://news.bbc.co.uk/2/hi/health/7948943.stm
http://www.telegraph.co.uk/news/majornews/2505011/Hospitals-infested-with-
rats-fleas-and-bed-bugs.html.
http://www.shropshirestar.com/2009/02/25/problems-of-hospital-parking/.
15

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Quality Improvement In Hospitals

 In industry, quality efforts focus on topics like product failures or work-related

(1.1) Long waiting time:-

(1.2) Lack of doctors:-

How long do you wait?

o Less than 10 min

When do you arrive?

o 1 hr-30 min early

How many doctors are available?

How do you consider the overall cleanliness?

Do you have a car?

Do you find a place in the parking?

How do you consider the care received?

How do you consider the information received?

Indicate your degree of satisfaction with:

Do you have a car ?

Do you find a place in the parking?

How many rooms are available?

How many workers are available?

How do you consider the quality of care offered by the department?

What is your degree of personal satisfaction with the work done?

 Sample Medical History Questionnaire:

1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)?

5. Have you ever been treated for diabetes?

8. Do you have or have you ever had high blood pressure?

NO YES (list any medication)

9. Do you have, or have you ever had, the following diseases?

Heart disease (heart murmur, rheumatic fever, other)

NO YES(give name and date)

Lung disease (pneumonia, other)

NO ( give name and date)

Kidney disease (infections, other)

NO ( give name and date)

Liver disease (mononucleosis, hepatitis, other)

NO YES (give name and date)

NO YES (list any medication)

11. Do you have or have you ever had a hernia or “rupture”?

NO YES (if so, has it been repaired?)

NO YES (if so, describe and give date)

NO YES (if so, describe and give date)

14. Have you stayed overnight in a hospital due to a head injury?

NO YES (if so, list date)

NO YES Type of injury Dates

16. Do you wear glasses or contacts during competition?

17. Do you wear any of the following dental appliances?

NO YES (Circle those that apply)

20. Have you ever had shoulder surgery?

21. Have you ever injured your back?

NO YES Type of injury? Dates

22. Do you have back pain?

NO YES (Circle any that apply)

Right or left? Dates

Signature of Athlete (or parent if athlete is a minor) Date

1.2 Flow Chart

1.3 Fish bone diagram:

Machine Man Power

Unreliable Software Technicians take long time gathering history

Patients late or early arrival

Increased Patient Wait Time

2 -Main Quality Indicators:

Many improvement methodologies are applied and followed the model of

•Measurement and improvement are possible.

•Identifying the root cause before making changes.