QUALITY ASSURANCE IN HEALTHCARE

1. QUALITY ASSURANCE IN HEALTHCARE MODERATOR- DR B S GARG PRESENTER- GAURIJ HOOD

2. FRAMEWORK 1. QUALITY – DEFINITION 2. DEFINING QUALITY IN HEALTHCARE 3. QUALITY MEASURES IN HEALTHCARE 4. DIMENSIONS OF QUALITY IN HEALTH SYSTEM 5. PERSPECTIVES ON QUALITY IN HEALTHCARE 6. WHAT IS QUALITY ASSURANCE IN HEALTH 7.PRINCIPLES OF QUALITY ASSURANCE 8. QUALTY ASSURANCE PROCESS 9. QUALITY ASSURANCE TOOLS 10. BUILDING A QUALITY ASSURANCE PROGRAM 11. KEY ACTIVITIES IN DEVELOPING A QUALITY ASSURANCE PROGRAM 12.QUALITY ASSURANCE PROJECT 13. TOTAL QUALITY MANAGEMENT 14. MEDICAL AUDIT 15. QUALITY ASSURANCE OF HEALTHCARE IN INDIA 16. REFERENCES

3. 1. Quality ? • Subjective • Different meaning to different people • Context dictated by situation »Need »Resources »Availability »Purchasing Power »Individual Perception »Expectation

4. DEFINING QUALITY • Quality means different things to different people. A general definition of quality normally includes the following: • Achievement of a predetermined standard or target • Involvement of clients’ requirement in determination of such a target or standard • Consideration of available resources financially and others in determination of such a target or standard iv) Recognition that there is always room for improvement and that targets and standards must be reviewed. • “Doing the right thing right, right away..”

5. 2. DEFINING QUALITY IN HEALTHCARE • The degree of quality is the extent to which the care provided is expected to achieve the most favorable balance of risks and benefits. - AvedisDonabedian, 1980 • ...proper performance (according to standards) of interventions that are known to be safe, that are affordable to the society in question, and that have the ability to produce an impact on mortality, morbidity, disability, and malnutrition. - M.I. Roemer and C. Montoya Aguilar, WHO, 1988 • The degree to which health care for individuals and populations increase the likelihood of the desired health outcomes and are consistent with current professional knowledge (1996, Institute Of Medicine )

6. 3. Quality Measures at different points in the health system (Donabedian’s) i. Structural Quality Measures (Structure) • Availability and quality of resources, management systems and policy guidelines. • Number of qualified staff, appropriate training programs, available capital facilities (e.g. functioning X-Ray equipment, number of road worthy vehicles, amenities, etc.) ii. Process Quality Measures (Process) • The care given, imparting information and clinical decision making are the actual processes of health care delivery • Collection of this data depends on the existence of proper monitoring system. • Process measures include waiting time, correct diagnosis, proper examination of patients, etc.

7. QUALITY MEASURES….contd iii. Outcome Quality Measures (Outcome) • It is the overall end result of health care delivered; the outputs and health status. • Outcome measures include such as mortality, morbidity, patient satisfaction, coverage, attendance levels etc. • If we want to improve health outcomes, we must understand the processes and structures that contribute to achieving the outcome.

9. Technical Competence • Refers to the skills, capability, and actual performance of health providers, managers, and support staff • Relates to how well providers execute practice guidelines and standards in terms of dependability, accuracy, reliability, and consistency. • Relevant for both clinical and nonclinical services. • Can also refer to material resources: for example, an X-ray machine must produce radiation that consistently meets accepted standards • A technically competent receptionist must be able to respond to information requests, while a pharmacist might be expected to possess competence in logistics and inventory management • A lack of technical competence can range from minor deviations from standard procedures to major errors that decrease effectiveness or jeopardize patient safety.

