Managing Outcomes Utilizing an Organizational

Performance Improvement Model

Out line
 Defining Quality of Care
 History of Quality
 Quality Principles
 Categories of Performance Outcomes
 Who Are the Customers in Health Care?
 Defining Customer Needs
 Patient Satisfaction Data
 Performance Improvement Concepts
 QUALITY DIMENSIONS
 Quality Improvement Process
 Quality control tools (Charts)
Objectives
 Upon completion of this Presentation , the Participant
should be able to:
 Know what is the Quality Care
 Identify the Customer and Customer Needs
 Know Performance Improvement Concepts
 Explain PI Process Methodologies
 Explain QUALITY DIMENSIONS
 Know Quality control tools (Charts)
 DO Performance Improvement Project
Defining Quality of Care
 “Quality of care is the degree to which health
services for individuals and populations
increase the likelihood of desired health
outcomes and are consistent with current
professional knowledge”.
- Institute of Medicine, USA
History of Quality :
 Quality assurance (QA) emerged in health care in
the 1950s as an inspection approach to ensure that
minimum standards of care existed in health care
institutions.
 With its emphasis on “doing it right,” some
thought that QA was very punitive and did little to
sustain change or proactively identify problems
before they occurred.
: History of Quality

 Total quality management (TQM) began in the

manufacturing industry, when W. Edwards Deming
and Joseph Juran consulted with Japanese
corporations in the 1950s.
 The end result of this method was to satisfy
customers rather than just “doing it right.”
 This approach became integrated in the health care
industry in the 1980s.
 Quality Principles

Contin Empowerment
u
Impro ous
vemen
t r m a nce
Pe r f o
Measures
QUALITY

Work Process Cust

omer
Focus Orie
ntati
on
Categories of Performance
Outcomes
Categories of Performance Outcomes

A. Doing the Wrong Things Right

 System Design is poor
 Staff performance is acceptable
- revisit the design step.make sure staff
members are trained to carry out any
changes in design
Categories of Performance Outcomes

B. Doing The Wrong Things Wrong

 System design is poor
 Staff performance is not acceptable
-Entire approach needs to be revisited (all five
steps)
Categories of Performance Outcomes

C.Doing The Right Things Right

 System design is good
 Staff Performance is good
Make sure you find out what makes it work so
you can repeat it
Categories of Performance Outcomes

D. Doing The Right Things Wrong

 System design is good
 Staff performance is not acceptable
Find out why staff are not able to carry out the
program as designed. Make necessary improvements.
Who Are the Customers in Health Care?

 A customer is anyone who receives the output of

your efforts.
 Customers can be internal, within the organization.
 Customers can be external, outside the organization.
Defining Customer Needs
 Who are my customers?
customers
 What do they need from me?
 What is my service to meet their needs?
 What are my customers’ expectations?
expectations
 What is my process for meeting their needs?
 Does my service meet or exceed their needs and
expectations?
 Do all the activities in the process add value to the
customer?
Empowerment of Everyone in the
Organization
 Each person must feel that he or she participates.

 Each takes responsibility for the success or

failure of an organization.

 Each takes an active part in developing new ways

of doing business and securing new customers.

 Each trusts that his or her efforts are valued.

Who Participates in the Improvement Process?

 All staff members should be encouraged to participate.

 All those involved with or affected by a goal or
process should participate.
 Staff can participate on individual, unit, or
organizational levels.
 Participants should include point-of-service staff, i.e.,
those workers on the front line who do the direct work
involved in the process being changed.
Improvement of the Health Care Process

