Quality Assurance in Health Care

Services

Dr. Pavneet Chona

BAMS,MBA(Health Care)
Consultant(RO),SHFWTC
 QUALITY OF CARE

A PROCESS FOR MAKING

STRATEGIC CHOICES
IN HEALTH SYSTEMS
Quality Assurance is a
comprehensive service,which
covers all the Healthcare
related departments for
quality improvement and risk
management
Six dimensions of Quality in Health
1) Safety-Avoiding preventable injuries,reducing medical errors
2) Effective-Providing services based on scientific
knowledge(clinical guidelines)
3) Patient Centred-Care that is respectful and responsive to
individuals
4) Efficient-Avioding wasting time and other resources
5) Timely-Reducing wait times,improving the practice flow
6) Equitable-Consistent care regardless of patient characterstics
and demographics
 STANDARDS OF CARE
• CREDENTIALS
• PATIENTS RIGHTS AND
RESPONSIBILITIES
• MANAGEMENT
• RECORDS
• PREVENTIVE HEALTH SERVICES
Quality Control Committee(QCC) And Quality
Circles(QC)
• Quality circles(informal group) are the working
groups of employees who joins voluntarily to
solve quality or performance related problems.
• A working Group will decide the no. and
constituion of QC.Each QC will have 4 to 6
members from all the categories of staff,right
from doctor to support
• They meet periodically to review the actions
 Functions of QCG
• To meet regularly,at least once a month
• To fix the date for next meeting
• There would be a moderator ,who write the
minutes of meeting and maintain the records
• Quality action plan should be discuss and
finalised
• The various QC’s should discuss the GAPS and
give suggestions
The QC’s should follow the following steps:

• To identify the problems

• To analyse the problem
• To set an objective
• To findout the appropriate solution
• To test and evaluate the methodology called
PDSA(PLAN-DO-STUDY-ACT) should be used
• PLAN-Establish the objectives in accordance
with the clients requirements and organisation
policies
• DO-Implement the plan and measure its
performance
• STUDY-The results should be measured against
the targets and conveyed to management
• ACT-If results are not desirable change the
plan train the concerned people and repeat
PDSA
 The QC should work by keeping these
variables in mind
• Structural variables-Should have clarity regarding
build of ping space,equipements,staff required
• Process variables-The committees should specify
the type of patients that are to be accepted for
investigations
• Outcome variables:These include length of stay of
patients in hospital,bed occupancy
rate,complication rate,death rate,referral rate etc.
The first step in moving towards lean operations is to be able to
identify waste

Waste Value Added Activity

▪ Materials or Value ▪ Value adding work is something
resources (e.g., Added that the customer would actually
space, equipment, Activity be prepared to pay for
time) that are in Waste
excess of what is
needed to meet Elements
customer of work
requirements

Incidental
Activity

Incidental Activity
▪ Work that does not directly add customer
value, but which is currently necessary to
maintain operations

11
Our objective is to reduce waste and increase the % value added

Waste

Incidental
Activity

Elements
of Work

Value Added
Activity

12
 Beliefs of lean
Basics of lean operations
What it is What it is not How do you do it?

▪ Objective is to ▪ A framework to ▪ Making people ▪ First, identify

deliver what the achieve continual work harder or do activities which add
patient needs and gains in the same with value vs. those
to eliminate any productivity while fewer people which are waste
process/task that satisfying patients’ ▪ A short-term ▪ Apply lean tools to
doesn’t add to expectations for project reduce variability
patient care or the service quality ▪ Limited to and redundancy in
teaching mission manufacturing order to eliminate
▪ Waste leads to poor plants waste and improve
service, quality, and ▪ Mean!! service, quality, and
financial outcomes cost
▪ Waste must be
eliminated
 Eight
Wasted motion major inefficiencies
Rework in hospital operations . . Excess
Overproduction . inventory
▪ Pharmacy tech spends ▪ X-ray tech has to reenter ▪ Admissions paperwork ▪ Medicines held over the
20 minutes looking in 10%-20% of requests having 7 redundant shelf-life because of
multiple places for a because of wrong side pages out in the 16 page excess ordering
particular med indication packet

Wasted transportation Excess processing Waiting time Wasted intellect

▪ 25% of patients admitted ▪ Nurse records ▪ OR team waits 20 ▪ Numerous ideas are
to wards are transferred respiratory rate on 4 minutes for a case to “lost” only to be
to a unit with a similar different forms in the begin, and is not free to rediscovered later
level of care within 36 chart do other tasks
hours of admission
 . . . which are driven by three root causes

Variability
Variability Redundancy
Redundancy Inflexibility
Inflexibility

Inherent
Inherent variability
variability Controllable
Controllable
created
created by
by external
external variability
variability
factors
factors created
created by
by us
us

Schedule variability Task variability

Sun Mon Tue Wed Thu Fri Sat

 Lean includes frameworks not only for diagnosis but also treatment of waste

. . . we can apply a set of lean levers

Now that we know 1 Visual

the root causes of management
waste . . .
4
Pull
Variability
scheduling

Redundancy 3 Standardized
2 operations
Process/
Inflexibility role
redesign
Pull scheduling reduces the over production.
Only the required amount is produced in 5 Error
every stage. Altogether this makes a
manufacturing system with very high
proofing
flexibility and no waste.
 Root Cause Analysis(RCA)

