DR.HJ.MUHD KHAIRI BIN MOHD TAIBI, AMN.

,AMP
PAKAR PERUNDING PERUBATAN KELUARGA

What is QUALITY?
Means Different Things
To Different People

What is Quality?
Invisible when Good
Impossible to Ignore when Bad

Quality assurance
KKM Definition
Securing optimum achievable result
for each patient,
avoidance of iatrogenic complications
and giving attention
to the patient
and family needs
in a manner
that is cost effective
and reasonably documented
Adapted from Thomson

ABNA concept
Ideal
100

Optimum

75
50

ABNA

Actual

With unlimited resource

ideal level of care

Optimal Achievable Level

targetted level within

means

ABNA
difference between OA &

25
0

present level
QA aims at narrowing or
eliminating the gap

QUALITY ASSURANCE
is equal to

ASSESS & CORRECT

Problem
identification
Problem
Prioritisation

Re-evaluation
of the Problem

Implementation of
Remedial Actions

Quality
Assurance
Cycle

Problem
Analysis

Quality
Assurance
Study

Identification
of Remedial
Actions

Evaluation

Verification of the
problem

Problem
identification

Problem
Prioritisation

Re-evaluation
of the Problem

Implementation of
Remedial Actions

Quality
Assurance
Cycle

Problem
Analysis

Quality
Assurance
Study

Identification
of Remedial
Actions

Evaluation

Problem identification
It is problem or perception

1.
1.

Verification of the problem check it out with

information /statistics/people involved/pilot study

Source of information to identify problem

2.

Suggestion from staff/Issues from

meeting/data/morbidity or mortality
review/brainstorming

Criteria used to decide if problem is worth studying

3.
1.

SMART

28
December
2014

Methodology of QA Study
1. Problem / Opportunity Statement
A complete opportunity/ problem statement should
describe :
* the problem or area of concern and its
significance for the quality of care
* possible causes and contributory factors
* rationale of the study
* scope of the study
* intention to use the results to improve the
quality of care

Quality Problem

Related to
Customer Satisfaction
Cost Savings

Increase Efficiency
Reduce Discomforts

11

28
December
2014

Non Quality Problems

Administrative Issues (Management problem)

Eg; Poor control of visitors outside visiting hours

High attendance of cold cases at A & E dept.
Not related closely to the quality of care,
May not improved customer satisfaction

Problem of Scientific/Academic interest

Eg; High mortality rate in diabetic ketoacidosis

High incidence of ADR from administering certain
antibiotics
28
Needs clinical research / study December
12

2014

Verifikasi Masalah Mengurangkan kejadian Diabetic Foot Ulcer

Dikalangan Pesakit Diabetes Type II

6000

4912

5013

108(2.7%)

127(2.6%)

145(2.9%)

2006
3916

2007
4912

2008
5013

108

127

145

3916

JUMLAH PESAKIT

5000
4000
3000

2000
1000
0
Kes DM Type II
Diabetic f oot Ulcer

TAHUN

Problem
identification
Problem
Prioritisation

Re-evaluation
of the Problem

Implementation of
Remedial Actions

Quality
Assurance
Cycle

nominal
Group
Technique

Problem
Analysis

Quality
Assurance
Study

Identification
of Remedial
Actions

Evaluation

Nominal Group Technique

( NGT)

THE GROUP
Common interest ----> quality improvement
NUMBER : 7 - 12
< 7 : Inadequate expertise
>12 : Too many
Unsatisfactory group dynamics
Few loud-mouth, many nodders & sleepers

15

28
December
2014

NGT steps
Silent generation phase:
individual think about ideas
free from comment and interference
Round robin phase:
one-by-one responses
list exact phrases and displayed
no discussion except clarification

16

28
December
2014

NGT steps

( cont)

Clarification phase :

Serial discussion to clarify, elaborate,

defend, dispute
Problems maybe reworded, grouped,
combined, deleted or modified

Voting phase:

select important items/problems

voting process and ranking
may revote and reprioritised

17

28
December
2014

Basis of Ranking - SMART criteria

SERIOUSNESS / SPECIFIC
Life at stake ( mortality)?