 A process is a set of causes and conditions that

repeatedly come together in a series of steps to
transfer inputs into outcomes.
 All processes have inputs, steps, and outputs.
Improvement of the System
 A system is an interdependent group of items, people,
or processes with a common purpose.
 Outcomes in a system can be improved by examining
not only processes, but also the relationships
between processes.
 Correct gathering and interpretation of data is an
essential component of continuous improvement.
 Shewart cycle: Shewart developed the concept that
improvement is a cycle; it is continuous because it is
linked to customer needs and judgments.
Implications for Client Care
 Quality improvement for patient care can be measured
by the overall value of care.
 Value is determined by outcomes and cost.
 Outcomes can be clinical/functional or related to
patient satisfaction.
 Cost can be direct or indirect.
 Goal: increase quality outcomes, reduce cost.
Improving Organization Performance

The Organization’s approach to improving its

performance must include the following processes:
 Designing Processes,
 Monitoring Performance through data collection,
 Analyzing current performance,
 Improving and sustaining improved performance
Patient Satisfaction Data

 Accumulated through questionnaires, focus groups,

and post care interviews
 Helpful if data can be compared/benchmarked against
data of similar organizations
 Time series data
 Allows a quality improvement team to see change in quality
over time
 Time series chart used to look for trends, shifts, and unusual
data
QUALITY IMPROVEMENT
 Collaboratively select existing processes & outcomes
for chronic problems in governance, management,
clinical & support activities.
 Analyzing causes of chronic process failure
 Systematically develop optimal solutions to chronic
problems
 Analyzing data for “better or best practice”
 End by quality control/measuring to holds the gains.
PERFORMANCE
IMPROVEMENTS
Performance Improvement Concepts

 Performance is what is done & how well it is done to provide health care.

 Level of performance:
 What is done, measured by DEGREE to which care is:
 Efficacious
 Appropriate

 How it is done, measured by DEGREE to which care is:

 Safe
 Available
 Timely delivered
 Efficient
 Effective
 Coordinated among care givers
 Respect & Caring to patient
QUALITY DIMENSIONS

16 3A 2P 4C 1D 2E 1R 1S 1T
3 A:
 Accessibility, Amenities, Appropriateness
2 P
 Prevention/Early detection, Preparedness
4 C:
 Caring, Communication, Competency, Continuity
1 D:
 Durability/reliability
2 E:
 Effectiveness, Efficiency, Efficacy
1 R:
 Respect
1 S:
 Safety
1 T:
 Timeliness
 ACCESSIBILITY
Availability, Affordability, Acceptability

 Physical, Financial, Intellectual Access.

 Intellectual (Perception) Access = Care Communication in

Customer’s Culture, Beliefs & Education

 With No Acceptability, Customer will not seek for the care

even if it is available & affordable.
 AMENITIES
 Esthetical Acceptable Environment of Care
Provision
 Pay Attention to Minute Details of Customer
Comfort & Wellbeing
 E.g. Cleanliness, Decoration.
APPROPRIATENESS
 Care Provision in Relation to:
 Customer Requirements (needs & expectations).
 Current State of Knowledge
 Correct and Suitable Resource Utilization
PREVENTION / EARLY DETECTION

 Risk Factors Detection

 Health Status Promotion
 Disease Prevention.
CARING
 Individual Involvement in his/her Own
Care & Service Decisions.
CONTINUITY
 It is “Managed” Care.
 Coherent Unbroken Succession of Health Care
Services Provision.
 Coordination of Needed Health Care Services for
Patients or specific population over time among:
 All Practitioners
 Across All Involved Organizations
Continue!

CONTINUITY
 Initiation, Rendering, Evaluation, Improvement &
Continuous Monitoring of Care Provision Even After
Patient cure from his present Illness.

 Extension of Care to Wellness, Health promotion &

Disease Prevention.
COMPETENCY
 Practitioner Adherence to Profession &/or
Organization Standards of Care & Practice.

 Practitioner Ability to Achieve both health &

satisfaction of customers.

 Competency Needs Ongoing Education & Training.

COMMUNICATION
 Interpersonal Relations for Personal Interaction
& Teamwork Practice among Professionals are
Effective Communication Tool for Holistic
Positive Care Outcome.
DURABILITY & RELIABILITY

 Consistency of Performance & Care Provision.

