QUALITY ASSURANCE

PROGRAM

QUALITY IMPROVEMENT
IN HEALTHCARE
The practice of
medicine….

• Is very complex
• It involves many players
• Involves many
intervention and
sophisticated
technology
• But does not
guaranteeing the best
outcome!!!
DEFINITION of
QUALITY

• Is…. Meeting and

exceeding customers’
expectation
• Customer … is anyone
• Customers focus
• Quality
improvement is the
science of process
management
DEFINING
CUSTOMERS
• HEALTH CARE
GIVERS: DOCTORS
& PARAMEDICS
• PATIENTS
• RELATIVES
• PUBLICS
• FUNDER
Why Do We Need
QI?
• Widespread variation in
practice
• Lack of rigorous monitoring
• Public not receiving value
for resources spent
• Rising cost of healthcare
• Rapid advance in medical
technology
• Accountability
• Medico-legal implication
The public…..

• Assertive
• Irritated with our
inability to deliver an
effective, courteous,
prompt, safe and
efficient services
• The quality of the services
is increasingly being
expected by the
customers, the funder
and provider
What people says

• First class infra-

structures and 3rd
class mentalities
• Quality products
comes from quality
man
• Quality saves the
cost
Why Do We
Complain?

• Malpractice/ negligence
• Lack of efficiency
• Delay in diagnosis
• High morbidity & mortality
• Rising cost of healthcare
• Accountability
• Public not receiving value
for resources spent
• Medico-legal implication
Enviromental sampling & In Use Test

BUMPSA SYMPOSIUM 11
March 2016
 BACILLUS SP FROM BLOOD C&S CONTAMINATION
AT WAD 2 IN 2018

BILANGAN KADAR
PERHANTARAN BILANGAN POSITIF KONTAMINASI KADAR/BIL.
BULAN BLOOD C&S BACILLUS SP (%) INFECTION

JAN 286 14 4.9% -

FEB 270 9 2.9% -

MAR 321 18 5.6% -

APR 268 9 3.4% -

MEI 292 18 6.2% -

JUN 261 4 1.5% -

JULY 334 18 5.4% -

OGOS 396 19 4.8% -

JUMLAH 2428 109 4.5% -

 Improve Quality in Healthcare

• It is about making a change

• Achieving optimum benefits
• Appropriate care to each
individual
• Consideration for human
dignity

Tan Sri Abu Bakar Sulaiman, Former DG of MOH

• Improved quality delivers:
 –better patient care…
 – at lower costs…
 –with potentially higher
reimbursements (pay-for-
performance)…
 –And it can make our jobs
more interesting, fun, and
rewarding.
 Quality Healthcare
Expectations

• Effective • Appropriate
• Efficient • Caring
• Accessible • Professional
• Timely • Team
• Safety
 Quality Improvement

• Voluntary self assessment

• Making adjustment in our daily
practice to achieve certain
standards
• We are at the frontlines seeing
system failures, process errors,
and performance gaps with our
own eyes -- which is our
competitive advantage
• In the pursuit of excellance!!!
Actual Scenario

• You can achieve Good results if you have full

understanding of what and why you are doing
• Know the detail of operation
• Understand the effect of not meeting the intent
• Take proactive measure
HOW CAN WE ACHIEVE QUALITY
IN HEALTH

•It is NOT…
• yelling at people to work harder, faster or safer
• creating order sets or protocols and then failing to
monitor their use or effect
• traditional Quality Assurance
• research (but they can co-exist nicely)
Reactive Methods

• Only react to problems

• Don’t understand the root problem
• Don’t have good direction
• Look busy but always fire fighting
• High chance of recurrence
DETERMINANTS
OF DEMANDS

• DOCTORS
• PATIENTS
• LABORATORY
PERFORMANCE &
QUALITY SERVICES
• PUBLIC HEALTH THREAT
• ENVIROMENT
Can we measure
QUALITY ??

• Can we recognise its

presence or absence?
• Can we measure the
QUALITY of our services?
• We cannot manage what
we do not measure

•PERFORMANCE
MEASUREMENT
WHERE CAN YOU
MEASURE?
• STRUCTURE
• Organization- staffing, equipment,
facilities, qualification, credentialing
• How? Bed
occupancy
rate Waiting
time/list
Readmission
rate
• PROCESS
• OUTCOME
WHERE CAN YOU
MEASURE?
• STRUCTURE
• PROCESS
• Services – preventive,
diagnostic,
therapeutic, patient
education
• What- right steps, right
sequence, right time, outcome
satisfactory
• Results- consensus, guidelines,
flow chart
• OUTCOME
PROCESS & OUTCOME

VS
WHAT TO
MEASURES?

OUTCOMES
• Physical
• Therapeutic
• Complications
• Services- satisfaction
(patient/staff/administrators)
• Cost outcomes-
cost/effective
WHAT CAN YOU
MEASURE?