Permanent disability ?
Complication? Pain?
Costly?
Causing distress to patient?
Impact on patient, community &
hospitals image
Impact on cost & resources
Frequent occurrence though not serious
Big room for improvement
Large ABNA
18

28
December
2014

Basis of Ranking - SMART criteria

Measurable
Data available to quantify extent of problem
Process clearly defined

( starting & ending points)

Indicators identifiable with problems
Appropriateness
How much related to CORE BUSINESS?
Objective consistent with organisational
goals
19

28
December
2014

Basis of Ranking - SMART criteria

Remediable
Resource & Expertise available
Solution is possible
Within capacity of group

Timeliness / Timed
no current operational, financial or political
issues which might affect the success of

project
Social, political, ethically acceptable
Does not take very long to remedy

28 December 2014

20

Problem
identification
Problem
Prioritisation

Implementation of
Remedial Actions

Quality
Assurance
Cycle

Problem
Analysis

Quality
Assurance
Study

Identification
of Remedial
Actions

Evaluation

Cause-effect

Re-evaluation
of the Problem

Problem
statement

PENYATA MASALAH/ PELUANG

PENAMBAHAIKAN
(PROBLEM /OPPORTUNITY STATEMENT)
Purpose is to justify the study (to sell the project)

Contents of problem statement

1)

Background information of the problem

2) Explaining the problem evidence if any

3) What are the effects (BAD)

4) What are the possible causes/contributing factors
5) Expected result

6) Why we want to do with the study

IMPROVING MANAGEMENT OF COMPOUND LONG BONE

FRACTURES
Management of compound fractures forms a major part of the
workload of the Orthopaedic Dept.. (INTRODUCTION)
Those with compound fractures shouldnt have to wait for a long
time in the ward before they are operated upon. They should be
treated promptly and effective rapid uncomplicated recovery
(DESIRABLE OUTCOME/ EXPECTATION)
There are ample opportunities to make this possible in our
setting such as timely availability of OT, consent, blood or
appropriate examinations and investigations
(OPPORTUNITIES)
We hope to identify areas that can be improved by carrying out a
study using certain indicators to identify contributing factors
28
and propose remedial actions. (INTENT TO IMPROVE)
December
23

2014

Problem Analysis
To analyse the problem and the factors influencing

it
(a) 4W1H What, Where, When,Who are
involved and How it happened

(b) Analyse the possible causes of the problem

and its effects using cause-effect diagrams
(bubble charts / Fishbone charts (Ishikawa)
1)

Cause-Effect Analysis
( In QA we use the bubble chart )
List down all possible causes first
Look at the main causes , then put in as 1st
generation bubble

Then propose and arrange the inter-related causes

in the 2nd generation and so forth

Bubble chart
Secondary causes
Secondary causes

Primary causes

Primary causes

Effect of the problem

/complication

Primary causes
Secondary causes

CARTA SEBAB DAN AKIBAT DALAM MENINGKATKAN AMALAN

PERANCANG KELUARGA DI KALANGAN IBU OA DI DAERAH PEKAN
Meningkatkan
promosi kepada
masyarakat
OA

Memberi
pendidikan kesihatan
kepada ibu OA

MENINGKATKAN PENGETAHUAN
TENTANG KEPENTINGAN
AMALAN PERANCANG KELUARGA

Meningkatkan
kefahaman mengenai
kepentingan perancang
keluarga

Melibatkan
orang berpengaruh
seperti bomoh,
Tok Batin
dan JHEOA

Menggunakan
flip chart bergambar yang
jelas dan menarik

MENINGKATKAN AMALAN
PERANCANG KELUARGA
DI KALANGAN IBU OA
DI DAERAH PEKAN

MENINGKATKAN
PENERIMAAN IBU
TERHADAP AMALAN
PERANCANG KELUARGA

Penggunaan
kaedah perancang
keluarga yang
sesuai
27

Memberi motivasi
kepada ibu, suami dan
keluarga terdekat tentang
kepentingan perancang
keluarga

Tingkatkan
perkhidmatan
klinik bergerak

Memberi
latihan berterusan
kepada anggota
kesihatan

MENINGKATKAN
PERKHIDMATAN
PERANCANG KELUARGA

Pengesanan
awal kes-kes cicir &
lawatan ke rumah
dijalankan

Penyelianan dan
pemantauan
yang berterusan

standards
Standard is the line that differentiates the good from the bad.
- Acceptable lowest limit
The standard is to :
i) verify problem exist (First level)
Ii) show factors identified are responsible for the
problems (Second Level)
Problem: Long waiting time in OPD
1st Level standard : within 60 mts. from registration and

seeing doctor,
2nd Level : 75%f the patient should <60 mts. waiting time

standards setting
Setting too high a standard may make the problem

unsolvable and the target unreachable

If its too low, it may not reflect quality level of care
thats acceptable
Use literature and other studies to determine the
appropriate standard in YOUR setup
Or set standards after knowing current level of car
When human factors are involved usually the
standard should not be 100%

Process of care
Flowchart / pathway of care the steps of
activities while delivering a particular care.

