BACHELOR OF NURSING SCIENCE WITH HONOURS (BNS)

MAY/2021

NBBS1104V2

MANAGEMENT AND MEDICO LEGAL STUDIES

NO. MATRIKULASI :
NO. KAD PENGENALAN :
NO. TELEFON :
E-MEL :

PUSAT PEMBELAJARAN : SEBERANG JAYA LEARNING CENTRE

 CONTENTS PAGES

1. INTRODUCTION 1

2. EXPLANATION ON THE QUALITY IMPROVEMENT IN THE 2-5

HEALTHCARE SYSTEM

3. DISCUSSION ON THE STRATEGIES TO IMPROVE THE QUALITY 6-9

OF CARE AND PATIENT SAFETY

4. CONCLUSION 10

5. REFERENCES 11-12
1.
Many people in healthcare today want to know what "quality improvement" means.
We propose that it be defined as the concerted and never-ending efforts of all relevant
parties, including healthcare professionals, patients and their families, researchers,
payers, planners, and educators, to effect changes that will improve patient health
outcomes, care system performance, and learning professional development. This concept
stems from our belief that healthcare will not reach its full potential unless a change is
made an integral part of everyone's job, every day and across all parts of the system
(Batalden & Davidoff, 2007).
A quality improvement program (QI) is a series of actions aimed to monitor, analyze,
and enhance the quality of processes in order to enhance an organization's healthcare
results. A hospital can effectively execute change by acquiring and evaluating data in
important areas. Many programs are company-wide, continuing, and long-term in nature.
Such programs, which are concerned with a hospital's more cyclical activities, attempt to
continuously improve levels of performance, such as enhancing patient safety or lowering
patient mortality (Agency for Healthcare Research and Quality, 2013).
Therefore, in the main section of this assignment the author will elaborate on the
quality improvement in the healthcare system that is redeem significant and relevant
hence continuing with the second major section whereby the discussion on the strategies
to improve the quality of care and patient safety will be elaborated and supported with
evidences from the current findings.

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2.
Quality improvement (QI) is a methodology used in health care to systematically
improve ways treatment is delivered to patients. Characteristics of processes can be
measured, studied, enhanced, and managed. Continuous attempts to create stable and
predictable process outputs, that is, to reduce process variance and enhance the outcomes
of these processes for both patients and the health care organization and system, are
referred to as quality improvement. To achieve long-term QI, the entire organization must
be committed, especially top-level management (Agency for Healthcare Research and
Quality, 2013).
According to Bartunek (2011), those involved in healthcare quality improvement
programs must concentrate on improving systems, structures, measurements, and
adaptive action. Positive working relationships among groups such as physicians, nurses,
and healthcare administrators are also crucial for the success of quality improvement
projects. In addition to physicians, nurses, and administrators, there are a slew of other
organizations that must work together for good healthcare delivery. Dieticians, various
types of therapists, pharmacists, laboratory technicians, and other professionals fall under
this category.
Agency for Healthcare Research and Quality (2020) stipulated that the need to
synchronize changes in behavior and procedures across different levels and sections of
the organization can be intimidating for health care delivery systems trying to improve
patient experience. The process of designing, testing, and eventually spreading those
modifications, on the other hand, does not have to be difficult. Health-care organizations
can benefit from well-established quality-improvement ideas and practices that are
already familiar to many clinical quality-improvement practitioners (QI).
Thinking of the organization as a system, or more especially as a collection of
interconnected "microsystems," is one beneficial way for health plans and medical groups
to approach the reform process. The phrase "microsystems" refers to the many tiny
groups of caregivers, administrators, and other employees who produce the "products" of
health care—that is, who provide everyday care and services. The idea of microsystems
in health care companies is based on research findings that show the most successful
major service firms place a high emphasis on tiny, functional units that carry out key

