PENERAPAN MANAJEMEN MUTU

Quality from the Patients Perspective

Keep me safe
Heal me
Be nice to me
In that order!

Safety + quality + satisfaction = Excellent Care

Definition of healthcare quality

Quality is working according to specifications
Quality is providing effective services with a
minimum of unnecessary use of resources
Quality is to satisfy customers

Basic Quality Tenets

Customer satisfaction
Respect for people
Management by fact
Continuous improvement

Important Principles
1. Productive work is accomplished (unggul)
through processes
2. Sound customer supplier relationships are
absolutely necessary (penting) for sound
quality management
3. The main source of quality defects is
problems in the process
4. Poor quality is costly
5. Understanding variability of process is key to
improving quality

Important Principles, continued

6. Quality control should focus on the most vital
processes
7. The modern approach to quality is thoroughly
grounded in scientific & statistical thinking
8. Total employee involvement is critical
9. New organizational structure can help achieve
improvement
10. Quality management employs three basic, closely
interrelated activities: quality planning, quality control,
and quality improvement
National Demonstration Project, 1990

Customer Supplier Chain

Customer

Process

Supplier

Inputs
(orders)

Process
Services
(med adminis) (cure)

Customers

Nurses
Technicians
Other MDs
Therapists
Labs

Foundation of Process Improvement

Set Standards (apa itu standar)
Measure (bagaimana cara mengukurnya)

Components of an Ideal Health Care

System
1.
2.
3.
4.
5.
6.

10

Long, healthy, productive lives

Quality
Access
Efficiency
Equity
Capacity to innovate and improve

The concept of quality in Health Care

Structure, process, outcome
Quality Domains: effectiveness, responsiveness
.
Quality of services versus quality of systems
Health care helps individuals and populations to
realize their potential health
Quality relates to compliance of practices with
evidence
Quality relates to health outcomes attributed to
services

Standards Proliferated in Many Areas

12

Rights and Ethics

Provision of Care
Medication Management
Infection Control
Performance Improvement
Environment of Care
Leadership
Medical Staff
Nursing
Human Resources

SERVICE
STANDARDS
INDICATORS

REGISTRATION DESK
Scope of services
well defined and
understood by staff

Patients rights and

responsibilities are
identified and respected

Increased
patient
satisfaction
and quality
of care

Increase in staff strength

in areas like enquiry, doctors
booking & console as per work load

Admission process
streamlined, admission
counseling started

Job responsibilities
of staff clearly
defined

Staff review meetings

for discussion
complaints &
suggestions

Procurement, storage &

dispensing policies/procedures
for medications well defined

PHARMACY

Improved inventory
practices as a result of
training of staff
Special care taken in handling,
storing and dispensing sound
alike, look alike and high risk
medicines
Regular medical audits

Adverse drug reactions &

medication error tracking &
review has been reinforced
Policies defined for handling
of narcotic, radioactive&
chemotherapeutic drugs.

Lower incidents of
medication related
adverse events in care

IT &
BILLING

New out patient and

in patient billing
counters to meet up
additional workload.

Auto log& limitation

on viewing privileges

Auto stoppage of
medication which have
serious side effects unless
reordered by the physician

IT generated
discharge summary

Safety of patient data

& decrease in waiting
time for billing

Introduction of
billing counseling

Schedule of charges
displayed through
kiosk and handouts

CLINICAL
STANDARDS
INDICATORS

OPD Consultation
Increased patient satisfaction

Corrective steps taken to

reduce OPD consultation
waiting time

More emphasis on preventive

care through patient
education.

Monthly review of statistics on

mortality, code blue occurrence,
capacity utilization, doctors
performance etc.

Protocols for preventive health

checks, cardiac evaluation, pre
operative anesthesia,
angiography have been
reinforced

DIAGNOSTICS
Procedures and policies for pathology
& radiology depts. implemented with
standardized processes

Wastages identified
and corrective actions
taken. Biomedical waste
practices improved

Regular training of
staff in
radiation safety

Continuous monitoring
of clinical tests
results

Increased patient safety and

enhanced quality of services
provided

Staff with requisite

qualifications and
experience is
employed

OT & Nursing
Improved practices in OT and
reduced chances of error

Proper documentation of
OT notes and sign offs by
treating surgeons are in
place

Rational use of blood

and blood products in
OT

Sterilization and
disinfection practices are
monitored and are in
place

Policy to prevent adverse

events like wrong site,
wrong patient &wrong
surgery is defined and
implemented

Infection and
environmental
surveillance carried
out regularly

CONCLUSION
Registration:
Staff awareness about various policies, procedures
and services improved considerably.
Patients rights are now recognized and respected.
Turn around time reduced

Pharmacy:
Waiting time reduced
Ready stock of emergency drugs at all times
Improved inventory practices.

IT and Billing:
Security policy for the access of data and OPD
records.
Restricted control and access to patients data.

OPD Consultations:
Mandatory nutritional assessment .
Patient rights regarding privacy and
confidentiality reinforced.

Diagnostics:
Equipment calibration/preventive maintenance
schedule monitored regularly.
Quality assurance programme implemented.
Corrective actions identified & implemented.

OT and Nursing:
Fumigation policy and hands washing is
continuously monitored in OT.
Better Infection control
Continuous training, incidental teaching and
supervision to ensure quality nursing service.
Motivation to nursing staff to be a partner in
delivery of healthcare.

Strategies to Improve Quality

Performance Improvement
Regulation (Hospitals: JCAHO; Plans: NCQA;
MDs: credentialing/licensure requirements)
Financial Penalties
Litigation (proses pengadilan)
Public Pressure (Disclosure (penyingkapan),
Foundation for Accountability-FACT)

Whats wrong in todays Health Care?

