basic tools for QA project

1. FUNDAMENTAL
PRINCIPLES IN MOH QA
PROJECTS
DR LEE OI WAH
PEGAWAI KESIHATAN KAWASAN II

2. DEFINITION OF QA
• Quality assurance means all actions taken to establish, protect,
promote and improve the quality of health care.
~Donabedian
• Fitness for use.
~Joseph Juran
• Zero defects, conformance to requirements.
~Philip Crosby
• Reducing variations in practice, never ending cycle of continuous
improvement .
~ Deming

3. DEFINITION OF QA
• Quality of care is the degree to which health services for individuals
and population increase the likelihood of desired health outcomes and
are consistent with current professional knowledge
~Institute of Medicine
• Do the right thing right, the first time, every time
~Joseph Juran
• Responsiveness to perceived care needs; level of communication,
concern and courtesy; degree of symptom relief, level of functional
improvement
~Patients

4. DEFINITION OF QA
• According to Joint Commission on Accreditation of
Healthcare Organisations (JCAHO), quality is defined as
“the degree to which health services for consumers
increase the likelihood of the desired health outcomes
and are consistent with the current professional
knowledge.”

5. TERMINOLOGY
Quality Assuarance (QA)
• QA refers to all of the processes and activities related to
the planning for quality, the setting and communicating of
standards, measuring and monitoring compliance to these
standards.

6. TERMINOLOGY
Quality Control (QC)
• QC refers to the processes of measuring the difference, if
any, between the current performance of an organization
and the desired levels of standards.

7. TERMINOLOGY
Quality Improvement (QI)
• QI refers to the process and activities to reduce variance
in performance from the desired standards, thus reducing
the gap between current performance threshold and the
desired thresholds.

8. TERMINOLOGY
Quality Improvement (QI)
• QI refers to the process and activities to reduce variance
in performance from the desired standards, thus reducing
the gap between current performance threshold and the
desired thresholds.

9. TERMINOLOGY
Continuos Quality Improvement (CQI)
• CQI is an incremental and continuos improvement for the
whole organization.

10. TERMINOLOGY
Quality management (QM)
• QM is the umbrella term that encompasses QA, QI and
QC. It is the term applied to all of the process related to
the coordinating and facilitating of quality related activities
and tasks in an organization.

11. TERMINOLOGY
Total Quality management (TQM)
• TQM is a theory and a management method that was first
introduced in Japan and involved 5 main principles:
system wide, leadership commitment, data driven
decision-making, customer focused and teamwork.

12. TERMINOLOGY
Healthcare Care Quality (HCQ)
• HCQ is another term that refers to an organization-wide
quality management program and processes.

13. 4 TENETS OF QUALITY ASSUARANCE
Meeting the needs and
expectations of
clients,community &
stakeholders.
Focuses on systems &
processes.
Uses data analyse service
delivery.
Using team approach for
problem solving 7 quality
improvement.
QA

14. DIMENSIONS OF QUALITY
EFFECTIVENESS the degree to which desired results are achieved.
EFFICIENCY OF
SERVICE DELIVERY
relates to the effective use of resources to produce those
delivery services.
ACCESSIBILITY reflects a lack/presence of geographic, economic, social,
organisational or linguistic barriers to services.
SAFETY the degree to which the risks of injury, infection and
harmful side effects are minimised.
TECHNICAL
COMPETENCE
refers to the degree to which tasks are carried out by
health workers and facilities in accordance with standards
and expectations.
INTERPERSONAL
RELATIONS
refers to effective listening and communication between
provider and client.
PHYSICAL
INFRASTRUCTURE &
COMFORT
also known as ‘amenities’ which includes a facility’s physical
appearance, cleanliness, comfort and privacy.
CHOICE OF SERVICES refers to client’s right to choose and make an informed
choice of provider.
PATIENT
CENTREDNESS
consideration for human dignity, confidentiality and privacy

15. ABNA
• Refers to the difference between what could be optimally
achieved with available resources and what is presently
achieved.
With unlimited resource
• Ideal level of care
Optimal acheivable level
• Targetted levels within the
means
ABNA
• Difference between OA &
present level
• QA aims at narrowing or
eliminating this gap

16. WHY WE NEED QA?QA
• Effectiveness
• Appropriateness
• Standardization
• Cost saving
• Benchmarking
• Accreditation,certification
etc
• Report card
QA
• Competition
• Professional satisfaction
• Pressure from consumers
• Continuos improvement
• Ethical consideration
• Peer pressure
• Legal requirement.