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operations that entail customer engagement. A microsystem in health care could be a core
team of health professionals, staff who regularly collaborate to provide care to discrete
subpopulations of patients, and a work area or department with the same clinical and
business goals, linked processes, shared information environment, and shared
performance outcomes (Agency for Healthcare Research and Quality, 2020).
Agency for Healthcare Research and Quality (2020) found that the microsystem
approach aims to promote a focus on tiny, repeatable, functional service systems that
enable personnel to give patients with efficient, high-quality clinical and patient-centered
care. Health-care organizations begin by establishing the smallest measurable cluster of
activities before developing and refining such systems. Once the microsystems have been
identified, a practice or plan can be used to identify the appropriate teams and/or
microsystem sites for testing and implementing new ideas for enhancing work processes
and reviewing progress. The microsystem's services must be effective, timely, and
efficient for all patients in order to deliver high-quality treatment, and they should ideally
be built in collaboration with patients and their families. To learn and grow, the
microsystem's principles must include measurement and performance feedback. If a
microsystem-level quality improvement intervention is successful, it can be scaled up to
other microsystems or the entire organization. Organizations should, however, adopt a
spread architecture that works within their structure and culture for successful scalability.
Although different approaches and methodologies are used in different QI models, one
underlying assumption is that QI is an ongoing activity, not a one-time event. There will
always be difficulties to address and obstacles to manage when you implement
improvements. You may learn from your mistakes and apply what you've learned to
adjust your strategy and attempt new interventions as needed to keep moving toward your
development goals (Agency for Healthcare Research and Quality, 2020).
The PDSA cycle, which stands for Plan, Do, Study, Act, is the core approach that
serves as the foundation for most process improvement models. This cycle is a set of
stages for obtaining essential knowledge and learning in order to enhance a product or
process over time. The premise that microsystems and systems are made up of
interdependent, interacting elements that are unpredictable and nonlinear in operation

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underpins the PDSA concept. As a result, modest adjustments might have a big impact on
the system (Agency for Healthcare Research and Quality, 2020).
The cycle is divided into four sections. Plan: This includes determining a goal or
purpose, developing a change intervention or theory, determining success metrics, and
putting the plan into action. Do: which elements of the strategy are put into action. Study:
monitoring outcomes to assess the plan's validity for indicators of progress and success,
as well as flaws and places for improvement. Act: This stage completes the cycle by
incorporating the knowledge gained during the process, which can be utilized to change
the goal, change the methodology, or even completely reformulate an intervention or
improvement program (Agency for Healthcare Research and Quality, 2020).
All employees are involved in the PDSA cycle, which entails identifying problems
and generating and testing viable solutions. This bottom-up approach increases the
possibility of employee acceptance of the changes, which is critical for successful QI.
When you're ready to use the PDSA cycle to improve your CAHPS scores, you'll need to
decide on your goals, strategies, and actions, then go ahead and put them into action
while tracking your progress. You can repeat this cycle numerous times, starting with a
small-scale intervention and then growing to larger-scale activities based on the lessons
learned in previous cycles (Agency for Healthcare Research and Quality, 2020).
The approach to service delivery, level of patient satisfaction, efficiency, and outcome
are all intimately tied to quality improvement. To attain an improved level of
performance and a successful organizational healthcare system, a successful program
always combines quality improvement principles. Work as systems and procedures, focus
on the patient, focus on the use of data, and focus on care coordination are four
fundamental principles that healthcare systems might consider for quality improvement
(Ipatientcare, 2016).
As stated by Ipatientcare (2016), an organization's delivery system and key procedures
must be understood as systems and processes, rather than being categorized as small and
simple or large and complex. The fundamental to every size organization's quality
improvement approach should be to streamline "Input – Process – Output" to match the
needs of that organization's health service delivery system. Besides, the primary notion
behind healthcare quality improvement is to align the needs and expectations of patients.

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Patient safety, patient engagement, systems that enable patient access, evidence-based
care provision, patient-centered communication, and patient health literacy are all
services that are designed to bring needs and expectations together. Moreover, quality
improvement hinges on data. It explains how present systems work, tracks changes, and
allows for comparison and monitoring in order to achieve long-term improvements.
Better outcomes, less variance, fewer re-admissions, lower infection rates, and fewer
medical errors are all achieved through data-driven insights. To improve the healthcare
system's quality, both qualitative and quantitative data collection approaches are
employed. Lastly, care coordination reduces a patient's care fragmentation by establishing
a secure network of trusted healthcare providers and ensuring effective referrals and easy
transitions between two or more providers.