• OUTCOMES
Mortality rate
Morbidity rate
Complications
Patient satisfaction
CARE GIVERS

• Doctors
 Diagnosis- correct
 Bed occupancy rate – work load Admission
rate
 Waiting time/list
 Procedures – number, type Staffing,
equipment, facilities
 Principle Qs

• What are we trying to

accomplish
• How do we know
that a change is an
improvement
• What changes can we make
that will result in an
improvement
PART II
CHOOSING THE TOOLS

• Audit- self, department, trainees progress,

institution
• QAP
• INNORVATION
• KIK
• RESEARCH
QAP VS RESEARCH

• “A key difference between research and quality

improvement is how patients are exposed to risk.”
• In QI projects, patients may not be exposed to more
than minimal risk, whereas in research the risk to
which the patient may be exposed is approved by the
institutional review board (IRB)
• A consent form that gives patients a choice about
whether they would like to participate
QAP VS RESEARCH

• QI is designed to bring about immediate

improvements in healthcare delivery.
• QI is designed to have its findings applicable
only to the local institution.
• QI is designed to sustain the improvements.
• QI does not require rigid, fixed protocols; within QI
activities it is acceptable to adapt the project over
time.
Clinical Audit

• Clinical audit is a process that has been defined as "a

quality improvement process that seeks to improve
patient care and outcomes through systematic
review of care against explicit criteria and the
implementation of change
• Standards-based audit - A cycle which involves defining
standards, collecting data to measure current practice
against those standards, and implementing any
changes deemed necessary.
CLINICAL AUDIT

• A process left unattended always

gets worse
• A good measurement is the key to
WHY managing improvement
• The cost of prevention is an

AUDIT?? investment
• The cost of correction without
prevention is an expense
• Continual improvement is a journey
 • What are we trying to
accomplish
• How do we know that
a change is an
improvement
• What changes can we
make that will result in
an improvement

Principle Qs
 PDCA / PDSA

• Plan a change
-modify the current
process
• Do it and try
• Study/ check
• Act
• measures
Clinical audit
 • Does not require
experience
• Identify possible/
probable problems
by collecting data

CLINICAL

AUDIT
Stage 1: Identify the problem Stage 2: Define criteria and
or issue standards

• Selection of a topic or • Decisions regarding

issue to be audited, the overall purpose of
eg: involve measuring the audit, either as
adherence to what should happen
healthcare processes as a result of the
that have been shown audit, or what
to produce best question you want the
outcomes for patients. audit to answer
 Stage 1: Identify the problem or
issue
•Selection of an audit topic is influenced by factors
including:
• national standards and guidelines exist
•there is conclusive evidence about
effective clinical medicine
• areas where problems have been
encountered in practice.
•what patients and public have
recommended that be looked at.
•where there is a clear potential for
improving service delivery.
•areas of high volume, high risk or high cost,
in which improvements can be made.
 Identify Problems:
Over use of drugs

• 7% of patients have
medication error in the
hospital
• 50% of patients receive
antibiotic prophylaxis for
surgery receive more than 3
doses of antibiotics
• 70% of patients
receive antibiotics for
URTI
Length of Stay – What is it and Why is it
Important?

• Length of stay measures the number of days a patient

spends in the hospital.
• A shorter LOS usually means a better outcome for the
patient. It indicates more efficient and effective care.
• Patient get home earlier, providing the opportunity to get
well in a familiar surrounding and is often less disruptive
for the patient and his/her family.
Compare Performance &
Criterias

• AUDIT ON
ISOLATION
POLICIES
AND PRACTICE
Problem Issue: Medication
Delay

Selection/ Procurement Preparing/

Prescribing / Ordering
Dispensing

Monitoring
Administration
 Antibiotic should be
provided within 2
hours of prescription

2. Set Inappropriate
antibiotic dosage

Criteria must be less than 5%

Handhygiene
compliance >80%
Stage 3: Data collection

• To ensure that the data collected are precise, and that

only essential information is collected, certain details
of what is to be audited must be established from the
outset.
• Ethical issues must also be considered; the data
collected must relate only to the objectives of the audit,
and staff and patient confidentiality must be respected -
identifiable information must not be used.
 Stage 4: Compare performance with
criteria and standards

This is the analysis stage,

whereby the results of the data
collection are compared with
criteria
• and standards.
The end stage of analysis is
concluding
•
how well the
standards were met
Identifying
• reasons why the
standards weren't met in all
cases.
•
These reasons might be
agreed to be acceptable
Suggest a focus for
improvement measure
 Quality Improvement:
Bridging the Implementation Gap

Scientific
understanding
Progress

Implementation
Gap

Patient care

Time
 Stage 5:
Implementing
change

• Once the results of the

audit have been published
and discussed, an
agreement must be
reached about the
recommendations for
change
• Action plan
• Person responsible
Quality Improvement Teams

• Team leaders eg surgeon,

nurse sister
• Facilitator
• Members- people with
operational, hands- on
fundamental knowledge
of the process
Improvement Strategies

• Collect meaningful
data
• Identify root causes
of problems
• Develop appropriate
solutions
• Plan and make
changes
 RE-AUDIT:
SUSTAINING
IMPROVEMENTS
HOW TO IMPROVE QUALITY

• Eliminate inappropriate process

• Reviewing process and sees
what needs to be changed
• Document continuous
improvement
• 85% of organization problems
are the result of inefficient
process/systems
MOH: Quality
Improvement Efforts

•
National Surveillance on Hand
Hygiene Compliance - as Key
• Performance Indicator (75%)
One Month Period Prevalence Survey
• on Blood Stream - Infection (BSI)
•
Surveillance
National Alert Organism
Surveillance
Carbapenem resistant
Enterobacteriaceae Surveillance
 STANDARD PRECAUTION…..

• We give more than

lip service to
guideline
implementation……
…
and we hold people
accountable for
guideline
adherence
Quality improvement project
 Quality
improvement
project

• Does it work
• Measures
• Any incremental
improvement
 THANK YOU
Quality Improvement Projects in
Health Care: Problem Solving
in the Workplace