The flowchart should contain specific

activity in the area of concern for

improvement `
The steps is adopted from the professionally
accepted standard or norm , SOP, guidelines,
circulars, CPG, etc
Flow of care can be used to guide the

development of Model of Good Care

Flow chart of Mx of Hypertensive patients

Pt with HPT

No

Uncontrolled

Out patient Tx

Yes
Admit to ward
Pt seen by HO
Pt seen by MO/Pakar

Education

No

Ix

BP optimally
controlled

Rx

Yes

Disc.

F/U

What is MOGC
MOGC is the process involves for specific health care

delivery to be implemented so as to produce the best /

expected outcome.
good process will produce good outcome
The protocol and sequence of essential elements of the

process of care preferably with the preset criteria and

standard of the critical processes so that the care is good.

Criteria ( of the process of care )

It is an essential element for good care,
Thing that make care good for the particular step
of care
Example of essential element
i) things should do
- perform ECG and serum enzyme on those
suspected MI
- X-match blood before transfusion
- take consent from those for operation
- drug counselling before dispensing
poly-medication

Standards of MOGC
For each criteria, a standard s set
Setting of standards is a percentage of fulfillment of

criteria
If the criterion is related to a vital indicator, the
standard is 100%

i) Blood transfused must be GXM , standard 100%

Ii) Staffs must pass the test , standard 85%

MOGC
Step
1

Process of care

Criteria

Standard

HPT pt seen in OPD/A&E/

MOPD

Admit :BP>160/100
mm Hg
(CPG 1998)

90%

Diagnosis of HPT
(Uncontrolled/For
stabilization)

100%

Registration & adm for pt w

uncontrolled HPT
Pt reviewed by HO

Pt reviewed by MO
4
Specialist

Seen within 15 min on

adm
Daily ward rounds
Prn if BP > 160/100
or any complaints
Daily ward rounds
Prn if 180/100
At least 1 X/week

100%

100%

No.
1.

Process
Registration

*2.

Address
Time of registration
Educational status
History Taking
LMP
Age
Parity
Family History
Past Obstetric History
History
Conduct / TBA
PE
IUGR
LSCS
Past gynae history
Past medical history
Symptoms of
eclampsia

Criteria

< 12 / 52

Standard

90 %

1x/
pregnancy
100 %
(During
booking)

Every ANC
visit
Every Home
visit

Problem
identification
Problem
Prioritisation

Re-evaluation
of the Problem

Implementation of
Remedial Actions

Quality
Assurance
Cycle

Problem
Analysis

Quality
Assurance
Study

Identification
of Remedial
Actions

Evaluation

To know
magnitude of
problem & to
prove the
cause-effect

QUALITY ASSURANCE STUDY

QA STUDY
A planned and systematic collection of data using

various methods for the purpose of

i. Verifying existence of Q problem
ii. Assessing the magnitude of the problem
iii. Identifying the factors contributing the problem
The method must be sound, it need not very complicated
as in research (which follows strict statistical criteria)
The components of the QA study
-Literature Review
-Objectives of the study
-Study methodology

Methodology of QA Study
1 Objectives: General & Specific
2 Type of study
3 Terms ( key words ) definition
4 Inclusion & Exclusion criteria
5 Proposed Indicator and Standard
6 Plan for data collection ( + proposed
formats )
7 Plan for data analysis ( + proposed
dummy tables )
8 Gantts chart
9 References

2. Literature review
will help us in;
clarify our problem
state the study objectives
know what has happen elsewhere
check the implicit standards
set explicit criteria and standards
suggest suitable study methods
find appropriate remedial actions
avoid duplication of works

Objectives of the study

The general objective will mention the overall final aim to

be achieved in the study

The specific objectives should be stated using action

verbs that specific enough to measures:

To determine

To verify
To calculate

- To compare
- To establish
- To describe

Avoid the use of vague non-action verbs such as;

To appreciate
To understand

Specific objectives for QA study

1.

To measure the magnitude of the problem

2.

To identify/describe the actual causes or

contributory factors involved

3.

To formulate the remedial or improvement

measures

4.

To evaluate the effectiveness of the measures

taken.

Variables
A characteristic of a person, object or
phenomenon that is measureable and can
take on different values
variable
Height
Sex
Knowledge
Socioeconomic status

value
tall , short
male , female
Good, poor
High, middle, low
income group

Type of Study
PAST

NOW

FUTURE

RETROSPECTIVE

CROSS-SECTIONAL

PROSPECTIVE

Looks for past

exposure to a factor or
describe the past event

Looks at the present

situation

Looks at development of
a condition over time

Descriptive study;

can be retrospective, prospective or

cross-sectional

Analytical study;

can be either retrospective or prospective

Experimental study

is always prospective

Key Word Definition

To describe the definition of certain/

selective key words and terminology

used in this study
The terminology probably applied only
for this study including application of
certain variables, situation, standard.
Must be sound valid, acceptable,
reliable, clear and not ambiguous.

