Quality Management in Healthcare Services: Dr. Waleed M Kattan

2/4/20
Quality Management in
Healthcare Services
HSAE 625
Dr. Waleed M Kattan

wmkattan@kau.edu.sa
Department of Health Services and Hospitals Administration

Faculty of Economics and Administration
King Abdulaziz University, Jeddah, Saudi Arabia
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Dr. Waleed M Kattan MD, MHA, PhD
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Introduction
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About me
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Syllabus
• Course Learning Outcomes
• References and textbooks
• Grading
• Assignments
• Midterm
• Final
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Course Learning Objectives

• Explain how to use systems to affect quality goals, how to set the
stage for successful quality management and how to employ
quality management techniques.
• Summarize the application of quality, safety and performance

improvement to the measurement and improvement of the patient
experience and from the perspective of the patient as a consumer
of healthcare services.
• Evaluate delivery, deployment and sustainability in healthcare

services provision.
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• Applying Quality Management in Healthcare: A Systems Approach – 4th edition- 2017, by

Patrice Spath, Diane L. Kelly, - Health Administration Press, ISBN-10: 1567938817, ISBN-
13: 978-1567938814
Textbook - Readings
• The healthcare quality book: Vision, strategy, and tools - 3rd edition- 2014 (HCQB), by
Joshi, Maulik S.; Ransom, Elizabeth R.; Nash, David B.; Ransom, Scott B. Print ISBN:
9781567935905, 1567935907 - eText ISBN: 9781567935905, 1567935907
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• The Current State of Healthcare: Five

Important Reports
Overview • Basic Concepts of Healthcare Quality
• Quality Evolution
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The Current State Five Important

Reports
of Healthcare Modified by
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Outline
• The current State of Healthcare: Five Important Reports
1. “The Urgent Need to Improve Healthcare Quality”

2. To Err Is Human
3. Crossing the Quality Chasm
• The Institute of Medicine’s Six Aims for Improvement
4. National Healthcare Quality Report

5. National Priorities and Goals
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The Current State of Healthcare: Five Important Reports
• Quality in the healthcare system is not what it should be.
• Five major reports identify gaps and call for action:

1. The National Roundtable on Health Care Quality’s “The Urgent Need to
Improve Health Care Quality” (1998)
2. The Institute of Medicine’s (IOM) To Err Is Human (2000)
3. IOM’s Crossing the Quality Chasm (2001)
4. The Agency for Healthcare Research and Quality’s (AHRQ) National
Healthcare Quality Report (2003–2011)
5. National Priorities Partners’s (NPP) National Priorities and Goals (2008)
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1- “The Urgent Need to Improve Health Care Quality” (1998)
• “Serious and widespread quality problems exist throughout

American medicine.”
• Establishes the classification scheme of “overuse, underuse, and

misuse” to categorize quality defects
• Quality of care is the problem
• Current efforts to improve will not succeed unless we undertake a

major, systematic effort to overhaul how we deliver health care
services, educate and train clinicians, and assess and improve
quality.
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2- To Err Is Human (2000)

• The landmark report by the National Academy of Medicine
(formerly the Institute of Medicine), called To Err Is Human,
helped to create a national awareness of the significant
quality and safety issue surrounding health
• The report estimated that between 44,000 and 98,000
people die every year from preventable accidents and
errors in hospitals.
• Equivalent to 3 jumbo jets crashing every other day
• The combined costs of these deaths and other quality issues
alone could amount to up to $29 billion each year.
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The National Academy of Medicine, formerly called the Institute of

Medicine, is an American nonprofit, non-governmental
organization.
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To Err Is Human
• Captured the attention of key
stakeholders for the first time
• Framed the problem in a way
everyone could understand
• Led to the identification of patient
safety as a solidifying force for
policymakers, regulators, providers,
and consumers
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Recommendations
• Establish a national focus to create leadership,
research, tools, and protocols to enhance knowledge
about safety.
• Learn from errors through immediate and strong
mandatory reporting efforts.
• Create safety systems inside health care organizations
through the implementation of safe practices at the
delivery level.
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IOM report: Crossing the Q. Chasm (2011)

• To achieve maximum customer service, eliminate:
• Overuse
• Unindicated, not beneficial (e.G. Antibiotics for viral
infections)
• Underuse
• Inadequate service (e.G. Not doing necessary diagnostic
tests)
• Misuse
• Medical errors, incorrect diagnosis, other avoidable
complications
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National Quality Forum (NQF), became increasingly involved in the collection and assess-
ment of quality data across the nation.
In 1998, Chassin and Galvin characterized the problems of overuse, underuse, and
misuse in medicine and called attention to practice variation in medicine and to the sub- 2/4/20
optimal patient outcomes associated with this variation (Table 1-3).9
In 1999, Kohn, Corrigan, and Donaldson estimated that at least 75,000 people
die from medical errors every year. Under their editorship, the IOM published To Err
Is Human: Building a Safer Health System in 2000.10 This report identified the systems
that must be developed to decrease the number of medical errors in the United States.
In a second report, Crossing the Quality Chasm: A New Health System for the 21st Century,11 the
IOM defined the state of the quality problem, offered recommendations for improve-
ments, and outlined specific targets that would contribute to nationwide improvements
(Table 1-4).
TABLE 1-3 Clinical Quality Problems in Health Services Provision

Overuse: The potential for harm from a health service exceeds the possible benefit.
Underuse: A health service that would have produced favorable outcomes was not provided.
Misuse: A preventable complication occurs with an appropriate service.
Adapted from: Chassin MR, Galvin RW. The urgent need to improve health care quality: Institute of Medicine
National Roundtable on Health Care Quality. JAMA. 1998;280(11):1000–1005.
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Crossing the Quality Chasm

• Offers a new framework for a redesigned US healthcare
system
• Six dimensions of US health care that need improvement
• Safe
• Effective
• Efficient
• Timely
• Patient centered
• Equitable
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Every health care system should be designed to provide care that is:
1. Safe: avoid injury to patients from the care that is intended to help;
2. Effective: provide services based on scientific knowledge to all who could
benefit, and refrain from providing services to those not likely to benefit;
3. Patient-centered: care that is responsive and respectful of individual patient
preferences, needs, and values; ensure that patient values guide all clinical
decisions;
4. Timely: reduce wait time and harmful delays for both those who receive and
those who give care;
5. Equitable: provide care that does not vary in quality (i.e., care that is not
influenced by personal characteristics such as gender, ethnicity, geographic
location, and socioeconomic status).
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6 Healthcare Q. Dimension
(Key Components of Quality Healthcare)
Every health care system should be designed to provide care that is:
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The Four Levels of the Healthcare System
The underlying
framework for achieving
the IOM’s Six Aims for
Improvement depicts the
healthcare system in four
levels, all of which
require changes.
*will be discussed in detail later in course
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4- AHRQ’s National Healthcare Quality Report (2003-2011)
• Aims to answer three questions:

1. What is the status of healthcare quality and disparities in the
United States?
2. How have healthcare quality and disparities changed over
time?
3. Where is the need to improve health care quality and reduce
disparities greatest?
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Exercise
• Think of an experience you, a family member, or a
friend has had with healthcare. Gauge the experience
against IOM’s six aims, and identify any opportunities
for improvement.
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5- National Priorities and Goals (2008)
• Focuses on national performance improvement efforts

that address four major challenges:
1.Eliminating harm,
2.Eradicating disparities,
3.Reducing disease burden, and
4.Removing waste
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Conclusion: Need for Healthcare Improvement

• As we approached the year 2020, there is a greater need for change and
improvement than ever before, especially in healthcare.
• Medical costs continue to grow at rates nearly triple those of other industries,
despite technology and other efforts to curb their growth.
• Health outcomes, quality, and cost-effectiveness of healthcare processes have

become center stage for every hospital or healthcare system.
• A big part of this expense is purely waste—waste in terms of duplication of

effort, overutilization of resources, and inefficient administration and clinical
processes.
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Quality Evolution
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Outline
• The Quality Foundation

• Quality Improvement Processes and Approaches
• Quality Tools
• Knowledge Transfer and Spread Techniques
• Case Study
• Conclusion
• Study Questions
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The Quality Foundation: Influential Leaders
• Walter A. Shewhart – common cause, special cause variation, statistical

control, statistical processes control
• W. Edwards Deming – “father of quality,” PDSA
• Joseph M. Juran – Pareto principle, “Juran Trilogy”
• Taiichi Ohno – Toyota Production System (TPS)
• Kaoru Ishikawa – Ishikawa diagram, total quality control (TQC)
• Armand V. Feigenbaum – total quality control
• Philip B Crosby – zero defects, “conformance to requirements”
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• Quality in business and industry was adopted after WWII.
• In healthcare, efforts began as early as the late 1980s.
• The past decade has shown a growing emphasis of quality

in public health.
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• The historical evolution of Total Quality Management has

taken place in four stages. They can be categorized as follows:
1. Quality Inspection:
• Ford Motors, 1910s. Shewhart and Dodge-Roming
2. Quality Control: WWII
3. Quality Assurance and auditing 1950s
4. Total Quality Management 1980s

• Dr Edward Deming, Dr Joseph Juran and Philip Crosby
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Dr. Edward
Deming (1982)
• (an engineer and statistician)
• Organization problems lie within the
management process
• Statistical methods can be used to trace the
source of the problem.
• In order to help the managers to improve the
quality of their organizations he has offered
them the following 14 management points.
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• Helped to create a philosophy of management that uses statistical

analysis to reduce variation or variability in processes and outcomes.
• Variability refers to the relative degree of dispersion of data points,
especially as they differ from the norm.
• Deming created control charts and other tools that continue in use
today.
• He strongly believed that management needs to embrace a culture
focused on continuous improvement for any change to be successful.
• This included a focus on long-term profits, constancy of organizational
purpose, and stability in the management among others, which he
defined in his “fourteen points” and “seven deadly diseases”
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System of Profound Knowledge