Avoidable errors
Underutilization of services
Overuse of services
Variation in services
Communication problems
Lack of Evidence
Dissatisfied clients

Continuous Quality Improvement

Important elements:
External and internal customer satisfaction
Management leadership
Involves all personnel
Uses statistical methods
Focuses on improvements

The Core Principles

The essentials are:
Assuring(I.e assessing and improving) quality
is the responsibility of the provider
Quality assurance is an evaluation and
improvement process
Of all the necessary
attributes(knowledge,skills,attitudes,values)
values and attitudes are the most important

TOTAL QUALITY
The end point of a development in phases:
Focus on professional quality
Focus on client satisfaction
Focus on system effectiveness
Focus on interconnections
Organizational and societal unification

Quality Planning

Establish Quality project: goals and team

Identify customers
Determine client needs
Design services to be provided
Design delivery process
Determine information need
Use and evaluate

Train professionals

Select key professionals

Design appropriate training
Organize continuous training sessions
Evaluate results of training including
satisfaction
Reward participants
Repeat training regularly

Evaluation

Includes assessment and improvement

Orientation:what are the possibilities?
Selection:What is most appropriate?
Implement: who is doing what?
Collect and discuss the results
Disseminate the results inside and outside
Prepare for the next round

Improvement of care

Focus:Structure,Process and Outcome

Structure:better equipment
Process:doing the right things better!
Outcome:obtain better results in
- effective services
-costs
- client and employee satisfaction

Improvement of structure

Includes building,equipment,personnel,manuals,
information systems,rules and regulations
Includes new provisions,and updating and
refurbishing of old provisions
Need to include recording of inputs and costs

Improvement of Process
Principle:Doing the right things better!
Doing the right things more effective!
Doing the right things more efficient!
Includes:
Appropriate use of technology
Appropriate use of personnel
Client/provider relationship

Improvement of outcome
Focus:
Programme effectiveness
Programme efficiency
Consumer and employee satisfaction
Consumer and employee education
Building and technology safety
Community relations
Information and communication needs

Tools for Improvement

Motivation
Insight
Evaluation methods
Communication tools
Dedicated personnel
Dedicated Management
Money

That implies:
Quality improvement is essential for survival
Customer satisfaction is important for survival
Monetary support will come only after wellexecuted quality assurance studies

Infrastructure for Quality

Assurance in Health Care

Infrastructural Needs
Assessment of actual situation:
Structural analysis
Rapid need assessment
SWOT analysis
Programme evaluation
Part of certification

Essentials
A Policy Document for Quality Assurance

A Blue Print for Quality Assurance

Quality Assurance Policy Document

Directed to Quality Assurance,not to quality
Based on National Needs for Improvement of
health services
Items:definitions,principles,locus,focus,actors,
costs,strategies

Listing the Infrastructure

The Body
The Engine
The Petrol
Assembly line and Maintenance
The Route Map
The Driver
And then On the road!

The Body
The system for quality assurance
Information systems
Conformity between healthcare system and
QA system

The Engine

Policies
Planning Mechanisms
Implementation strategies
Organization
Resources
Knowledge,skills,attitudes
Value systems

The Driver

Roles and Functions

Education and Training
License
Rewards
Remuneration
Accountability
Value Systems

The Petrol

Epidemiology of Health and disease

Epidemiology of quality(ABNA)
Willingness to evaluate/be evaluated
Willingness to Change and Improve
Legislation
Value Systems

Epidemiology of Quality

Rumours and Hearsay

Surveys:Opinions,Dissatisfaction
Registration of Facts:Incidents
Registration of Facts: Trends
ABNA:Achievable Benefit Not Achieved

Maintenance

Support mechanisms
Research and Development
Internal Quality Assurance System
Value Systems

Decision Making in Healthcare

Improvement

Key Concerns:
To find the decision makers:
Who decides about quality?
Who decides about quality improvement?
To identify the client in health care quality
improvement

Roles and Functions in Decision making in Quality

Improvement

The Consumers
The Professionals
The Managers
The Government,Policy Makers

The Seven Roles of the Consumer

Definers of Quality
Evaluators of Quality
Informants of Care
Co-producers of care
Targets of Quality Assurance
Controllers of Practitioner Behavior
Reformers of Health Services

The Seven Roles of the Provider

To be accountable
To provide quality care(plan,implement)
To safeguard the quality of care services
To be evaluated by colleagues
To evaluate his colleagues
To continue learning
To collaborate with colleagues and
management

Seven Roles and Functions of Management

Do their job(Quality Management)

Exert leadership
Participate in Quality Management
Communicate on Quality matters
Be accountable re: quality
Evaluation of Quality Management
Provide resources

Role of Government
Still open:
Active role with responsibilities
Support role with limited responsibilities
No role at all

AUDIT
Key Tool for QA Implementation

Audit: a modern definition

Is a criterion referenced review of health care
delivery to establish quality followed by, if
necessary, specific activities to improve care
delivery
The method is used by professionals to assess
and, if needed, improve the quality of their
work

Audit :Applied with little more discipline

Practical Solutions:
Focusing on relevant health care delivery
Focusing on multidisciplinary professional work
Retrospective and concurrent in orientation
Focus on assessment and improvement
Based on reliable and valid data
Not more time consuming than others

Audits Building Stones

A well selected topic

A limited number of relevant criteria
Well selected reliable and valid data
A functioning judgment procedure
A will to change when needed
Relevant changes leading to improvements

What are benefits in health care?

Improvement in health status
Increase in satisfaction
Elimination of impairment
Elimination of disability
Elimination of risks
Elimination of malfunctioning
all due to present health care

What is ABNA?

ABNA
Maximum conceivable benefit
Achievable benefit

Benefit not achievable

Achievable benefit achieved Achievable benefit not achieved

Errors of commission

Errors of omission