10. Access to Services • Geographic access may be measured by modes of transportation, distance, travel time, and any other physical barriers that could keep the client from receiving care. • Economic access refers to the affordability of products and services for clients. • Social or cultural access relates to service acceptability within the context of the client’s cultural values, beliefs, and attitudes • Organizational access refers to the extent to which services are conveniently organized for prospective clients • Linguistic access means that the services are available in the local language or a dialect in which the client is fluent

11. Effectiveness • Does the procedure or treatment, when correctly applied, lead to the desired results? • Is the recommended treatment the most technologically appropriate for the setting in which it is delivered? • Effectiveness is an important dimension of quality at the central level, where norms and specifications are defined. • To determine effectiveness, the procedure’s potential harm must be compared with its potential net benefits

12. Interpersonal Relations • Interaction between providers and clients, managers and health care providers, and the health team and the community. • Establish trust and credibility through demonstrations of respect, confidentiality, courtesy, responsiveness, and empathy. Effective listening and communication are also important. • Sound interpersonal relations contribute to effective health counseling and to a positive rapport with patients. • Inadequate interpersonal relations can reduce the effectiveness of a technically competent health service. • Patients who are poorly treated may be less likely to heed the health care provider’s recommendations, or may avoid seeking care.

13. Efficiency • it affects product and service affordability and because health care resources are usually limited. • Efficient services provide optimal rather than maximum care to the patient and community; they provide the greatest benefit within the resources available. Efficiency demands that necessary or appropriate care is provided. • Poor care resulting from ineffective norms or incorrect delivery should be minimized or eliminated. In this way, quality can be improved while reducing costs. Continuity • Continuity means that client receives the complete range of health services that he or she needs, without interruption, cessation, or unnecessary repetition of diagnosis or treatment

14. Safety • Safety means minimizing the risks of injury, infection, harmful side effects, or other dangers related to service delivery. • Safety involves the provider as well as the patient. • For example, safety is an important dimension of quality for blood transfusions, especially since the advent of AIDS. • Patients must be protected from infection, and health workers who handle blood and needles must be protected by safety procedures • Health center waiting rooms can put clients at risk of infection from other patients if risk-reducing measures are not taken. • If a health worker does not provide proper instruction on the preparation of oral rehydration solution (ORS), a mother may administer to her child ORS containing a dangerously high concentration of salt

15. Amenities • Refer to features of health services that do not directly relate to clinical effectiveness but may enhance the client’s satisfaction and willingness to return to the facility for susbsequent health care needs. • May affect the client’s expectations about and confidence in other aspects of the service or product. • Where cost recovery is a consideration, amenities may enhance the client’s willingness to pay for services. • Amenities relate to the physical appearance of facilities, personnel, and materials; as well as to comfort, cleanliness, and privacy. • May include features that make the wait more pleasant such as music, educational or recreational videos, and reading materials

17. 5. Quality- Perspective among different Stakeholders (Ovretveit’s) a. Client: • Relief from the ailment • Service & Treatment with compassion b. Provider: • Offering state of the art- technical care, skills • Outcome comparable to known standards • Protection from legal systems c. Program Manager: • Will quality improvement impact utilization? • If yes, does the investment justify the return ? • Must provide for the needs and demands of both providers and patients. • Also, they must be responsible stewards of the resources entrusted to them by the government, private entities, and the community.

18. 6. What is Quality Assurance in Health ? • Assurance is defined as “maintaining and formally accounting for the quality and appropriateness of care” • All the arrangements and activities that are meant to safeguard, maintain, and promote the quality of care. ( Dr. Donabedian ) • Systematic process for closing the gap between actual performance and the desirable outcomes. . . (Drs. Ruelas and Frenk) • It is a process of measuring quality, analyzing the deficiencies discovered, and taking action to improve performance followed by measuring quality again to determine whether improvement has been achieved .. (Dr. Heather Palmer)

19. Quality Assurance in Health • A systematic managerial transformation designed to address the needs and opportunities of all organizations as they try to cope with increasing change, complexity and tension within their environments (Dr. Donald Berwick ) • In essence, quality assurance is that set of activities that are carried out to set standards and to monitor and improve performance so that the care provided is as effective and as safe as possible • Introduced into modern medicine by a British nurse, Florence Nightingale, who assessed the quality of care in military hospitals during the Crimean War. • She introduced the first standards in nursing care; these resulted in dramatic reductions of mortality rates in hospitals.