Inclusion & exclusion criteria

Inclusion criteria
Criteria of study subjects (from a defined study
population) that is to be included in data (sample to
collected)
List should not be too long
Exclusion criteria
Subjects (from a defined study population) to be

excluded from study

Limits sample size to relevant subjects

Proposed Indicator and Standard

Describe the indicator proposed to be

applied in the study.

If rate based, what numerator and
denominator will you use.
Proposed the most acceptable
standard.

Sampling

Better to get intended information from a

certain population ( all ), but limited with
problems of logistics, costs, time & other
resources.
Thus, we have to do sampling; a
representative sample with all important
characteristics of the drawn population
Sampling involves the selection of a
number of the study unit from a defined
study population

Sampling method
1. Non-probablility
-

-Convenience : study unit that happen to be

available at the time of data collection are
selected in the sample
- Purposive sampling :targeting a certain
group

2. Probability sampling

- Simple random sampling

- Systematic sampling (using regular interval)
- Stratified sampling (by geographic boundaries)
- Cluster sampling (by Group/ characteristic)
- Multi-stage sampling (

Data Collection Techniques

Review of recorded sources
Observation
Interview
Written questionnaires

Plan for Data Collection

WHAT data to collect

WHERE to get the data
HOW to collect them
WHO will collect
WHEN will the data be collected
HOW LONG will it takes
QUALITY CONTROL of the data

Plan for Data Analysis

The plan includes;

Data handling and

storing
Data processing
Data analysis

Mapping the Proposal

Construct the Gantts Chart
List down the the plan of processes to

be undertaken in conducting the study

Chart the appropriate time frame for
each process
To mark the plan and actual task
carried out

GANTTs CHART
Tugas

T/jawab

Taklimat

Ahli kumpulan

Surat arahan

Ketua Jabatan

Sediakan format
pengumpulan
data

Ahli kumpulan

Pengumpulan
data

Ahli kumpulan

Analisa data

Ahli kumpulan

Perlaksanaan

Ahli kumpulan

Penilaian

Ahli kumpulan

Sediakan laporan

Ketua kumpulan

Jul
03

Ogos
03

Sept
03

Okt
03

Nov
03

Dis
03

Jan
04

Feb
04

plan

1
1
1

actual

9. References
List down all references quoted or

referred in the study

References
1. Clinical Practice Guidelines on The Management of
HPT ( Academy of Medicine; 2002 )
2. Standard Operating Procedure for MA ( Ministry of
Health; 2000 )
3. King H. Revers M. Diabetes in adults is now a third

world problem. Bulletin of WHO 1991. 69 (b):643

648.14

choosing indicator
Reflects the QUALITY of service that is measured ( proxy )
Can be assessed objectively using certain CRITERIA
Can differentiate between the ones with quality from those

without
Should directly address the problem
Usually expressed in the form of rates (%) (rate based)

or nil occurrence (zero defect)

variables
IN SIMPLE TERMS ARE MEASURABLE DATA
A VARIABLE is a characteristic of a person, object or

phenomenon that can take on different values. It is

measurable
Is basically

data collected

It can take various values

All factors must be put in a variable form

 Each step will contribute to the final service

outcome.
Essential elements is the critical steps of care

that should be accomplished within the set

criteria and standard.
If violated, it might cause a multiplying effect of

failure in the series of care. Finally end-up with

an undesired product or sequalae of care.
( ie: NOT the good care )

MODEL OF GOOD CARE

STEP NO PROCESS OF CARE CRITERIA
A
B
C
C1
C2
C3
D
(*) refers to

Standard of EACH Process of Care

STANDARD

(*)

Standard setting in the MOGC

is the minimum level of acceptable performance for
the respective step in the process of care ( referred to as
Optimum Achievable Standard (OAS )
the value of a Criteria that marks the line between good

and poor
widely / professionally accepted value

( evidence-based / best practice )

preferably for the critical steps only
consensusly agreed

SIQ: Investigation process

Evaluate every steps in the process of care & to

determine whether the step was appropriate, timely

& adequate
Where is the shortfall ?
check your MOGC !
Why is the shortfall ?
check bubble chart !
Guidance in providing the remedial measures and
planning to prevent or overcome similar shortfalls in
future
To reduce magnitude of ABNA by:
eliminating or minimising

Error of ommision
Error of commission

improving the quality of care

Perbandingan peratus pencapaian

pengendalian kes anemia
BIL

FAKTOR / KRITERIA

2001

2002 (*)

1.