• Theory of improvement from W. Edwards
Deming
• The 4 parts of Deming's theory tie into his
14 points.
• It is so important as it helps individuals to
transform within their organizations,
which would, in turn, improve the
outcomes in quality improvement efforts.
• Understanding and applying the four
parts of Deming's theory, he believes, will
create a better leadership culture.
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1- Appreciation of a System
• What is the whole system that you’re trying to manage?
• Each organization is composed of a system of interrelated
processes
• People make up system’s components.
• The success of all workers within the system is
dependent on management’s capability to orchestrate
the delicate balance of each component for optimization
of the entire system.
• The people, free of fear and competition within the
system can band together for optimization of the system
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95% of performance is governed

by the system
Deming
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2- Understanding Variation
• What is the variation in results trying to tell you about the system?
• The goal of quality or continuous improvement is to reduce the
range of variation over time, in addition to adjusting the process
level to the desired level.
• The control chart is a tool to determine if the system is in control
(the system gives predictable results) and what those predictable
results are
• Common cause variations are the natural result of the system. In a
stable system, common cause variation will be predictable within
certain limits.
• Special cause variations represent a unique event that is outside the
system.
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Stable Processes
• A process with only common causes affecting the
outcome is stable, or in a state of statistical control. Stable
means only that the variation is predictable within
statistically established limits, not that there is no
variation.
• An unstable process is one where the variations can be
attributed to both common and special causes.
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Deming describes the benefits of a stable process as:

• A process has an identity and its performance is predictable;
therefore there is a rational basis for planning.
• Costs and quality are predictable.
• Productivity is at a maximum and costs are at a minimum for the
process.
• The effect of changes in the process can be measured faster and
more reliably.
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3- Theory of Knowledge
• What are your predictions about the system’s performance?
• Improvement is learning and developing new knowledge

about the system
• Tampering with the system: actions applied to individual

components without the guidance of profound knowledge
works against the system even when best efforts are made.
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4- Theory of Psychology
• What are the important interactions among people in the
system?
• The system self-organizes around its Identity.
• That includes its vision, purpose, guiding principles, values,
history, theory of success and shared aspirations.
• A clearly designed, shared identity allows the organization to
self-organize in alignment with the identity desired by
leadership.
• People are born with intrinsic motivation, self-esteem, desire
to learn, creativity and joy in accomplishment, and a need for
freedom and belonging
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Change management principles

• To change performance you must act on the system.
• To act on the system, you must change the way you

manage.
• To change the way you manage, you must change the way
you think.
Changing thinking and management behavior changes

system performance.
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Dr. Joseph Juran (1980)

• An engineer and consultant
• He was stressing the customer’s point of
view of products’ fitness for use or
purpose.
• According to him: a product could easily
meet all the specifications and still may
not be fit for use or purpose.
• Juran advocated 10 steps for quality
improvements as follows:
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Juran trilogy
• He also developed the 3 phases of
quality management (planning,
control, and improvement)
• He advocated the use of a Pareto
chart
• 80% of a problem can be attributed to
20% of the cause
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Philip Crosby Definition of quality —conformance

to requirements.
Absolute
Requirement Quality system —prevention.
For QI
Quality standard —zero defects.
Measurement of quality —price of

non-conformance.
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Week 1b
Quality Management Fundamentals
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Applying Quality
Management in Healthcare:
A Systems Approach- 4th
Edition
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Chapter 1
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• Why Focus on Managing Systems
• What Is Quality and Safety
• Creating a Common Understanding of Quality Methods
• Three Principles of Total Quality
• Quality Continuum for Organizations
• Define a mature quality continuum
• Why Q in healthcare
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Basic Concepts of Healthcare

Quality
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What is Quality
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Quality
• In the business world, QM is a way of doing business that
continuously improves products and services to achieve
better performance
• According to ASQ (2017), the goal of QM in any industry is

to achieve maximum customer satisfaction at the lowest
overall cost , while continuing to improve the process
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What Is Quality?
“The degree to which health services for individuals

and populations increase the likelihood of desired
health outcomes and are consistent with current
professional knowledge.”
Institute of Medicine, 1990
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What is Quality?
• No universally accepted definition exists
• But there are common shared elements in most

definitions:
• Meeting or exceeding customer expectations
• It is dynamic (what is considered Q today, may not be good
enough tomorrow)
• Quality can be improved (since expectations may change, Q
must be continuously improved)
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Stakeholders in Q Care
• Each group perceive Q differently
• Each group define Q differently
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What Is Safety?
“Freedom from accidental or preventable

injuries produced by medical care”
AHRQ, 2016
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A more contemporary perspective on quality is to reflect

upon the following questions:
• Are we doing the right things?
• Is there a better way to do this?
• Are the things we are doing getting us to where we want to
end up?
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Pediatric office story

• “Dissatisfied with the hours wasted at the pediatrician’s office and
disappointed with the need to return to finish the checkup, the
mother begins to investigate other healthcare options.”
• Doctor is highly trained and knowledgeable
• Organizations concerns--- did not meet her expectations
• Organization: a structured system designed to accomplish a goal or set of goals
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g Quality Managementin Healthcare: A Systems Approach
This book focuses on managing the quality of the structured system

in which health services are delivered. Like any organization, the structured
system in the pediatric clinic is a by-product of numerous variablesthat
affect the design and execution of many interrelated factors. What are the
specific goals of the healthcare organization and how are they determined?
Does everyone in the organization understand and agree with these goals?
How are patient appointments, office workflow, and staff hours scheduled to
enable the practice to meet these goals?How are patient and familyneeds and
expectations taken into account? How are clinic employeesrecruited, hired,
trained, and evaluated?Does the pediatriciandevote all of her time to the
office or does she also have hospital commitments? How is the pediatrician
compensated for services?How does reimbursement influence the office
structure and work systems? Does the practice operate according to a budget?
Does the practice employ an office manager?If so, how is the manager's role
defined? How do the pediatrician and the staff communicatewith each other
and with patients and their families?
These are just some of the questions that influence managerialdecisions
about how the structured systemwill operate. In the example,the mother's
experience resulted from how her pediatrician'spractice addressed such
organizational questions. This mother's perception of quality had nothing
do with the
to do with the quality of the medicølcare. It had everythingto
is on
organizational quality of the health services.The focus of this text
of health-related services—withinand between
managing the structured systemsModified by
organizations—to Dr. Waleed
provide the highest-quality
M Kattan MD, and
MHA, safesthealthcare.
PhD
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Different Definitions of Q
• Different stakeholders tend to attach different levels of
importance to individual attributes.
• Clinicians
• Patients
• Payers
• Managers
• Society
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Stereotypical Differences in Importance of

Selected Aspects of Care to Key Stakeholders’
Definitions of Quality
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Why Focus on Managing Systems?
Patients may not receive the benefits of good medical

care when the system of delivery is poorly managed.
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Shared Responsibilities for Quality
• Clinical and technical professionals—provide

the medical care and produce the services
• Management—create and manage the

structured system in which clinical and
technical professionals work
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Donabedian
Structure Process Outcome Patient Experience
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Measurement-Related Concepts:
Structure, Process, and Outcome
• Evaluations of care quality can be classified in terms of one of three
measures:
• Structure
• Process
• Outcome
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Structure
• A good example of Structure measures are the static characteristics
of the individuals who provide care and the settings in which the
care is delivered.
• E.g., education, training, certification
• Structure-focused assessments are most revealing when

deficiencies are found.
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Process
• Process measures focus on what takes place during the delivery of care.
• Two aspects:
• Appropriateness: whether the right actions were taken
• E.g., whether the correct test was ordered
• Skill: how well the actions were carried out

• E.g., how well a surgeon completed a procedure
• The use of process measures to assess quality assumes that if the right
things are done and are done right, good outcomes of care for the
patient will result.
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Outcome
• Outcome measures focus on whether the goals of care

were achieved.
• E.g., whether a patient’s pain subsided, the condition cleared up,
or the patient regained full function
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TABLE 3.3.
Measurement Performance Measures Performance Measures Structure, Process,
Category for an Emergency Department (ED) for a Fast-Food Restaurant
and Outcome
Structure Number of hours per day that a person Percentage of time food storage
skilled in reading head CT scans is available equipment maintains proper temperature
Performance
Process Percentage of ED patients ≤13 years old Percentage of hamburger patties cooked Measures
with a current weight in kilograms to an internal temperature of 160°F
documented in the ED record
Outcome Median time from ED arrival to ED Median time between food order and
departure for patients admitted to delivery to the customer
the hospital
24 hours per day to interpret special tests, but that person could misread the results. To
ensure quality, measures of process and outcome also must be taken.
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PROCESS MEASUREMENT Dr. Waleed M Kattan MD, MHA, PhD
Measures of process evaluate whether activities©2020
performed during the delivery of healthcare
services are delivered satisfactorily. For instance, if an emergency department has a policy
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that all patients with confirmed pneumonia receive an antibiotic within two hours of ar-
rival, we would measure caregiver compliance with the policy to determine whether their
performance is acceptable.
In healthcare quality management, process measures are most commonly used.
Process measures provide important information about performance at all levels in the
organization. However, good performance does not automatically translate to good results. 12
In the previous example, even if all patients with pneumonia receive antibiotics within
two hours of arrival in the emergency department, some may not recover. For this reason,
another dimension of healthcare quality—outcome—must be measured.
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Example: Childhood Immunizations
• Number/location of • “What is done to a • “What happens to • Overall mother’s

pediatric clinics patient” a patient” impression
• Available vaccines • Immunization rates • Measles rates
(i.e., inventory) (e.g., MMR vaccine)
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Quality Terms Term Manager Actions