20. 7. The Four Tenets of Quality Assurance a. Oriented toward meeting the needs and expectations of the patient and the community. b. Quality assurance focuses on systems . c. Quality assurance uses data to analyze service delivery processes. d. Quality assurance encourages a team approach to problem solving and quality improvement

21. The Quality Assurance Process • The QA process is based on QAPs experience working with health services in developing countries. • However, it also integrates lessons learned from earlier quality assurance methodologies.

23. 8. Quality Assurance Process a. Planning for quality assurance b. Developing guidelines and setting standards c. Communicating standards and specifications d. Monitoring quality e. Identifying problems and selecting opportunities for improvement f. Defining the problem operationally g. Choosing a team h. Analyzing and studying the problem to identify its root causes i. Developing solutions and actions for improvement j. Implementing and evaluating quality improvement efforts

25. 9. TOOLS FOR QUALITY ASSURANCE – Quantitative and Qualitative • Checklists can be prepared for various parameters based on Inputs/Structure, Process/Services and Outcome (Health benefits/client satisfaction) indicators • Qualitative methods such as indepth interviews, focus group discussions can be used to assess quality of services provided, training and proficiency of health workers etc • Both methods can be used in combination as tools for quality assurance FACILITY CHECKLIST (Input) • Clinic Timings properly displayed • Availability of Service Provider • Presence of adequate and sheltered waiting area • Availabilty of drinking water and running water • Availability of Screen in examination room • Availability of Electricity

26. QUALITY ASSURANCE TOOLS • Process Quality Assessment Checklist- OPD Services provided by MO PHC Curative Services i.History Taking- MO asked chief complaints, History of present illness taken, Past history taken ii. Clinical Examination- Vital signs assessed, Systemic examination conducted iii.Prescription writing- Provisional diagnosis written Counselling and follow up Services- Prescription explained to patient, Health Education given, Patient’s queries answered • Eg Client Satisfaction- Can be assured using Quantitative Methods- Checklists and Qualitative methods- In depth interviews or Focus Group Discussion i. Using health facility regularly, Felt that clinic hours are adequate, Health personnel gave sufficient time to listen and treat etc. • eg. Interviewing mother of under five children for assurance of quality of services provided on VHND

27. 10. Key Activities in the Development of a Quality Assurance Program i. Foster commitment to quality ii. Conduct a preliminary review of QA-related activities iii. Develop the purpose and vision for the QA effort iv. Determine level and scope of initial QA activities v. Assign responsibility for QA vi. Allocate resources for QA vii. Develop a written QA plan viii. Strengthen QA skills and critical management systems ix. Disseminate QA activities x. Manage change

28. 11. QUALITY ASSURANCE PROJECT • Initiated in 1990 to develop and implement sustainable approaches for improving the quality of health care in less developed countries. • QAP has two broad objectives: • To provide technical assistance in designing and implementing effective strategies for monitoring quality and correcting systemic deficiencies 2) To refine existing methods for ensuring optimal quality health care through an applied research program. • QAP helps LDC health managers to apply systematic methods for problem identification and resolution through the project’s research component, known as Methodology Refinement. • QAP staff is developing, refining, and validating cost-effective measures for improving the quality of health care. • The project team is working toward this goal by reviewing the current state-of-the-art in quality assurance and collaborating with host-country colleagues in conducting seminal studies on how to best achieve optimal quality of care.

29. INTERNAL QUALITY ASSURANCE vs EXTERNAL QUALTY ASSURANCE • Activity is conducted by those undertaking the clinical activities concerned, such as the physicians in a hospital • They are responsible for setting standards and implementing change. • Advantage of fostering a sense of ownership • Requires a culture in which it is accepted that clinical practice should be open to examination by one's peers • Involves a body outside the health care facility examining measures of quality. • Focuses on structure, largely because this is so much easier to measure than process or outcome. • Typical example is hospital accreditation

30. 12. Total quality management • Total quality management (TQM), as defined by ISO 2002, Management approach for an organization, centred on quality based on participation of all its members and aiming at long term success through customer satisfaction and benefits to all members of organization and to society. • Quality standards of an organization be maintained in all aspects and requires ensuring that things are done right the first time and that defects and waste are eliminated from operations. • Places strong focus on process measurement and controls as means of continuous improvement. • It encompasses quality assurance, quality control and quality improvement within its purview.