17. STRUCTURE,PROCESS, OUTCOME APPROACH
(DONABEDIAN)

18. QA CYCLE
Problem
identification
Problem
prioritiSation
Problem
Analysis
Problem
Verification
QA Study
Identification
for strategy
for change
(remedial
actions)
Implementati
on of
Remedial
Actions
Monitoring &
re-
evaluation of
the problem
QA
Cycle

19. STEPS IN QA STUDY
Formulate study objectives
Measure Quality
Identify Indicator
Identify variables
Identify Criteria
Set Standard
Develop MOGC
Plan for data collection
Plan for data analysis

21. PROBLEM IDENTIFICATION
Criterias:
1. Related to core business
2. Issues brought up in meetings and discussions.
3. Appeared in complaints.
4. Issues brought up by staffs.
5. Unsolved problems

23. PROBLEM PRIORITISATION
Techniques include:
i. Nominal Group Technique(NGT)
ii. Multivoting
iii. Consensus

24. NOMINAL GROUP TECHNIQUE (NGT)
• It is a weighted ranking technique that allows members of a team to
prioritise a large number of issues without creating any winners or
losers.
• The problems are ranked in order of importance individually by
members of the group. Then it is put to vote. The problem which
received the highest vote gets the priority.
• Number of group members: 7 – 12.
• Established criteria to determine priority eg SMART .

25. SMART CRITERIA
S Seriousness
How important is this problem in relation to the quality of patient care?
Does it have an impact on patient, society and hospital image?
Does it have an impact on cost and resources?
Is there room for improvement?
How large is the ABNA - Is it worth studying?
M Measurable
The process of care is clearly defined with easily identifiable starting
and ending points.
The indicators are identifiable to the problems.
Data related to the problem are available or can be obtained.
A Appropriateness
The process or project is related to core business and is consistent
with the organisation goals and values.
The proposed opportunity for improvement has direct impact on the
customers and will likely result in an improvement in the quality of care.
The cost of not solving this quality problem may be significant. This
may be financial, legal or related to image of the organization.

26. SMART CRITERIA
R Remediable
Are solution available?
Availability of resources and expertise to do the study
or correct the situation?
T Timeliness
There are no current operational, financial or political issues which
might affect the success of the project.
The study and remedial measures can be carried out within a
reasonable period by the group.

27. SMART TABLE
PROPOSED
TOPIC
S M A R T TOTAL
SCORE
Rating Scale:
1: Low 2: Medium 3. High

28. MULTIVOTING
• Multivoting is a group decision-making techniques used to reduce a
long list of items to a manageable number by means of a structured
series of votes.
1. Brainstorm for a list of options.
2. Review the list from the Brainstorming activity.
3. Participants vote for the ideas that are worthy of further discussion.
4. Identify items for next round of voting.
5. Vote again.

29. CONSENSUS
• Consensus decision making is a process used by groups seeking to
generate widespread levels of participation and agreement.
• Elements considered during the process are :
a. Inclusive
b. Participatory
c. Collaborative
d. Agreement seeking
e. Cooperative

30. CONSENSUS
Stepwise models of consensus decision making
S1
Discussion
S2
Identify emerging
proposal
S3
Identify any
unsatisfied
concerns
S4
Collaboratively
modify the
proposal
S5
Assess the degree
of support
S6
Finalise the
decision OR circle
back to step 1 to 3

32. PROBLEM ANALYSIS
• 5W 1H technique:
WHAT What is the actual problem ?
WHERE Where does it occur?
WHEN When does it happen?
WHO Who are those involved in the process?
WHO Who are those affected?
HOW How does it happen?

33. PROBLEM ANALYSIS CHART
(BUBBLE CHART)
PROBLEM
1st
generation
2nd
generation
2nd
generation
2nd
generation
1st
generation
2nd
generation
2nd
generation
2nd
generation

34. PROBLEM ANALYSIS CHART
(FISHBONE /ISHIKAWA DIAGRAM)

36. FORMULATING THE PROBLEM STATEMENT
Purpose :
1. To justify why study needs to be carried out.
2. To help in defining scope of study
3. To anticipate the expected result.

37. PROBLEM STATEMENT
 Brief statement about the process of care where the
problem occurred
 Explaining what the problem is – Supported by evidence,
if any
 What are the consequences?
 What are the possible causes?
 Why we want to do the study?