 Useful Life of health Care Service.
EFFECTIVENESS
 Doing the Right Thing Right
 Provision of Care:
 In Correct Manner
 According to current state of knowledge
 To Achieve Desired/Projected Outcomes

 Performance is Equivalent to Stated requirement &

agreed standards.
 Positive Results of Care.
EFFICIENCY
 Combination of Skillfulness & Economy in provision
of care, i.e. Elimination of Redundancy, Duplication
& Rework.
 Delivery of maximum number of “units” of health
care for a given “unit” of resources.
 Relationship between Outputs (services provided) &
Inputs (resources used to produce these services).
 EFFICACY
 Potential, Capacity, or Capability to produce
Desired Outcome as already shown e.g.
through scientific research (evidence-based)
findings.
 Power of a procedure to improve health status.
 RESPECT
 Sensitivity & Care about Customer’s
Requirements (needs, expectations) &
Individual Differences during Provision of
Care & Services.
SAFETY
 Health Care Intervention reduces Risks of
Adverse Outcomes for Both Patient &
Providers.
 Organizational Environment is Free from
Hazard or Danger for Both Patient &
Providers.
TIMELINESS
 Performance & Service Provision are in accordance
with customer perception of promptness.

 Provision of Health Care Services is at the most

Beneficial or Necessary Time for Patients.
Quality Improvement Process
 A series of steps to think about & work through from initial
improvement challenge to successful completion of the effort.
 These steps help to:
 Ask questions
 Gather information
 Take actions efficiently & effectively
 It has many benefits:
 Prevent from skipping important steps along the way.
 Help a group work together & communicate to others
 Can be used by any one from frontline to executive level.
 QI Process Methodologies

 TEN Steps QI Process

 FOCUS-PDCA
 Six Sigma “3.4/million defects”
 Lean QI Process “No waste”
 Kizen QI Process “Zero Defect”
The FOCUS-PDCA Problem-Solving Approach

FOCUS
 Find a process to improve
 Organize team that knows the process.
 Clarify current knowledge of the process
 Understand causes of process variation
 Select the process improvement
F.O.C.U.S.
F ind an improvement project (initiative):
 Review related standards & documents
 Analysis of collected data
 Identify problems & desired outcomes
Identify
Problem
How To Identify the Problem

 Is it a real problem?
 Do we have enough reliable data to prove that it is a
problem?
 What is the scope of the problem?
 Who are the Stakeholders?
 What is the impact of this problem on Patient Care?
 Is the solution within the scope of the team?
 How To Write A Problem Statement

A good problem statement

 Should be:
 specific
 measurable
 supported by data
 objective
 And should not:
 include any causes or solutions or blame anybody
F. O.C.U.S.
O rganize (task force) team:
 Identify & involve stakeholders (e.g. physicians,
nurses, administrative …etc)
 Cover all related departments to the improvement
initiative
 Select team members who best do or know the
process to be improved
Team Responsibility

 Accept or identify improvement projects

 Investigate the cost of poor quality
 Describe the specific problems/opportunities
 Gather and analyze data
 Identify root causes
 Develop alternative processes
 Apply alternative processes and track results
 Recommend replication
 Feedback helpful experiences (lessons , learned)
Team Leader
 Role
 Guide team to reach established goal (s)
 Provides direction and support to Team

 Key Responsibilities
 Coordinates & conducts Team meetings
 Encourages member participation
 Interacts with CQI Council on Team issues/programs
 Functions as an equal Team Member
Team Facilitator
 Role
 Promotes effective team dynamics
 Serves as consultant/coach to the Team

 Key Responsibilities
 Provide training in QI concepts & methods
 Assist team members in building strengths
 Assist Team Leader in team process
Team Facilitator (Cont.)