Kedatangan pertama < 12/52

36.7%

71.4%

2.

Penggunaan senarai semak yang betul

60.0%

92.2%

3.

Pemberian Ferrous fumarate pada POG 18-20/52

78.3%

92.2%

4.

Ujian Hb 2/52 sekali dibuat.

48.3%

93.5%

(*) selepas tindakan penambahbaikan

LANGKAH-LANGKAH PENAMBAHBAIKAN
Bil

Isu/ masalah

1.

Pendaftaran
antenatal <12/52
yang rendah

a. Pengesanan kes secara aktif

b. Memberi penerangan/ ceramah
kepada komuniti.
c. Menjalankan klinik dengan masa
yg lebih fleksibel.

a. JM & S/N
b.S/Kesihatan.
P. Penasihat
c. JM/SN

2.

Penggunaan
senarai semak
yang tidak lengkap

a. CME penggunaan senarai semak

kepada JM/SN baru dan
kursus 6/12 sekali kepada
kakitangan.
b. Penyeliaan secara berkala bagi
JM yg dikenalpasti

a. KJK/JKU

a. CME di setiap klinik

b. Penggunaan senarai semak
pengendalian anaemia
c. Ceramah/nasihat mengikut
format yg disediakan.

a. FMS/MHO/
KJK
b. SN/JM
c. SN/JM

3.

Pengendalian kes
a. Perawatan &
pencegahan
anaemia

Aktiviti

Staf b/jawab

b. KJK/ SN

5
4

3.95

ABNA
sebelum

3
2
Peratus anemia
pada 36/52 POA

ABNA
selepas

1.7

1
0
2001

2002

std

Formulating DSA: the proposal

1. TAJUK
2. Group
3. Problem Identification/ Opportunity for Improvement
4. Prioritisation & chosen/refined topic
5. (Situational analysis / Literature review )
6. Opportunity statement
7. Quality factor analysis / cause-effect analysis
8. Process of care
9. Model of Good Care
10. QA study: Methodology
10.1 Objectives: General & Specific
10.2 Type of study
10.3 Terms ( key words ) definition
10.4 Inclusion & Exclusion criteria
10.5 Proposed Indicator and Standard
10.6 Plan for data collection ( + proposed formats )
10.7 Plan for data analysis ( + proposed dummy tables )
10.8 Gantts chart
10.9 References

Study Criteria
Inclusion criteria:
Specific conditions or characteristics that are applied

and included in the study

Exclusion criteria:
The certain characteristic of the samples that to be

excluded in the data collection for specific reason.

The excluded data shouldnt has any effect
( little or almost negligible ) on the result of the study

8. Mapping the Proposal

Construct the Gantts Chart
List down the the plan of processes to

be undertaken in conducting the study

Chart the appropriate time frame for
each process
To mark the plan and actual task
carried out

GANTTs CHART
Tugas

T/jawab

Taklimat

Ahli kumpulan

Surat arahan

Ketua Jabatan

Sediakan format
pengumpulan
data

Ahli kumpulan

Pengumpulan
data

Ahli kumpulan

Analisa data

Ahli kumpulan

Perlaksanaan

Ahli kumpulan

Penilaian

Ahli kumpulan

Sediakan laporan

Ketua kumpulan

Jul
03

Ogos
03

Sept
03

Okt
03

Nov
03

Dis
03

Jan
04

Feb
04

plan

1
1

actual

9. References
List down all references quoted or

referred in the study

Clinical Practice Guidelines on The Management of HPT
( Academy of Medicine; 2002 )
2.
Standard Operating Procedure for MA ( Ministry of Health; 2000 )
1.

Problem
identification
Problem
Prioritisation

Re-evaluation
of the Problem

Implementation of
Remedial Actions

Quality
Assurance
Cycle

Problem
Analysis

Quality
Assurance
Study

Identification
of Remedial
Actions

Evaluation

Principles for remedial action

- based on actual findings ( periodic
assessment / QA study )
- not construed as fault finding

not to imply to any party as negligent

not to be punitive

- be practical:
* specific
* realistic
* flexible

* manageable
* cost effective
* timeliness

74

The key to remedial

actions is

CHANGE
75

Reevaluation: Why SIQ /

problem recurs ?
1.
2.
3.
4.
5.
6.
7.
8.

SMART concept not properly applied

Impose wrong strategies
Improper implementation
Weak leadership, poor commitment
Change resistance
Poor problem identification /selection
Lack of resources
Beyond control interference

76