38. FLOW CHART : PROCESS OF CARE FOR
SKIN BIOPSY

39. RELATIONSHIP BETWEEN PROBLEM &
CONTRIBUTING FACTORS

40. PROBLEM STATEMENT
Introduction
• Skin biopsy is a common procedure in the skin clinic.
Problem
• High incidence of wound infection for diagnostic skin biopsy in Skin
Clinic, HRPBI
Effect
• Non healing wound due to secondary infection can cause higher
morbidity and increase cost of health care
Possible cause
• Multiple risk factors can influence the risk of postoperative wound
infection e.g. improper aseptic technique and wound care
Aim of study
• To reduce skin biopsy wound infection rate to < 2% (national target)

42. PHASES OF QA STUDY
Verification Study
Pre-remedial Study
Post-remedial
/Evaluation

43. 5.1 FORMULATING STUDY OBJECTIVES

44. PRESENTING YOUR GENERAL & SPECIFIC
OBJECTIVES

45. 5.2 IDENTIFY INDICATORS
Definition :
An indicator is a measurable form of a standard relating to structure ,
process or outcome.
Characteristics of a good indicator :
Specific/objective
Verifiable
Comprehensive
Reliable
Valid
Easy to use
Sensitive
Acceptable

46. 5.2 IDENTIFY INDICATORS
Definition
A proxy indicator is used to measure a problem indirectly. It is useful
only as a flag to indicate that a problem may exist.

47. 5.3 IDENTIFY VARIABLES

48. 5.3.1 OPERATIONALIZING VARIABLES
• To make vague variables measurable.

49. 5.4 IDENTIFY CRITERIA
Definition

50. TYPES OF CRITERIA
Inclusion Criteria To define the sample to be included in the study.
Exclusion Criteria To define the sample not to be included in the study.
Implicit Criteria Subjective assessments by peers or experts.
Explicit Criteria A definite written model set by a committee that everybody
understand.
Problem Specific
Criteria
Looks at the process of care and set a model for each
process of care of certain disease specific condition.
Ideal criteria Criteria put into a perfect model (Dreamland) eg Zero
complication rate.
Empirical Criteria A guesswork especially whre no reference can be found.

51. 5.5 SETTING STANDARD
Example :
Long waiting Time in Outpatient department
Standard : Not > than 15% patients should wait > 1 hour

53. Clinical indicator:
Percentage of patients that develop wound infection after a
diagnostic skin biopsy in Dermatology Clinic, HRPBI
Numerator : Number of patients with wound infection
Denominator : Total number of patients underwent diagnostic
skin biopsy in Dermatology Clinic, HRPBI.
Number of patients with wound infection_______________x 100%
Total number of patients underwent diagnostic skin biopsy

54. Clinical indicator:
Percentage of patients that develop wound infection after a
diagnostic skin biopsy in Dermatology Clinic, HRPBI
Inclusion Criteria:
Patients undergoing diagnostic skin biopsy in Dermatology Clinic, HRPBI
Exclusion Criteria
 Patient with infected preoperative skin surface.
 Patient unable to turn up for suture removal in Dermatology Clinic,
HRPBI.
 Patient undergoing diagnostic skin biopsy in ward
STANDARD
Wound infection for diagnostic skin biopsy should be < 2% (based on
national standard)

55. 5.6 MODEL OF GOOD CARE (MOGC)
Definition :
A process of care that is thought to fulfill the standard set.

58. 5.7 PROCESS OF GATHERING INFORMATION
WHAT
• What data
needs to
be
collected
?
HOW
• How to
collect
data-?
technique
s,methods
& tools
WHO
• Who will
collect the
data?
WHERE
• Where will
the data
be
collected?
WHEN
• When will
the data
be
collected?

59. DATA COLLECTION TECHNIQUES
• Locate and analyse information eg literature, statistics, medical records.
REVIEW OF RECORDED SOURCES
• Selection, watching & recording of behaviour.
OBSERVATION
• Face-to-face interview, telephone interview, group interview and in-depth
interview.
INTERVIEW
• Collect data through written response.
WRITTEN QUESTIONAIRE

60. METHODS OF INTERVIEW

63. 5.8 DATAANALYSIS

64. TYPES OF DATA
QUANTITATIVE
• Frequencies
• Percentage
• Proportions
• Ratios
• Rates
• Median
• Min
• Mode
• Standard deviation
• Normal Distribution Curve
QUALITATIVE
• Matrix
• Diagrams
• Flow charts
• Tables

65. GANTT CHART

66. TOOLS FOR DATA COLLECTION
1. Master Sheet
2. Dummy Table

67. MASTER SHEET

68. DUMMY TABLE

69. TOOLS FOR DATA DISPLAY
1. Problem Analysis Chart
2. Flow Chart
3. Pie Chart
4. Pareto Chart
5. Bar Chart
6. Histogram
7. Run Chart
8. etc

71. 6.1 STEPS IN RECOMMENDING REMEDIAL
ACTIONS

72. GUIDE ON IMPLEMENTING CHANGE
CHANGE
Implement
simple
measures
immediately
Go for
sustainable
measures
Involve
process
owners in
decision for
change

73. TYPES OF CHANGE

74. PLANNING FOR STRATEGY OF CHANGE

76. WHY RE-EVALUATE?
To evaluate effectiveness of remedial
measures carried out.
To assess progress of the
implemented remedial measures.
To provide evidence to further improve
or modify remedial measures if
necessary.