 Not a member of the team,

 Keep the team focused
 Seek opinions of all team members
 Coordinate ideas and test for consensus
 Assist team in applying Ql tools and techniques
 Summarize key points
 Provide feedback to the team
Team Member

 Role
 Shares knowledge & expertise of process/issues
 Key Responsibilities
 Active participant in team process
 Performs assignments
 Represents/communicates with the work group
F.O. C.U.S.
C larify current process & desired outcomes:
 Fully understand the current process by all team
member
 Draw flow chart to clarify the process
variation/problem
 Collect data from all affected areas relevant to process
& desired outcomes
F.O.C. U.S.
U nderstand Process Variation, Root Causes &
Desired Outcomes:
 Identify tools needed to describe & analyze process
variation, root causes & desired outcomes
 Obtain Information from benchmark, best practice
..etc
 Identify all possible solutions to achieve the desired
outcome
F.O.C.U. S.
S elect the best practice procedure:
 Analyze alternative solutions related to process
improvement
 Choose the best solution that will achieve desired
outcome
 Develop approval with a summary of required
information about expected outcomes, resources
needed, time-frame, responsibilities ..etc
P.D.C.A.
P lan for improvement project (initiative):
 Assign tasks with agreed criteria checklist & set time
frame
 Allocate resources, determine responsibilities & gain
support from all who will be affected by
implementation.
 Establish monitoring system to collect necessary data
to keep project on the track
 P. D.C.A.
Do the improvement project:
 Implement the best solution stated in FOCUS process.
 Empower all people involved by training, education &
moral support.
 Collect data & update checklist
 P.D. C.A.
C heck the results
 If the desired outcome is obtained & lead expected
improvement.
 Compare data collected from FOCUS process with
that during DO
 Check for any unexpected, undesired consequences or
outcomes
P.D.C. A.
A ct to hold gains or re-adjust FOCUS-PDC
 If improvement initiative is reaches; standardize the process,
adjust documents & empower people
 If improvement initiative is not reached, repeat FOCUS-PDCA
cycle
 For both situations, continue to monitor the process to identify
further improvement.
Quality control tools (Charts)

 Flow Chart
 Fishbone charts
  Pareto
 Pie charts
Flowchart
• A flowchart graphically represents the steps of a process or the steps that
users have to take to use a service.
• It is a good technique to use for describing activities, identifying problems
and their causes, detecting bottlenecks, unnecessary steps, repetitions and
other obstacles and for defining indicators.
• A flowchart can use numerous different symbols to indicate different
types of actions in the process.

Three major ones are:

 Beginning or end of process

 Step in the process (activity)

 A decision point
 Fishbone Diagram
• Also called Cause-and-Effect Diagram or
Ishikawa Diagram.
• A graphical technique for grouping ideas
about the causes of a problem or effect.
 How to do it
• Agree a problem statement.
• Write it at the centre right of a flipchart and draw a box (fish
head) around it and draw a horizontal
arrow running to the box. This arrow is the backbone or spine of
the ‘fish’.
• The direction of the arrow shows that the items that feed into it
might cause the problem described in the head.
Brainstorm the major categories or causes of the problem.
• Some generic examples for categories would be:
– Methods – Machines – Manpower – Materials – Measurement
• Write the categories of causes as branches (large bones) from
the main arrow.
 How to do it
Now brainstorm all the possible causes of the problem.
• As each idea is raised, write it as a branch from the appropriate
category.
• Causes can be written in several places if they relate to several
categories.
• Keep asking ‘Why?’ about each cause.
• Write sub-causes branching off the causes.
• Layers of branches indicate causal relationships.
!!! Exercise
 There is a high rate of Delay and cancel in Operation
Theater.
 Group 1….…. Find a process to improve
 ……….……. Organize team that knows the process.
 Group 2……. Clarify current knowledge of the process
( use flow Chart)
 Group 3……. Understand causes of process variation
( use fish bone)
 ………..……. Select the process improvement
 Find a process to improve
Since the delay and cancellation of surgical procedures
was found to be high ( during three weeks 21% for
canceled cases, and 30% for delay cases) a process to
reduce this rate was proposed . This process starts from
reservation till the time of the procedure itself started
The Opportunity Is Important Because It Will
Lead To:
 Effective use of staff time & operating rooms
 Improve arrangement of work flow according to the schedule.
 Reduce waiting time of the patients and increase patients satisfaction
 Organize team to work on improvement
(Team Building):

 ??????/ Team leader.