Quality control (QC) Fulfill process requirements
and Actions Find and repair faulty processes causing defective
Quality assurance (QA)
outputs
Quality improvement
Incrementally and continuously improve processes
(QI/CQI)
Umbrella of Continuously review, evaluate, and
Performance
improve performance to meet changing customer,
management
stakeholder, and regulatory requirements
Aggressively improve processes and reduce variation
Six Sigma
to achieve zero defects
Seek better ways to organize human actions and
Lean/Lean thinking
processes to eliminate waste
Manage differently using a customer focus,
Total quality (TQ/TQM)
continuous improvement, and teamwork
Organizational
Understand and improve the system to achieve goals
effectiveness
Use systematic methods to transition individuals,
Change management
teams, and the organization
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Total Quality Management

• Three principles:
1. Customer focus
• Internal
• External
• Stakeholders
2. Continuous improvement
3. Teamwork
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Quality
Continuum
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Less Mature Developing More Mature
Quality Complying with quality Internal quality improvement Internal quality improvement
priorities requirements of external is one of three or four is the organization’s top strategic
stakeholders is an operational strategic priorities priority
imperative
Quality scope Internal customers Internal and external Internal and external customers
customers and stakeholders and stakeholders and the
community served
Quality Key quality measures not Key quality measures Key quality measures reported
transparency reported internally throughout reported internally internally and publicly; reports
the organization and not throughout the organization; include benchmark data from
reported publicly few reported publicly best practice organizations
Quality No organization-wide Data-driven, statistical Managers trained in data-driven,

methods approach to quality methods used in some statistical methods and these
improvement improvement initiatives methods are used for all
improvement initiatives
Performance Only measures used are those In addition to measures In addition to measures required
measures required by external required by external by external stakeholders, internal
stakeholders stakeholders, internal measures linked to the quality
measures are used to goals of the organization are used
evaluate quality priorities of
managers
Information There is little or no IT support IT supports some quality IT support is provided for all
technology for quality activities activities
Modifiedbut
bymany are still quality activities
Dr. Waleedpaper based
M Kattan MD, MHA, PhD
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Exercise
• Based on what we have discussed, summarize the state of
healthcare quality in the Saudi Arabia in one or two
paragraphs.
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Why quality in Why quality in
healthcare? healthcare?.PDF
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Week2a
Understanding the system

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Chapter 3. Characteristics Of Complex Systems

Chapter • Dynamic Complexity
• System thinking
• Levels of HC system
Chapter 4. Understanding System Behavior

Chapter • System Metaphor (Iceberg)
Chapter Chapter 5. Visualizing System Relationships
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Chapter 3 - Characteristics of Complex Systems
• The presence of a large

number of variables that
interact with each other in
countless and often
Complex unpredictable ways
Health • Recurring problems

• Budget problem
Services • Workforce shortage
• Eg. Nurses shortage
• Short term fixes
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• Dynamic complexity: “cause

and effect are subtle, and
Dynamic
where the effects over time of
interventions are not obvious”
(Senge 2006)
• Obvious interventions
complexity produce nonobvious

consequences
• We need to alter the
fundamental behaviors
of the system
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Healthcare systems contain a

complex variety of
interdependent organizations
Systems
Thinking
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• System
Different • Mega system
• Macrosystem
levels in • Microsystem
Healthcare • Clinical Microsystem
System
• P35-37
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Systems Thinking
“A view of reality that emphasizes the relationships and interactions

of each part of the system to all the other parts”
McLaughlin and Olson 2012
• The blind men and the elephant
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Chapter 4 -Understanding System Behavior

A Systems Metaphor for Organizations
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Improvement Questions
What does an individual do differently?
What does an organization do differently?
How can we better understand the

results we are getting?
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The iceberg
Metaphor for
Systems
thinking
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Strategies managers may use:

Going 1. Understanding history
Below the 2. Being aware of mental models
3. Integrating double-loop
Waterline learning into management
philosophy and approach
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Chapter 5 - Visualizing System Relationships

Basic System Structure
Input(s) Conversion process Output(s)
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Models for System Relationships

Many models are available to help managers understand
the system relationships
1. Interconnected Systems Model
2. Three core Process Model
3. Baldrige Performance Excellence Program Framework
4. Socioecological Framework
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Interconnected Systems Model

Payers want to reduce
costs for chemotherapy
New payment methods
More efficient
treatment
Maintain quality and

reduce cost
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Three Core Process Model
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Compare to TQ principles
1. Costumer focus
2. CQI
3. Teamwork
External environment?
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IHI: Science of Improvement: How to Improve

• http://www.ihi.org/resources/Pages/HowtoImprove/Scie
nceofImprovementHowtoImprove.aspx
• https://youtu.be/nPysNaF1oMw
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Chapter 6 - Establishing System Direction

Purpose
Purpose/Desired outcomes Process Structure
• Setting direction
• Mission
• Vision
• Values
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Chapter 7- Setting Improvement

Goals in Complex Systems
• Explicit
• Clear
Effective • Multiple
Goal • Specific
Statements • Positive
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10
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Organizing for
Quality
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• Every healthcare
Quality organization must create a
Does framework for
accomplishing quality
Not activities.
Happen • Trustees and senior leaders
must champion an
by environment that supports
continuous improvement.
Accident
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Board Has Ultimate

Responsibility
• Legal and moral responsibility for the quality of
patient care and services lies with the governing
board.
• Personal involvement by board members is a key
factor in high-performing organizations.
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Groups Involved in QM
Board of Trustees
Administration/Senior Leaders
Coordinating Committee/Individual
Organized Medical Staff
Departments within the Organization
Quality Support Services
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QM Plan
• Document describing the
organization’s structure and
process for measuring, assessing,
and improving performance
• Required by some
accreditation standards and
regulatory mandates
• May have one organization-
wide plan
• May have an organization-
wide plan and plans in each
department
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The “Jaws of Culture” Often Disrupt

Change Initiatives (including QM)
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Quality Does Not Happen by Accident
Measurement
How are we
doing?
• Effective framework for
Yes
accomplishing QM activities
Assessment
Are we meeting • Culture supportive of
expectations?
continuous improvement
No
Improvement
How can we improve
performance?
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Identifying Quality Performance

Improvement Initiatives
• High-risk
• High-volume
• High-cost (Resource-intensive Process)
• Problem-prone Process
• Other Factors
• Related To International Patient Safety
• Relevant With Mission, Vision And Strategic Goals
• Covers One Or More Of Quality Dimensions
• Covers Structure, Process And Outcome
• Meeting Patient Or Staff Needs And Expectations
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Week 2b
Chapter 8
Fostering a Culture of Collaboration
and Teamwork
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• Patients in our hospital are often

in pain
• or
• Mortality rates from sepsis is
23% (too high)
The
• We want to change that
Problem • …how do we do that?
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Executing the Model

for Improvement The Aim
The Measure
• Form a team The Change

• Three Questions:
• The Aim, The Measures, The changes
ACT PLAN
• Test changes - PDSA Cycle
• Implement changes that work
STUDY DO
• Spread the changes to other areas
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The Aim
The Aim
• A strong, measurable aim with a clear time
frame will help keep your project on course The Measure
• It has to be important to those involved The Change
• A good aim: SMART GOAL ACT PLAN
STUDY DO
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Choose your team: Effective teams require three

kinds of expertise
1. System leadership
2. Clinical -Technical expertise
3. Day to day leadership - Project leader
What processes will be affected?

1. Nursing/Triage
2. Pharmacy
3. Stocking
4. Doctors
5. Registration
6. ED chief/director/ manager.
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Collaboration and
Teamwork
To keep the silo syndrome from disrupting quality
improvement effects, healthcare leaders and
managers must adopt an organization-wide
collaborative culture that rewards teamwork.
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Creating a Supportive Culture

• Organizational culture: a • Levers to encourage cross
consistent, observable pattern of discipline teamwork:
behavior in an organization; the • Appealing to personal values
way things get done • Inviting input on the vision
• Celebrating change
• Promoting psychological
safety
• Enabling knowledge sharing
• Encouraging collaborative
iteration
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Teams in Healthcare
1. Work teams charged with accomplishing tasks in
an ongoing manner
2. Parallel teams formed to address specific
challenges
3. Projects teams responsible for time-limited
deliverables
4. Management teams with oversight responsibilities
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When Considering a
Team Approach
Ask:
1. What is the purpose of the team?
2. What is the ideal, step-by-step
process or approach to achieve
that purpose?
3. What is the most appropriate
structure to support and carry out
that process?
4. How does the team define and
measure success?
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Collaboration and Teamwork
Collaborative team: a group with “health care professionals assuming complementary

roles and cooperatively working together, sharing responsibility for problem-solving
and making decisions to formulate and carry out plans for patient care”
(O’Daniel and Rosenstein 2008)
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Mental Models About

Work Team
Differences
• Diverse perspectives
supply the essential
elements of creative
tension that often
result in innovations
and improvements
• “Ideal” Employee
Behaviors May Not
Promote Learning
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How to effectively deliver safety in

healthcare organizations?
• Parallels to the aviation industry
• Teamwork
• Patient safety
Culture
Communication
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Leading
Improved
Patient Safety
• Leadership of an organization is the
driving force behind the culture that
exists and the perceptions that it creates.
• Messages must be visible and consistent.
• Leaders should round.
• Policies should be nonpunitive.
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• Leaders and management

must work with everyone
involved to prevent a
blame-focused or punitive
response.
Dealing with • Disclosure of harm to
Adverse patients and families must
be managed.
Events
• Involving patients and
families in discussions about
their care throughout the
entire process is an essential
element in cultural change.
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Reporting Errors and Adverse Events