• THE SAFETY CASE

• A laboratory aide was cleaning one of the gross dissection rooms where
the residents work. This aide was a relatively new employee who had
transferred to the department just a few days prior to the event. When
she was cleaning the sink in the dissection room, she accidentally ran her
thumb along the length of a dissecting knife—an injury that required 10
to 15 stitches.
• “ASK WHY 5 TIMES” TECHNIQUE
• The simplest way to perform a root cause analysis is to ask why 5 times. In
the case above, the answers might read as follows:
• The laboratory aide was cut by a dissection knife.
• The knife was left by the sink.
• The area was not cleared on the previous day.
• Clearing is not a daily habit.
• Standard operating procedures/documentation for clearing do not exist.
Indicators of quality assurance in hospital

• Waiting time for services viz:-registration and

outpatientconsultation,admission,radiological service
• Medical Errors
• Hospital Infections
• Main key areas:Blood bank,lab,radio
dept,CSU,pharmacy,outpatient and inpatient dept
• Patient satisfaction
• Satisfaction of health professional,visitors and
referring hospitals
Measures which can be taken to improve the satisfaction level:

• Cordial,well trained,dedicated staff having

sense of empathy
• Quick response time
• Minimum waiting time
• In-house invstigation all the time
• Display of information
• Good quality food
Measure to improve the satisfaction level of
the staff
• Good working enviornment
• Provision of induction training
• Provision of professional training
• Recognition and Reward(R & R) for good work
• Involvement of staff in taking decision
• Provision of PPE’s
 Pareto Principle
• Pareto Analysis is a statistical technique in decision
making that is used for the selection of a limited
number of tasks that produce significant overall
effect. It uses the Pareto Principle (also know as the
80/20 rule) the idea that by doing 20% of the work
you can generate 80% of the benefit of doing the
whole job. Or in terms of quality improvement, a
large majority of problems (80%) are produced by a
few key causes (20%). This is also known as the vital
few and the trivial many.
The 80/20 rule can be applied to almost anything:

• 80% of customer complaints arise from 20% of your products

or services.
• 80% of delays in schedule arise from 20% of the possible
causes of the delays.
• 20% of your products or services account for 80% of your
profit.
• 20% of your sales-force produces 80% of your company
revenues.
• 20% of a systems defects cause 80% of its problems.
• The Pareto Principle has many applications in quality control. It
is the basis for the Pareto diagram, one of the key tools used in
total quality control and Six Sigma.
 The following data should be maintained

• Medical records
• Incident Review:drug reaction,assault on
patients by employee/outsider
• Wrong patient for investgation/surgery
• Suicidal attempt by patient
• Emergency patients not being taken care
promptly
• Un-necessaary referral of the patients
 Patient satisfaction survey variables:
• Delay in attendance by doctors,nurses and helpers
• Discourtesy shown to patient during
hospitalization
• Lack of amenities,incident of wrong
treatement,iatrogenic complications
When a patient acquires a new illness, or is injured by the
services provided by a medical provider, then the result is
considered to be "iatrogenic". Iatrogenic events may result
during diagnosis or treatment, and they may be physical,
mental or emotional problems.
 Clients in hospitals
Two types of clients
External-External clients include the
patients,their relatives and friends

Internal-The internal clients are all the staff

involved in providing the services
 Measures to reduce the waiting time

• Increase the no. of service counter

• By giving appointments
• Provision of computerised machine
• Display information
• Provision of all service under one roof
 General Instructions
• Hospital day should be held once a year
• Free camp’s and exhibitions
• A conducted tour of in-patients
• First hand treatment should be free to all
• Presciption of one doctor should not be changed by other to
protect the patients faith
• The smart card holder’s should be conveyed to bring certificates
• Mirrors on the turns on the ramp
• No frill hospitals
• Medical tourism
• Steel OT’s
• HEPA filters
 Emergency codes
• Code Red: Fire
• Code Blue: Cardiac Arrest
• Code Orange: Disaster or Mass Casualties
• Code Green: Evacuation
• Code Yellow: Missing Patient
• Code Amber: Missing or Abducted Infant or Child
• Code Black: Bomb Threat
• Code White: Aggression
• Code Brown: Hazardous Spill
• Code Grey: System Failure
• Code Pink: Pediatric Emergency and/or Obstetrical Emergency
 Feedback
• Exit interviews-survey can be handled by
independent agency
• Complaint Box/Suggestion box
• Consumer Protection Act
 General instructions
• CLINICAL ATTIRE
• DONATION BOXES,BOARDS AND REGISTERS
• HUMAN RESOURCE DEVELOPMENT
• COLOUR CODING
• PAGING
• DIFFERENT COLOURED OPD SLIPS FOR
DIFFERENT PATIENTS
• Negative Pressure Isolation Room
Quality initiative at RH Chamba
 Quality Initiative at H.P
• Kiosks at IGMC

• Prize distribution under Swach Bharat Mission

• Birth waiting Home

• Different Mother & Child Health trainings

KNOWLEDGE
IS THE
ANTIDOTE TO FEAR