31. 13. Medical Audit • Defined- as the evaluation of the quality of medical care through the analysis of medical records in retrospect. The term quality in the above definition refers to the degree of conformance with standards, with the best of medical knowledge and with the accepted principles and practices • Medical audit is also a method of appraising the quality of care rendered. Dr. Mudaliar (in Health Survey and Planning Committee report, 1959-61, Vol.1, Government of India) defines medical audit as “the review of the professional work in the hospital that could take place whenever, the medical staff meet to analyse the hospital clinical work.” • According to Myers and Slee (1956), simple review of medical records cannot be termed as medical audit.

32. 14. QUALITY ASSURANCE IN HEALTHCARE IN INDIA • Quality Council of India (QCI) was set up in 1997 jointly by the Government of India and the Indian Industry • The “Hospital Accreditation" approach is a concept and practice that yields beneficial results to patients, customers, hospital personnel, the hospital, the Faculty of Medicine, the society and the country as a whole. • National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a constituent board of Quality Council of India, set up to establish and operate accreditation programme for healthcare organisations Structured to cater to much desired needs of the consumers and to set benchmarks for progress of health industry • NABH is an Institutional Member as well as a Board member of the International Society for Quality in Health Care (lSQua).

33. Accreditation Program • Allopathic Clinics , AYUSH Hospitals, Blood Banks, Dental Facilities, Hospitals, Medical Imaging Services, Medical Laboratory Programme, OST Centre, PHC/CHC Accreditation, Small Healthcare Organisations, Wellness Centre STANDARDS- • IPHS Standards for Subcentre, PHC, CHC, Subdistrict Hospitals, District Hospitals • SOP- STANDARD OPERATING PROCEDURES

34. Tracking Quality Assurance in healthcare….. • Regulation • Certification • Accreditation & Credentialing • Grading / Rating • Quality Awards • ……. and others???

35. Regulation • A legal restriction • Mandated by the government or state • Attempts to produce outcomes • Control market entries • Prices, wages, pollutions, • Employment for certain people in certain industries • Standards of production • Non-compliance / Non-conformance leads to cancellation of operational eligibility • …registration of hospital or functional services under different laws / acts

36. Certification Designation earned by a person / organization to perform a job or task • Renewed periodically, • Valid for a specific period of time • Qualifies for certain level of proficiency Can be provided by • Body formed / mandated by regulatory mechanism • Professional society / body

37. Accreditation Accreditation a process in which • Certification of competency, authority, or credibility • Assessment by Independent agency Credentialing refers to • A type of designation, award, status, recognition, or "seal of approval" • Refers to individuals or organizations • …provides a visible commitment towards improving quality of patient care ensuring a safe environment and reducing risk to staff in healthcare setting

38. Grading / Rating • Is evaluation or assessment of something, in terms of quality (as with a critic rating a novel), quantity (as with an athlete being rated by his or her statistics), or some combination of both Grading / Rating is also a voluntary process • wherein an organization opts for comparative evaluation of its services Quality Awards • Recommendation on appraisal / evaluation for high degree of consistent & sustained performance over a period of time or range including quality improvement initiatives in a particular sector / domain instituted by professional societies / bodies and / or independent entities

49. REFERENCES • Roemer M , Montoya-Aguilar C. Quality Assessment and Assurance in Primary Healthcare, World Health Organization, Geneva , 1988 • Guideline on Implementation of Quality Assurance System in Health Facilities. Quality Assurance & Standardisation Division ,Ministry of Health, Thimpu, Bhutan (2007) • Brown L R, Franco LM, Rafeh R, Hatzell T. Quality Assurance Methodology Refinement Series- Quality Assurance of Healthcare in Developing Countries. Quality Assurance Project, Bethesda,USA. • OffeiAaron, Bannerman C, KyermehK.Healthcare Quality Assurance Manual for Sub districts- July 2004 • Quality and accreditation in health care services- A Global Review: WHO,Geneva,2003 • GangulyE et al . Developing quality assurance system for the primary health centers attached to MGIMS, Sevagram • PHC – MAP Module • DetelsR, Beaglehole R, Lansang MA, Gulliford M. Oxford textbook of public health. Volume 2 . Methods of public health. 5th edition, Oxford University Press, 2009