• Voluntary reporting systems are often not reliable, and underreporting is a
significant problem.
• To increase reporting:
• Education fairs, posters, safety hotlines, shorter reporting forms, raffles or prizes
for departments with the most reports
• Emphasis should be placed on the guaranteed anonymity of reporting mechanisms
and the assurance of nonpunitive approaches.
• To sustain high levels of reporting, the underlying culture must change.
• Visible leadership commitment
• Dialogue and feedback
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• Healthcare has undergone a

more dramatic technological
explosion in the past few
decades than perhaps any other
industry, yet healthcare
Understanding organizations have not reacted
with the same speed and agility
Change to improve quality processes
Management and decrease error as other
industries have.
in Healthcare • The ability to manage change is
the distinguishing feature of
successful healthcare
organizations and leaders in the
twenty-first century.
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Managing
Change for QI
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The Aim
Measurement
The Measure
• Measurement is critical
for testing and
implementing changes The Change
• 4 dimensions for
measuring
• SMART
ACT PLAN
STUDY DO
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Measurement
• For any improvement project
you want to identify a family
of measures Outcome
Measure
Process
Measure
Outcome
Measures
Pt.
Feedback
• Aim = Decrease sepsis
mortality by 20% by January
2011
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Aim = Decrease sepsis mortality by 20% by January

2022
• Time it takes to register and triage

• % of patients being appropriately triaged
• Time from triage to initiation of resuscitation
• % of patients getting properly fluid resuscitated
• % of patients getting antibiotics
• Availability of medications and supplies
• Time to antibiotics
• Delay to getting to hospital
• Mortality rate
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What change can we make that will

lead to improvement?
The Change
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The Aim Developing

The Measure
Changes
• Depends what you are trying to change.
The Change Critical Thinking
• Flow Chart/Diagram
Benchmarking
ACT PLAN • Compare to best practice
Using Technology
• Barcodes for medications
STUDY DO Creative Thinking
• Become a patient for a day
Using Change Concepts
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Critical Thinking Flow Chart/Diagram

Use a Flow Chart/Diagram It helps to clarify complex processes
A flow chart allows to “visualize” the It identifies steps that do not add value
system you are trying to change to the internal or external customer,
Allows all to see the system in the same including:
way. Delays
Needless storage and transportation
Unnecessary work, duplication, and
added expense
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Breakdowns
Dr. Waleed M Kattan MD, MHA, PhD in communication 24
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Change Concepts
Eliminate Eliminate Waste - an activity or resource that does not add value
Improve Improve Work Flow
Optimize Optimize Inventory - is your work being held up because items are not properly organized or available.
Change Change the Work Environment (does the work culture enhance or impede change)
Manage Manage Time
Focus on Focus on Variation - what aspect of the system vary and make your outcomes unpredictable
Focus on Focus on Error Proofing (checklist)
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Diffusion of Innovations and Other

Change Theories
• Why do some new ideas in healthcare gain broad acceptance, whereas

other ideas that present an equally strong (or even stronger) case for
change never catch on?
• Science of innovation diffusion
1. How an innovation is perceived
2. The characteristics of the people who choose to adopt or not adopt
an innovation
3. The context in which the innovation is introduced and how the
change is communicated and led
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Diffusion of Innovations and

Other Change Theories
• Relative advantage – the degree to which the innovation is seen as better than
the convention it replaces
• Compatibility – the degree to which potential adopters perceive the innovation
as being consistent with their past experiences, values, and needs
• Complexity – the perception of the difficulty of the innovation’s application
• Trial-ability – whether or not the innovation can be used on a trial basis before
deciding to adopt it
• Observability – the ease with which a potential adopter can view others trying
the change first
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Diffusion of Innovations and

Other Change Theories
• Everett Rogers’s theory of innovation diffusion

• Natural diffusion
• Innovators
• Early adopters / opinion leaders
• Early majority
• Late majority
• Laggards
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The adoption of new behaviours however is frequently mixed, with groups of

people implemen ing he e beha io r and orking le a differen age
Categories Of People Change adoption curve
The Diffusion of
Innovation Theory Early
Adopters
13.5%
Early Late
Majority Majority
34% 34%
Innovators Laggards
2.5% 16%
Everret M. Rogers
High Speed of adoption Low
10
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The Diffusion of Innovation Theory

Everret M. Rogers
• Describe why and how individuals adopt innovations, ideas, and new
technologies over time
• DOI mostly used to facilitate the process of adopting a new program that
targets manipulating the attitude or behavior of a social system
• Diffusion is a process that occur through communicating innovation via
different channels over time
• For an individual to adopt innovation, he or she first needs to perceive
this innovation or technology as new and innovative
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Its not in organizational

strategy, structure, or
rules
The The main challenge in

changing people
Challenge behavior
At it's core, change

management is
about getting people to
change their behaviour.
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Pros
• Easy to understand
Cons
• Does not discuss ways
that leaders can deal
with people who are
resistant to changes
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Kotter’s Change Model
• American change and leadership guru John Kotter

• Only a 30% chance of organizational change success.
• Change is not always experienced as pleasant and it
often leads to resistance in organizations
• This is why organizations implement changes
unsuccessfully and fail to achieve the intended result.
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Creating a Culture of Safety

• Culture is largely a subjective experience with a lot of individual perspectives.
• Eight steps of change (Kotter’s model):
1. Sense of urgency
2. Guiding coalition
3. Create a strategic vision
4. Communicate this strategy widely
5. Empower broad-based action
6. Short-term wins
7. Consolidate gains
8. New status quo
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‫ﺗﺮﺳﻴﺦ ﺛﻘﺎﻓﺔ اﻟﺘﻐﻴﻴﺮ‬
‫ر ﺑﻂ اﻟﻨﺘﺎﺋﺞ اﻹﻳﺠﺎﺑﻴﺔ ﺑﺎﻟﺘﻐﻴﻴﺮ‬
‫ﺗﺤﻘﻴﻖ ﻣﻜﺎﺳﺐ ﺳﺮﻳﻌﺔ‬
‫اﻟﺘﻤﻜﻴﻦ‬
‫إ ﻳﺼﺎل اﻟﺮؤﻳﺔ‬
‫وﺿﻮح اﻟﺮؤ ﻳﺔ‬
‫ﺗﻜﻮﻳﻦ ﻓﺮﻳﻖ ﻗﻴﺎدي ﻗﻮي‬
‫اﻟﺤﺎﺟﺔ ﻟﻠﺘﻐﻴﻴﺮ‬
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Pros
• Employee resistant
• Effective
communication plan
Cons
• Top-down strategic
approach
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19
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• To change performance you must act on the system.

• To act on the system, you must change the way you manage.
• To change the way you manage, you must change the way you think.
Changing thinking and management behavior changes system performance.
Change management principles
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Change
Management
Organization People Process
Transformational Execution
Structure, Vision, Tech. Leadership (Communication,
Resources)
People Capability
(Engagement,
Culture, Resistance Empowerment, training, CQI
Modified by skills)
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Leading Change
• There is a critical need for clinicians to lead quality and patient
safety in healthcare organizations.
• Reducing variation
• Clinical practice guidelines
• Active implementation strategies
• Audit and feedback
• Reminders
• Academic detailing
• Opinion leaders
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Leading Change
Decision support / informatics Checklists Financial incentives
IT and EHRs
Computerized chronic disease registries
Evidence-based prompts
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1. Focus on high-impact interventions

2. Assess how you are performing now
3. For every hour spent discussing the
content of the initiative, spend four hours
planning its implementation
4. Determine who needs to change Keys to
5. Do a cost–benefit analysis Successful
6. Enlist multidisciplinary teams Implementation
7. Think big, but start small and Lessons
8. Once you have defined your goal, construct Learned
a timeline and publicize it
9. Communicate the change effectively
10. Back up talk with actions
11. Celebrate successful change
12. Create a culture of continual change within
your organization
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Testing Changes:
PDSA Cycle
All improvement will require
change, but not all change will
result in improvement.
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Week 2c
Improvement Models
Modified by Dr. Waleed M Kattan MD, MHA, PhD

Dr. Waleed M Kattan MD, MHA, PhD ©2020
©2020
• Analyzing performance of
various processes and
improving them repeatedly
to achieve quality objectives
Continuous • Some performance
Improvement problems can be
resolved quickly, but in
other situations an in-
depth evaluation may be
required.
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Identifying Quality Performance Improvement

Initiatives
• High-risk
• High-volume
• High-cost (Resource-intensive Process)
• Problem-prone Process
• Other Factors
• Related To International Patient Safety
• Relevant With Mission, Vision And Strategic Goals
• Covers One Or More Of Quality Dimensions
• Covers Structure, Process And Outcome
• Meeting Patient Or Staff Needs And Expectations
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Define the improvement

goal
Common Analyze current practices

Steps of
Performance
Improvement Design and implement
Models improvements
Measure success
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Quality Improvement
Models
1. PDCA/PDSA cycle
2. FOCUS PDCA model
3. Rapid Cycle Improvement (RCI)
4. Lean/Toyota Production System
5. Six Sigma
6. Lean 6 Sigma
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1. PDCA / PDSA
Act Plan
• Walter A. Shewhart Check Do
• W. Edwards Deming
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Walter Shewhart, who developed

the concepts and techniques of
statistical process control, was
one of the first quality experts to
discuss a systematic model for
continuous improvement.
Deming modified Shewhart’s
original model and renamed it
the Plan-Do-Study-Act (PDSA)
cycle. PDSA is the most widely
recognized improvement process
today
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Shewhart Cycle
Do
Study/
Plan
Check
Act
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2- FOCUS PDCA Model - 1990s
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3. Rapid Cycle
Improvement
(RCI)
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• Problem
• Appointment issues / problems (too long >4 weeks)
• Team: (Leader / members)

• Admin (appointments dept.)
• 2 Doctors
• Reception
• IT
• Nurses
• Clarify the process Modified by