 ??????? /Team Facilitator.
 ?????? /Team member.
 ??????? /Team member
 ???????? /Team member
 ???????? /Team member.
 C larify current knowledge of the process
Detailed Flowchart Of Patient Ready For Surgery
No
Patient arrives at
canceled
admission office

Yes

Bed Yes
Patient admitted Patient fit Yes Patient Yes Yes
?Available Surgeon
to floor for surgery prepared on
Available
time
No
No No No
Delay or Delay or
canceling canceled Delay
canceling

Yes
Operation
Patient ready for surgery
room ready

No
Delay
U nderstanding process variations
Causes of Delay And Canceling
Problem Underlying causes
Bed availability -1 Admitted Emergency cases in I.C.U-
Full Capacity-

Patient fitness-2 Low platelet at the time of procedure-

Low immunity –High B/P - on Warfarin-

Incomplete pre-op -3 incomplete consent form-

preparations incomplete per-op preparation checklist-
Documentation & Availability of lab investigation-
Surgeon evaluation-
Anesthesia evaluation-
Readiness of Operation -4 Not clean-
Room Previous case not finished-
Delay of surgeons-5 Part time surgeons -Involvement in other activities-
 Understanding process variations
Using Fish bone (cause &effect )

Personal
Communication
Documentation Delay of surgeon

Doctor notes
Booking mistake Cleaner
Consent form Short of nursing
Delay And
Cancel
Elevator s Missing Not arrives
Not Fit
Operation setup Not Ready

Patient
Equipment
Environment
 Select the process Improvement
 Statistics During JAN/2009
-Total no. of cases: 224
-Total no. of delay cases:68
-Percentage of delay cases:30%
Delay Cases Analysis
Statistics During Nov/2006
-Total no. of cases 224
-Total no. of canceled cases: 47
-Percentage of canceling cases: 21%
Cancellation Cases Analysis

Causes Quanti Percentage Cause Quantity Percentage

ty
postponed 8 17%
Delay of surgeons 9 13%
Pt. not come 9 19%
Incomplete 15 22%
preparations Pt. not fit 12 26%
Operation room not 19 28% Patient refuse 11 23%
ready surgery
Booking mistakes 11 16%
Incomplete 7 15%
X-ray not available 10 15% preparation
Time for platelet 4 6%
Transfusion
Delay CasesUsing Pareto chart

60 90%
80%
50
70%
NumberCases

40 60%
50%
30
40%
20 30%
20%
10
10%
0 0%
D B A C E F
Delay cases

D Operation room not ready 19 27.9%

B Incomplete preparations 15 50.0%
A Booking mistakes 11 66.2%
C Delay of surgeons 9 79.4%
E X-ray not available 10 94.1%
100.0
F Time for platelet Transfusion 4 %
Cancel Cases Using Pareto chart

45 90%
40 80%
35 70%
No of Cases

30 60%
25 50%
20 40%
15 30%
10 20%
5 10%
0 0%
D A B C E

Cancel cases

Pt. not fit 25.5%

D 12
Patient refuse surgery 48.9%
A 11
Pt. not come 68.1%
B 9
postponed 85.1%
C 8
E Incomplete preparation 7 100.0%
P.D.C.A.
Act Plan

C heck Do
 ACTION PLAN
Goal:………………………………….
Ob Re
s
Re Mo
nth
j po so We or
ec ns
ib ur ek
tiv ili ce s
es ty s 12 3 4 5 6 7 8 9 10

1-

2-

3-
 Outcomes
 Outcomes are a measurement of the patient
response to structure and process.
 Outcomes:
 Measure actual clinical progress
 Can be short-term or long-term

 Outcome data can be helpful in identifying

opportunities for improvement.