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4- Lean/Toyota Production System
• Lean: Eliminate inefficiencies adversely affecting performance.
• Lean’s project goal is to minimize waste.
• Lean manufacturing or Toyota Production System (TPS) is a performance

improvement approach focuses on the removal of waste (muda) and improving flow.
• The Japanese term for waste, a concept taken from Lean manufacturing (Muda is
anything that doesn’t add value for the customer)
• also called Lean manufacturing or Lean thinking
• A Lean process includes only value-added steps and therefore produces little waste.
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Lean
“a focused, short-term project aimed at improving a particular

process”
(McLaughlin and Olson 2012)
• Steps similar to the PDCA cycle
• Often completed in an accelerated fashion
• Three core concepts: standard work, user friendliness, and

unobstructed throughput
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Types of • Movement • Inventories
Waste • Waiting • Transportation
(Muda) • Overprocessing • Design
• Defects • Overproduction
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Lean Improvement
Techniques
• 5S methodology
• Kanban
• Mistake-proofing
• Value stream map
• Visual control
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• Six Sigma is a systematic, data-driven

improvement approach aimed at near-
elimination of defects from every product,
process, and transaction.
• Works on reducing process variation for the

5- Six purpose of eliminating defects
Sigma • Six Sigma originated in the manufacturing

sector at Motorola and was refined by General
Electric
• The popularity of Six Sigma is growing in many

industries, including healthcare.
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• The aim of Six Sigma is to reduce

variation in key business processes.
• The goal of a Six Sigma project is to

create processes that operate within
Six Sigma quality, meaning the defect
rate is less than 3.4 per million
opportunities.
• This rate translates into a process that

is 99.9997% defect-free.
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• Six Sigma: Reduce performance variability

• Goal:
• Create processes that operate
within Six Sigma quality.
• The higher the sigma level, the lower
the defect rate.
• 1 sigma = 32% defect rate
• 2 sigma = 5% defect rate
• 6 sigma = 99.999% defect rate
(near perfect)
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• Although Six Sigma projects can

include a variety of structured steps,
they most commonly follow the five
steps of DMAIC (pronounced dee-
MAY-ick) methodology
• Define the problem.
• Measure key aspects of the
process.
• Analyze the data.
• Improve the system.
• Control and sustain the
improvement.
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Six Sigma
Project
Steps
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• A process improvement model

that combines the techniques of
Lean and 6 Sigma
6- Lean 6 • Results are usually better
Sigma • Lean à improve efficiency by

standardizing work, reduce
inventory, eliminate waste
• 6 Sigma à DMAIC reduces

process variation
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Improvement
Models:
Lean Six Sigma
Lean Six Sigma: Eliminate waste and
reduce process variation
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Six Sigma and Lean Comparison
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13
creating steps in the best possible sequence in order to deliver services or products just
as the customer needs them and in just the manner the customer requested. One of
the most commonly used tools is called Value Stream Mapping whereby the process is
depicted in a physical graph in order to identify wasted effort or steps that do not add 10/3/20
value for the customer.
The three QI methods discussed are summarized and compared in Table 1-12.
Commonly Used Quality Improvement Strategies

Most published literature suggests the use of multipronged approaches for successful QI
as opposed to single interventions. Descriptions of commonly used QI strategies follow.
Academic Detailing
Academic detailing, also called educational outreach, employs trained providers (e.g., pharma-
cists, physicians) to conduct face-to-face visits to encourage adoption of a desired
TABLE 1-12 Comparison of Improvement Methodologies

PDSA Six Sigma Lean
Process Steps Plan; Do; Study; Design; Measure; Analyze; Eliminate non-value–laden
Act. Improve; Control. steps; eliminate defects;
reduce cycle time.
Improvement Rapid cycles of Elimination of defects; cus- Enhanced efficiency;
Focus improvement tomer-centric. elimination of non-value
toward identifying activities, variance reduc-
optimal process tion and reduced cycle time.
improvement. Product “flows” when the
customer wants and needs it.
Ideal Use A target project A targeted project is Process efficiency is the
is chosen for chosen for improvement focus.
improvement; time and resources are available. Process can be clearly
and resources are The project consists of an defined and is laden with
limited. activity that is repeated non-value activities.
with high frequency.
Supports– Environment for Statistical process control Value stream mapping, value
Tools testing, proto- charts, analytical tools, Six analysis, Kaizen events.
for success typing, and Sigma experts (i.e., black
piloting of ideas. belts, green belts).
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Six Sigma vs. Lean Characteristics
Six Sigma Lean

• Remove variation from • Remove waste, rework,
processes inventory
• Design more capable • Improve flow, velocity

processes
• Immediate results
• Research projects (1-2 weeks)
(3-4 months)
• Focus on system
• Focus on parts
•High Complexity • Low Complexity

•Unknown Root Cause • Known Solutions
•Good Data Available
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Six Sigma
• DMAIC
Six Sigma • Design for Six Sigma
vs. Lean • Design of Experiments
Tools & Lean

Approaches • Value Stream Mapping
• Kaizen Events
• 5S
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Summary
MOST OF THE WASTE AND CYCLE LEAN AND SIX SIGMA ARE AN INTEGRATED APPROACH TO LEAN
TIME OPPORTUNITIES STILL REMAIN COMPLEMENTARY AND SIX SIGMA CAN IDENTIFY AND
EXPLOIT OPPORTUNITIES
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Performance
Improvement Models
• Organizations don’t choose

one approach to the
exclusion of the others.
• The approach most likely to

achieve improvement
goals for a particular
project is used.
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Continuous
Measurement
How are we
doing?
Improvement
• Various improvement
Yes
models are used to
Assessment improve healthcare
Are we meeting
expectations?
quality.
• The different models
No
share a common thread
Improvement
of analysis,
How can we improve implementation, and
performance?
review.
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Week3a
Fostering a Culture of Collaboration and
Teamwork
Modified by
©2020
• A group of people working together to

implement an improvement or solve a
problem
• The team consists of:
• Team sponsor
Improvement • Team leader
Project Team • Team members
• Facilitator
• Recorder
• Timekeeper
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Team Members
• Five to ten people with personal and detailed
knowledge of some part of the performance
problem
• Share responsibility in achieving improvement
goals
• Participate in discussions, decision making,
and other team tasks
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Team Meetings
• First meeting
• Review goals and project charter
• Establish ground rules
• Define time schedule for project
completion
• Subsequent meetings
• Advance through the improvement
model to achieve project goals
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Improvement Team Ground

Rules
• Participate by sharing your own opinions and experiences.
• Contribute but do not dominate.
• Actively listen and consider the opinions of others.
• Stay focused on the improvement goal.
• Avoid side conversations.
• Respect other people’s time (e.g., arrive on time, don’t leave early, return from
breaks promptly).
• Complete assignments to which you have committed.
• Speak one at a time.
• Leave rank at the door; all team members are equal.
• Address conflict by dealing with the issue, not the person.
• Turn off cell phones and pagers.
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• Be a participant, not a lurker.

• Have fun, but not at the expense of someone else’s feelings.
• Be physically and mentally present during meetings.
• Listen, listen, listen, and respond.
• Allow for some mistakes; acknowledge them, let go, and move on.
• Accept conflict and its resolution as necessary catalysts for
learning.
• Be open-minded to new thoughts and different behaviors.
• Honor confidentiality.
• Accept diversity as a gift.
• Begin and end all meetings on time.
• Share in the responsibilities of the recorder.
• Criticize ideas, not individuals.
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Stages of Team Development

Stage 1: Forming
Characteristics of forming: Role of team leader:
• Interactions are polite and • Introduce members to project
superficial; open conflict is goals and the timeline for
rare. completion.
• Group thinking (conformity of • Help members become
opinion) tends to dominate. acquainted.
• Members rely on the leader • Allow time for members to get
for direction. comfortable with one another
• Project goals are not clear. while still moving the project
along.
• Establish ground rules.
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Stage 2: Storming
Characteristics of storming: Role of team leader:
• Participation increases; members • Clarify team’s role in achieving
want some influence on the project goals.
project.
• Address conflicts as they
• Group thinking decreases; open
conflict increases. surface; review and enforce
ground rules.
• Members are more critical and
question how and why decisions • Revisit purpose of the
are made. improvement project.
• Members may challenge the team • If necessary, engage project
leader directly or indirectly. sponsor in resolving conflicts.
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Stage 3: Characteristics of
norming:
Role of team leader:
• Encourage
Norming • Members are more
friendly, more
members to
spend less time
supportive of one generating
another. ideas and more
• Ground rules that time making
may have been decisions.
overlooked in the • Keep the team
beginning are now on track toward
taken more seriously. the
• Subgroups may be improvement
formed to move the goals.
project along faster. • Provide time
• Conflict is handled for discussion
openly and and feedback.
constructively.
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Stage 4: Characteristics of
performing:
Role of team leader:
• Take a less directive
Performing • All contributions are
recognized and
and more supportive
role.
appreciated.
• Members develop a
sense of cohesiveness
and team identity.
• Project goals are
achieved; the team may
look for additional
improvement
opportunities.
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Improvement Teams
Teams of people are personally involved in improving performance.
The team environment must foster Such an environment promotes

interaction and open generation of new ideas and
communication. continuous improvement.
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FIGURE 7.1.
Charter for
Problem Statement
Improvement
Project
Goal
Project Scope
Out-of-Project Scope
Measures
Deliverables
Sponsor
Team Leader
Team Members
Team Facilitator
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When expectations are unclear or©2020
too broad, an improvement project can flounder.
At one hospital, for example, staff members voiced concerns about the safety of the process
13 of ordering, dispensing, and administering chemotherapy medications. An interdisciplin-

ary team was chartered, which included representatives from the hospital’s inpatient, out-
• The problem statement influences many aspects of the

project, including the makeup of the team and improvement
expectations.
• The project goal should include measurable performance
expectations. The project sponsor sets these expectations and
defines the time frame for achieving them. The sponsor
identifies people who need to be included in the project. The
following questions can guide their selection:
ØWhere is the problem occurring?
ØWhat tasks are involved?
ØWho carries out these tasks?
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CBAHI committees
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Chapter 9
Measuring
Process and
System
Performance
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QM Activities
Measurement Assessment Improvement

Collection of information Use of performance Planning and making
for the purpose of information to determine changes to current
understanding current whether an acceptable practices to achieve better
performance and seeing level of quality has been performance.
how performance changes achieved.
or improves over time.
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Measurement: The Starting Point

Measurement
How are we
doing? Measurement is a tool used to
monitor the quality of some aspect
Yes
of healthcare services.
Assessment
Are we meeting
• Absolute number
expectations?
• Percentage
No • Average
Improvement • Ratio
How can we improve
performance?
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Accurate Useful
Effective
Measurement
Easy to interpret Consistently

reported
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Measurement Characteristics
• Measurement is a tool – usually in the form of a number or

statistics – used to monitor the quality of some aspect of
healthcare services.
• These numbers are called performance measures or quality
indicators.
• A measure expressed as a percentage is generally more useful
than a measure expressed as an absolute number.
• For example, the percentage of nursing home residents who
develop an infection is more meaningful than the number of
nursing home residents who develop an infection.
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Measurement Categories
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Structure
• A good example of Structure measures are the static characteristics
of the individuals who provide care and the settings in which the
care is delivered.
• E.g., education, training, certification
• Structure-focused assessments are most revealing when
deficiencies are found.
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Process
• Process measures focus on what takes place during the delivery of care.
• Two aspects:
• Appropriateness: whether the right actions were taken
• E.g., whether the correct test was ordered
• Skill: how well the actions were carried out
• E.g., how well a surgeon completed a procedure
• The use of process measures to assess quality assumes that if the right
things are done and are done right, good outcomes of care for the
patient will result.
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Outcome
• Outcome measures focus on whether the goals of care
were achieved.
• E.g., whether a patient’s pain subsided, the condition cleared up,
or the patient regained full function
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TABLE 3.3.
Measurement Performance Measures Performance Measures Structure, Process,
Category for an Emergency Department (ED) for a Fast-Food Restaurant
and Outcome
Structure Number of hours per day that a person Percentage of time food storage
skilled in reading head CT scans is available equipment maintains proper temperature
Performance
Process Percentage of ED patients ≤13 years old Percentage of hamburger patties cooked Measures
with a current weight in kilograms to an internal temperature of 160°F
documented in the ED record
Outcome Median time from ED arrival to ED Median time between food order and
departure for patients admitted to delivery to the customer
the hospital
24 hours per day to interpret special tests, but that person could misread the results. To
ensure quality, measures of process and outcome also must be taken.
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PROCESS MEASUREMENT Dr. Waleed M Kattan MD, MHA, PhD
Measures of process evaluate whether activities©2020
performed during the delivery of healthcare
services are delivered satisfactorily. For instance, if an emergency department has a policy
26
that all patients with confirmed pneumonia receive an antibiotic within two hours of ar-
rival, we would measure caregiver compliance with the policy to determine whether their
performance is acceptable.
In healthcare quality management, process measures are most commonly used.
Process measures provide important information about performance at all levels in the
organization. However, good performance does not automatically translate to good results. 13
In the previous example, even if all patients with pneumonia receive antibiotics within
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Example: Childhood Immunizations
• Number/location of • “What is done to a • “What happens to • Overall mother’s

pediatric clinics patient” a patient” impression
• Available vaccines • Immunization rates • Measles rates
(i.e., inventory) (e.g., MMR vaccine)
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Measurement Levels
System level and activity level
Organization-Wide System-Level Activity-Level
Setting
Performance Goal Measure Measures
Hospital Reduce incidence of Percentage of • Rate of staff compliance
hospital-acquired patients who develop with hand hygiene
infections an infection while in procedures
the hospital • Percentage of central vein
line catheter insertions
done according to protocol
• Percentage of staff
immunized for influenza
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Quality Measures
and Their Uses
• Quality measure (or metric):
“any type of measurement
used to gauge a quantifiable
component of performance”
(Spath 2013)
• Indicators: statistical measures

that give an indication of
process or output quality
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Key Performance Indicators (KPI) A set of quantifiable measures that the organization
uses to measure the organization’s performance
over time. It is also called Performance Measures.
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Quality Measures and Their Uses

Performance management measures are used to better understand the system’s behavior.
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Selecting Performance Measures

• Select performance indicators that are
• linked to and aligned with the organizations’ goals,
• business strategy,
• and customer and stakeholder requirements.
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Selecting Performance Measures
• Critical performance measure characteristics:

• Relevant
• Reliable
• Valid
• Cost-effective
• Under the provider’s control
• Precisely defined and specified
• Interpretable
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Benefits of Performance
Measurement
• Provides factual evidence of performance
• Promotes ongoing organizational self-evaluation and
improvement
• Demonstrates improvement
• Facilitates cost–benefit analysis
• Helps meet external requirements or demands for
performance evaluation
• May facilitate the establishment of long-term
relationships with various external stakeholders
• May differentiate the organization from competitors
• May contribute to the awarding of business contracts
• Fosters organizational survival
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Compare Results with

Expectations
• Performance measures should be tied to a pre-defined

goal or expectation.
• Interpretation of measurement results is meaningful
only when they are associated with goals.
• Measurement without defined performance
expectations does not contribute to quality
improvement.
• Well-defined targets have the following
characteristics, known as SMART: Specific,
Measurable, Achievable, Realistic, Time-bound.
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Internal
and
External
Measures
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Choosing a Comprehensive Set of Measures
Balanced score card: an organization-defined set of

measures that provides leaders with a concise but
comprehensive view of business performance
Kaplan and Norton (2005)
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Clinical
Value
Compass
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Pillars of Excellence
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Chapter 10
Using Data
Analytics
Techniques
to Evaluate
Performance
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What Is Data Analytics?
“the extensive use of data, statistical and quantitative analysis,

explanatory and predictive models, and fact-based
management to drive decisions and actions”
(Davenport and Harris, 2007)
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Descriptive Analytics
Helps to answer questions such as:

• What is happening?
• How often and where is it happening?
• What may be causing the results?
• When should actions be taken?
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Time Series Plot (Run

Chart) (Line graph)
• Graphically shows trends and changes in the data

over time
• Time recorded on the horizontal axis
• Measurements recorded on the vertical axis
• Points connected by straight lines
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Time
Series Plot
(Run
Chart)
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Oscillating Sequence
Center
line
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Patterns of Process Variation
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Stability
A process whose output distribution
does not change over time is said to
be in a state of statistical control, or
simply in control. If it does change, it
is said to be out of statistical control,
or simply out of control. The figure on
the next slide illustrates a sequence of
output distributions for both an in-
control and an out-of-control process.
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Stability
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Statistical
Process
Control
The process of monitoring
and eliminating variation in
order to keep a process in
a state of statistical control
or to bring a process into
statistical control is called
statistical process control
(SPC).
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• Benefits of SPC in healthcare:

• Increased quality awareness on the part of healthcare
organizations and practitioners
• Increased focus on patients
• Ability to base decisions on data
• Implementation of predictable healthcare processes
• Cost reduction
• Fewer errors and increased patient safety
• Improved processes that result in improved healthcare
outcomes and better quality care
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Control Chart
• A control chart is a graphical devices used for
monitoring process variation, identifying when to
take action to improve the process, and assisting in
diagnosing the causes of process variation.
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• Pioneered by Walter Shewhart

who worked at Bell Labs in the
1920’s
• Helped to improve the
reliability of the telephone
transmission system at
Bell
• A structured, prepared form for
collecting and analyzing data
• A generic tool that can be
adapted for a wide variety of
purposes.
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• Upper and lower reference thresholds called control limits (3 Std.

Deviations from Mean) are plotted: define natural range of
variation within which plotted points should fall
• Any points falling outside of control limits may indicate that all
data were not produced by the same process, either because of
lack of standardization or a change in the process may have
occurred
• Such changes could represent either quality improvement or
quality deterioration, depending on which control limit is crossed
• Useful both for monitoring if processes get worse and for testing
and verifying improvement ideas
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• Common cause variation versus special cause

Control Chart variation
Analysis • A control chart can tell us whether observed
variation results from common or special causes.
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• Using three-sigma control limits offers the best

balance between making either the first or second
mistake.
• A trend is six consecutive data points incrementally
increasing or decreasing.
• 20 to 25 data points are recommended to evaluate
the stability of a given process.
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Control Chart Uses

• Monitor process variation
• Differentiate between variation due to common causes v.
special causes
• Evaluate past performance
• Monitor current performance
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Specification Limits
• Specification limits are boundary points that define the

acceptable values for an output variable (i.e., for a quality
characteristic) of a particular product or service.
• They are determined by customers, management, and
product designers.
• Specification limits may be two sided, with upper and lower
limits, or one sided, with either an upper or a lower limit.
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Specification
Limits
© 2011 Pearson Education, Inc

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---------Understanding Variation
• What is the variation in results trying to tell you about the system?
• The goal of quality or continuous improvement is to reduce the
range of variation over time, in addition to adjusting the process
level to the desired level.
• The control chart is a tool to determine if the system is in control
(the system gives predictable results) and what those predictable
results are
• Common cause variations are the natural result of the system. In a
stable system, common cause variation will be predictable within
certain limits.
• Special cause variations represent a unique event that is outside
the system.
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Stable Processes
• A process with only common causes affecting the
outcome is stable, or in a state of statistical control.
Stable means only that the variation is predictable
within statistically established limits, not that there
is no variation.
• An unstable process is one where the variations can
be attributed to both common and special causes.
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Deming describes the benefits of a stable process as:

• A process has an identity and its performance is
predictable; therefore there is a rational basis for
planning.
• Costs and quality are predictable.
• Productivity is at a maximum and costs are at a
minimum for the process.
• The effect of changes in the process can be measured
faster and more reliably.
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Converting the Frequency Distribution to a Control Chart
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Interpreting Control Charts
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Common causes of
variation are the methods,
materials, machines,
personnel, and environment
that make up a process and
Common the inputs required by the
Causes of process. Common causes
are thus attributable to the
Variation design of the process.
Common causes affect all
output of the process and
may affect everyone who
participates in the process.
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Special Causes of
Variation
Special causes of variation
(sometimes called assignable
causes) are events or actions that
are not part of the process design.
Typically, they are transient, fleeting
events that affect only local areas or
operations within the process (e.g., a
single worker, machine, or batch of
materials) for a brief period of time.
Occasionally, however, such events
may have a persistent or recurrent
effect on the process.
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Week3b
QI tools
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KFSHRC
• https://www.kfshrc.edu.sa/en/home/about/qualitypatien
tsafety/performanceimprovement/pisecond
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Improvement Tools
• Diagrams, charts, techniques, and methods used during an

improvement project (also called analytic tools)
• Quantitative: Used to measure performance, collect and
display data, and monitor performance
• Qualitative: Used to generate ideas, set priorities,
maintain direction, determine causes of problems, and
clarify processes
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Quantitative Tools
Used in performance assessment and performance
improvement
• Bar graph Type of
Complaint
Product Defect
Tally Total
14
• Check sheet Service
Billing Error
Shipping Error
6
2
8
• Control chart Totals 30
Effect
• Histogram
30 30
20 20
• Line graph 10
0 A B C DE F GH
10
0
Suspected Cause
5 10 15 20 25 30
• Pareto chart 40
• Scatter diagram 30
20
10
0 B G A DHC E F
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Used
for
creativ
e
explor
ation
Brainstorming of
option
s in an
enviro
nment
free of
criticis
m
Used
to pare
Qualitative
down
a
broad
Multi-voting list of
Tools
ideas
and
establi
sh
prioriti
es
Nominal A
structu
red
group form
of
technique multi-
voting
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Tools for Identifying, Collecting and

Displaying Data
• Surveys
• Brainstorming
• Bain writing
• Focus group
• Logs
• Check Sheets
• Task list
• Affinity diagrams
• Pie Charts
• Scatter Diagram
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• Histograms Dr. Waleed M Kattan MD, MHA, PhD
©2020
Tools for Quality Improvement and

Monitoring
Nominal Group Multi-Voting Weighted Voting Rank Ordering

Technique Technique Technique Technique
Trend and Run

Charts
Balance Sheets Flowcharts Pareto Diagram
• Control Charts
Cause and Effect

Diagram / Fishbone Decision-making
Diagrams/ Ishikawa Matrices
Diagrams
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Improvement Tools
Measurement
How are we
Help to answer these questions:
doing?
• How does the process work
Yes
now?
Assessment
• What can we improve?
Are we meeting
expectations? • How do we improve it?
• How should we measure and
track performance?
No
Improvement
How can we improve
performance?
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7 Common Tools of
Quality Improvement
• A fixed set of graphical
techniques identified as
being most helpful in
troubleshooting issues
related to quality
• Suitable for
troubleshooting most
quality-related problems,
and require little formal
training in statistics
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What Are These Tools?

1. Ishikawa (fishbone) diagram
2. Check sheet
3. Control chart
4. Histogram
5. Pareto chart
6. Scatter diagram
7. Flowchart/Flowmap
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1- Fishbone Diagrams
Ishikawa Diagrams
Cause and Effect Diagrams
• Identifies many possible causes for an effect or problem and

sorts ideas into useful categories.
• No statistics involved
• Maps out a process/problem
• Makes improvement easier
• Looks like a “Fish Skeleton”
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Benefits of Using a Cause-and-Effect Diagram:

• Helps determine root causes
• Encourages group participation
• Uses an orderly, easy-to-read format
• Indicates possible causes of variation
• Increases process knowledge
• Identifies areas for collecting data
The major categories typically utilized are:

The 6 M’s:
Methods, Machines, Materials, Manpower, Measurement, Mother Earth
(environment)
The 8 P’s:
Place, Procedure, People, Policies , price, promotion,
process, plant
The 4 S’s:
Surroundings, Suppliers, Systems, Skills
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Fishbone Diagram
Cause 1 Cause 2
Problem
Cause 3 Cause 4
Cause Cause
3.1 3.2
Modified by
Copyright 2017M
Dr. Waleed Foundation of MHA,
Kattan MD, the American
PhD
College of Healthcare Executives. Not for sale.
©2020
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Cause and Effect “Skeleton”
Materials Procedures
Quality
Problem
People Equipment
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15
Qualitative Tools
Cause-and-effect diagram
• Used to identify all possible causes of an effect (a problem
or an objective)
Environment Procedures
Effect
Equipment People
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Fishbone Diagram: Example

Policies Plant/Equipment
Not enough hand sanitizer
Policy is outdated dispensers in patient care areas
Sinks not conveniently located
Statement of
Problem:
Staff perceive they
Inadequate resources to monitor are doing a good job already
Low hand hygiene
hand washing technique compliance
Lack of Not a manage-
Too busy feedback ment priority
Lack of knowledge
Poor attendance at
training sessions
Procedures People
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Copyright 2017M
Dr. Waleed Foundation of MHA,
Kattan MD, the American
PhD
College of Healthcare Executives. Not for sale.
©2020
17
IHI.OR
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G
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2- CHECK SHEET
• A structured, prepared form for collecting and analyzing data;

a generic tool that can be adapted for a wide variety of
purposes.
• Used when data can be observed and collected repeatedly by
either the same person or the same location
• Effective tool when collecting data on frequency and
identifying patterns of events, problems, defects, and defect
location, and for identifying defect causes.
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19
Number of people in wait line at

Registration Desk
This helps
to
determine
staffing
needs and
size of
waiting
room
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Check Sheet
Shifts
ÖÖÖ ÖÖÖÖ Ö ÖÖÖ
ÖÖ ÖÖÖ
Defect Type
ÖÖÖÖ ÖÖÖ
ÖÖ Ö
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4- HISTOGRAM
The most commonly used graph for showing frequency

distributions, or how often each different value in a set of data
occurs.
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HISTOGRAM
Continuous data, so there

are no spaces in between
the bars
Data collected into

categories of width 30
LB
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5- PARETO CHART
• Vilfredo Pareto (1848-1923) Italian economist
• 20% of the population has 80% of the wealth
• 80% of the land in Italy was owned by 20% of the population
• Juran used the term “vital few, trivial many”. He noted
that 20% of the quality problems caused 80% of the
dollar loss.
• Built on observations of his such as that
• The purpose is to highlight the most important among
a (typically large) set of factors causing defects/delays
• Shows on a bar graph which factors are more
significant.
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Lt. vertical axis:

Frequency of
occurrence Rt. vertical axis:
cumulative
percentage of
total number of
occurrences,
GO AFTER THE 2 OR
3 MOST IMPORTANT
FACTORS TO GET
THE DESIRED
RESULTS
CRITICAL FEW TRIVIAL MANY

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6- SCATTER DIAGRAM
• When trying to identify potential root causes of problems.

• After brainstorming causes and effects using a fishbone
diagram, to determine objectively whether a particular
cause and effect are related
• Pairs of data where a relationship is suspected are plotted
on the X axis(independent variable) and Y axis(dependent
variable)
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TYPES OF
RELATIONSHIPS
BETWEEN THE
VARIABLES
• Pairs of data where a

relationship is suspected
are plotted on the X
axis(independent variable)
and Y axis(dependent
variable)
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7- FLOW CHART/WORKFLOW DIAGRAM

• Diagram that represents a process, showing steps
as boxes of various kinds, and their order by
connecting them with arrows
• Used in analyzing, designing, documenting or
managing a process
• A technique that separates data gathered from a
variety of sources so that patterns can be seen
(some lists replace “stratification” with “flowchart”
or “run chart”).
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Qualitative Tools
Flowcharts are used to
• identify and document the flow or sequence of events
in a process, and
• develop an optimal new process during the solution
stage.
Most Common Symbols Used in Flowcharts
Start/End
No
Decision
Process Step
Yes
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• Flowcharts are used to document the flow

or sequence of events in a process or to
develop an optimal new process during the
solution stage of improvement.
• They can be used to detect unexpected
complexity, problem areas, redundancies,
unnecessary steps, and opportunities for
simplification.
Cont. • They also help teams agree on process
steps and examine activities that most
influence performance.
• When the team is satisfied that the chart
represents the process accurately, it asks
questions to locate improvement
opportunities:
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1. Can any steps be eliminated?

2. Can any steps be combined with others?
3. Can any steps be simplified?
4. Can delays in the process be eliminated?
5. Can rework loops be eliminated?
6. Can buildup of paperwork be minimized?
7. Can handoffs between people or departments be
streamlined?
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Cont.
• A detailed flowchart maps all the steps and activities that

occur in the process and includes decision points, waiting
periods, tasks frequently redone, and feedback loops.
• High-Level Flowchart of Retail Pharmacy Medication Dispensing Process
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Detailed
flowchart
of the
Process of
Taking
patient X-
rays
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START/STOP
BOX
DECISION
DIAMOND
PROCESS
BOX
CONNECTIN
G ARROWS
DETERMINE
ORDER OF
PROCESS
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Other tools
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1. Brainstorming
It is a technique that maximizes Brainstorming is where a group

the ability to generate new of people generating new ideas
ideas. and solutions
Brainstorming is a part of
problem solving which involves It stimulates creativity and
provides many perspectives.
the creation of new ideas by
suspending judgment.
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2. Multi-voting
• To narrow a broad list of ideas to those

that more important.
• Helps in choosing the best idea to pursue
• Voting is a useful tool to follow up a group
cause-effect analysis or brainstorming
session, as after you have identified a list of
possible problem causes or actions, the
problem now is to select the most likely
candidates upon which to act.
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3. Selection Grid (prioritization Matrix)
• Can help the team choose on option out

of many possibilities
• It reassures the team members about the
validity of their group in DECISION-
MAKING process.
• Brainstorm - Conduct a brainstorming
session on the problems users or team Problem Frequency Im portance Feasibility Total
members have with your program or Points
service. You may visit the brainstorming Problem 1
tool to learn how to conduct a group
Problem 2
brainstorming session.
Problem 3
• Fill out the prioritization matrix chart with
the group
• Sum up all the votes.
• The totals help you see clearly how to
prioritize the problems
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Decision Matrix
• Improvement teams can use a decision matrix to

systematically identify, analyze, and rate the strength of
relationships between sets of information.
• This type of matrix is especially useful when considering a
large number of decision factors and assessing each factor's
relative importance.
• Teams frequently use this tool to select improvement
priorities and evaluate alternative solutions.
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“5 WHYS”
• Before developing solutions, teams need to
confirm they have found the underlying causes of a
performance problem.
• The Five Whys tool helps an improvement team dig
deeper into the causes of problems by successively
asking what and why until all aspects of the
situation are reviewed and the underlying
contributing factors are considered.
• Usually by the time the team has asked and
answered five why questions, it will have reached
the core problem.
• Teams often uncover multiple, underlying root
causes during this exercise.
• The root cause is eventually discovered by asking
why repeatedly.
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Qualitative Five Whys

• Used to find the underlying causes of
Tools performance problems
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FIGURE 6.4.
The Five Whys
Process Water in sink Problem
drains too slowly
Pipe keeps
clogging
Why?
Food stuck
in drain
Why?
Garbage disposal
broken
Why?
Spoon jammed Root Cause

in disposal
Why?
solution stage. They can be used to detect unexpected complexity, problem areas, redun-
dancies, unnecessary steps, and opportunities for simplification. They also help teams agree
on process steps and examine activities that most influence performance.
Standard flowchart symbols are shown in Table 6.3. When developing a flowchart,
especially in a group environment, the goal is to illustrate the process. Don’t waste time
debating the best shapes to use. A flowchartModified
that doesn’t
byuse these symbols can be just as
useful as a chart that does. When designingMa Kattan
Dr. Waleed flowchart,
MD,write the process
MHA, PhD steps on index
cards or sticky notes. The team can then rearrange the diagram without erasing and re-
©2020
drawing the chart.
After identifying the process adversely affecting performance, the improvement
44 team defines the beginning and end of the process and the steps between these two points.
It then sequences the steps in the order they are executed. The flowchart should illus-
trate the process in its current state—the way it is operating at that moment. To test for
completeness, the team may validate the flowchart with people outside the team or those
who execute the process. When the team is satisfied that the chart represents the process
accurately, it asks questions to locate improvement opportunities:
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Workflow Diagram
• A visual illustration of the movement of employees
or information during a process
• also illustrate general relationships or patterns of
activity among interrelated processes (such as all
processes occurring in the radiology department).
• Workflow diagrams are used to document how work
is executed and to identify opportunities for
improvement.
• A common type of workflow diagram is a floor plan
of the work site. Lines are drawn on the floor plan
to trace the movement of people, paper, data, etc.,
to identify redundant
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FIGURE 6.9.
Workflow
Diagram Showing
Movement
of Pharmacy
Technician During
Peak Hours
The technician’s movements are chaotic because of the layout of the department.
The central medication supply is located in the middle of the pharmacy, and medications
that are infrequently prescribed line the back wall of the department. The narrow walkway
between the two sections causes delay and congestion because it comfortably accommodates
only one person at a time. The resources needed to fill prescriptions are not easily acces-
sible. Two printers in the lower left corner of the department, approximately 26 feet from
the medication area, print prescription enclosures. The technicians must travel to this area
through a narrow doorway. After studying the workflow in the pharmacy department, sev-
eral changes were made to the department layout and the prescription receiving process.
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SURVEYS
Surveys are instruments used to gather data or information.
©2020 The case study at the begin-
ning of Chapter 3 described a survey used at Redwood Health Center to gather satisfac-
46 tion information from patients. This survey gathered quantitative (numeric rankings) and
qualitative (comments) information. There is some debate among researchers as to whether
surveys are a quantitative tool, a qualitative tool, or a combination of both. For this reason,
surveys are listed as both in Table 6.1.
There are two types of survey: questionnaires and interviews. Questionnaires are
usually paper or electronic instruments that the respondent completes independently. In-
terviews are conducted with the respondent face to face or over the phone. The interviewer
is responsible for documenting the respondent’s comments.
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Workflow
diagram
• Used to show the

movement of people,
materials, paperwork,
or information
during a process
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• A workflow diagram is a visual representation of the

movement of people, materials, paperwork, or
information during a process.
• The diagram can also illustrate general relationships or
patterns of activity among interrelated processes (e.g.,
all processes occurring in the radiology department).
• Workflow diagrams are used to document how work is
executed and to identify opportunities for improvement.
• Surveys are instruments to gather data or information.
This survey gathered quantitative (numeric rankings)
and qualitative (comments) information.
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24
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Surveys
• Instruments used to obtain information from a
group of individuals about a process, product, or
service
• There are two types of survey
1. Questionnaires: Forms (paper or electronic)
containing questions to which subjects
respond
2. Interviews: Formal discussions between two
parties (face to face or over the phone) in
which information is exchanged
• Improvement teams typically use questionnaires to
gather people’s perceptions of a service or process.
• These perceptions are not necessarily factual.
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• Sort. Separate the necessary from the unnecessary

by removing superfluous tools, equipment, and
procedures from the workplace.
• Simplify. Put everything in its place and organize
material according to how frequently it is used,
preferably with the help of visual aids.
• Sweep. Visually identify potential problems and
5S deal with unsafe conditions or damaged
Methodology equipment early in the process.
• Standardize. Define how a task should best be
done and effectively communicate this to everyone
involved. Document process changes as they occur.
• Self-discipline. Ensure that all housekeeping
policies are adhered to by everyone. (This usually
paves the way for success in other quality-
improvement efforts.)
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Planning matrix Gantt Chart:

Shows the tasks needed to complete an Graphic representation of a planning
improvement activity, the people or matrix
groups responsible for completing the
tasks, and the deadlines for completion
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Recap: Two Types of Tools
Quantitative tools Qualitative tools

Used for measuring performance, collecting Used for generating ideas, setting priorities,
and displaying data, and monitoring maintaining direction, determining causes of
performance problems, and clarifying processes
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26

Quality Management in Healthcare Services: Dr. Waleed M Kattan

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Quality Management in Healthcare Services: Dr. Waleed M Kattan

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2/4/20

Dr. Waleed M Kattan

Department of Health Services and Hospitals Administration

Course Learning Objectives

• Summarize the application of quality, safety and performance

• Evaluate delivery, deployment and sustainability in healthcare

• Applying Quality Management in Healthcare: A Systems Approach – 4th edition- 2017, by

• The Current State of Healthcare: Five

The Current State Five Important

1. “The Urgent Need to Improve Healthcare Quality”

4. National Healthcare Quality Report

The Current State of Healthcare: Five Important Reports

• Quality in the healthcare system is not what it should be.

• Five major reports identify gaps and call for action:

1- “The Urgent Need to Improve Health Care Quality” (1998)

• “Serious and widespread quality problems exist throughout

• Establishes the classification scheme of “overuse, underuse, and

• Quality of care is the problem

• Current efforts to improve will not succeed unless we undertake a

2- To Err Is Human (2000)

The National Academy of Medicine, formerly called the Institute of

IOM report: Crossing the Q. Chasm (2011)

TABLE 1-3 Clinical Quality Problems in Health Services Provision

Crossing the Quality Chasm

The Four Levels of the Healthcare System

*will be discussed in detail later in course

4- AHRQ’s National Healthcare Quality Report (2003-2011)

• Aims to answer three questions:

5- National Priorities and Goals (2008)

• Focuses on national performance improvement efforts

Conclusion: Need for Healthcare Improvement

• Health outcomes, quality, and cost-effectiveness of healthcare processes have

• A big part of this expense is purely waste—waste in terms of duplication of

• The Quality Foundation

The Quality Foundation: Influential Leaders

• Walter A. Shewhart – common cause, special cause variation, statistical

• W. Edwards Deming – “father of quality,” PDSA

• Joseph M. Juran – Pareto principle, “Juran Trilogy”

• Taiichi Ohno – Toyota Production System (TPS)

• Kaoru Ishikawa – Ishikawa diagram, total quality control (TQC)

• Armand V. Feigenbaum – total quality control

• Philip B Crosby – zero defects, “conformance to requirements”

• Quality in business and industry was adopted after WWII.

• In healthcare, efforts began as early as the late 1980s.

• The past decade has shown a growing emphasis of quality

• The historical evolution of Total Quality Management has

2. Quality Control: WWII

3. Quality Assurance and auditing 1950s

4. Total Quality Management 1980s

• Helped to create a philosophy of management that uses statistical

System of Profound Knowledge

95% of performance is governed

Deming describes the benefits of a stable process as:

• Improvement is learning and developing new knowledge

• Tampering with the system: actions applied to individual

Change management principles

• To act on the system, you must change the way you

Changing thinking and management behavior changes

Dr. Joseph Juran (1980)

Philip Crosby Definition of quality —conformance

Measurement of quality —price of

Quality Management Fundamentals

Quality Management Fundamentals