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3.
As stated by Hughes (2008), “the degree to which health services for individuals and
populations increase the likelihood of desired health outcomes and are compatible with
current professional knowledge,” according to the definition of quality health care. The
majority of medical errors, according to the Institute of Medicine (IOM) report To Err Is
Human, are caused by flawed systems and processes, not by individuals. The complexity
of health care is exacerbated by inefficient and changeable processes, changing patient
case mix, health insurance, disparities in provider education and experience, and a slew
of other factors.
Hughes (2008) stipulated that the Institute of Medicine (IOM) argued that today's
health-care business is operating at a lower level than it might and should be, and it
proposed the six health-care goals of effective, safe, patient-centered, timely, efficient,
and equitable treatment. The goals of efficacy and safety are targeted through process-of-
care assessments, which assess whether health-care practitioners follow methods that
have been shown to meet the desired goals and avoid those that are inclined to damage.
As mentioned by Hughes (2008), the aim of assessing health care quality is to
determine the impacts of health care on desired results and to assess the degree to which
health care complies to methods based on scientific evidence or agreed upon by
professional consensus, as well as patient preferences. Because system or process failures
create errors, it's critical to apply diverse process-improvement strategies to uncover
inefficiencies, poor care, and preventable errors, and subsequently influence system
modifications. Each of these methods entails evaluating performance and using the
results to guide improvement. The following sections will go over quality-improvement
strategies and tools, such as failure modes and effects analysis, Plan-Do-Study-Act, Six
Sigma, Lean, and root-cause analysis, that have been used to improve health-care quality
and safety.
Failure mode and effects analysis (FMEA) is a proactive tool, methodology, and
qualitative technique that allows for the early detection and prevention of process or
product faults. The goal in healthcare is to avoid negative events that could endanger
patients, their families, employees, or others involved in patient care. Early in the
development of a process or new service delivery, FMEA can assist identify and address

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issues. It's a method for systematically examining a process in advance for potential
failure points and then restructuring the procedures so that the new model decreases the
risk of failure. When performed appropriately, FMEA can contribute to enhance overall
satisfaction and safety (Smith, 2015). Besides, Institute for Healthcare Improvement
(2017) mentioned that FMEA was established outside of health care and is now used in it
to analyze the risk of failure and harm in processes and to identify the most significant
areas for process improvement. Hundreds of hospitals have applied FMEA as part of the
Institute for Healthcare Improvement's Idealized Design of Medication Systems (IDMS),
Patient Safety Collaboratives, and Patient Safety Summit program. Yu et al. (2010) found
that by identify potential failure modes, create risk mitigation strategies, and improve
disinfection quality monitoring with HFMEA helped to improve the disinfection effect
monitoring procedure certification rate.
Deming (2021) stipulated that the PDSA Cycle (Plan-Do-Study-Act) is a methodical
method for obtaining valuable knowledge and learning in order to improve a product,
process, or service over time. This integrated learning and improvement paradigm, often
known as the Deming Wheel or the Deming Cycle, was initially taught to Dr. Deming by
his mentor, Walter Shewhart of the renowned Bell Laboratories in New York. Plan is the
first phase in the cycle. Identifying a goal or purpose, establishing a theory, defining
success measures, and putting a plan into action are all part of this process. These actions
are followed by the Do stage, which involves putting the plan's components into action,
such as manufacturing a product. The next step is the study, in which the plan's validity is
tested by looking for indicators of progress and success, as well as difficulties and
opportunities for improvement. The Act stage completes the cycle by incorporating the
knowledge gained throughout the process. This knowledge can be utilized to change the
aim, change the methodology, reformulate a theory, or expand the learning –
improvement cycle from a small-scale experiment to a broader execution Plan. These
four processes can be performed indefinitely as part of a never-ending cycle of progress
and learning. Leg ulcer patients should have access to a service that delivers
comprehensive, equitable, and evidence-based care. Using a well-known improvement
model, such as the PDSA cycle, can help provide an organized method to implementing a

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quality improvement project in practice, improving leg ulcer patient outcomes, lowering
NHS costs, and preventing clinician variance (Mahoney & Simmonds, 2020).
In the healthcare industry, Lean Six Sigma (LSS) is a commonly used management
tool and process optimization approach. Both Six Sigma and lean systems have the same
goal of eliminating waste and creating the most efficient system feasible. However, they
address waste in different ways: waste in a lean approach stems from needless stages in a
process, whereas waste in a Six Sigma approach stems from variance within the process.
Lean Six Sigma identifies and eliminates waste using lean approaches, then uses Six
Sigma tools to reduce process variation. As a result, LSS combines lean and Six Sigma
principles to improve a system's overall performance by easing the discovery of reasons
of deviations from the ideal process, their elimination, and, as a result, the improvement
of process performance. Lean Six Sigma has been used to increase operating room
efficiency, minimize patient waiting time in an outpatient department, improve primary
care practices, and shorten the length of stay associated with liver transplants, to name a
few examples. In addition, it has been used to improve the quality and costs of hip
replacement surgery, increase patient happiness, and minimize hospital registration
processing times by upgrading a hospital medical records department. It's also been used
in emergency rooms to reduce hemolysis, minimize departmental inefficiencies and costs,
shorten wait times, and boost patient satisfaction. It has also been used to successfully
minimize the occurrence of catheter-related bloodstream infections in a critical care unit
and surgical site infections (Improta et al., 2018).
The automotive industry pioneered root cause analysis as a technique to improve
production quality and efficiency. Root cause analysis is commonly employed in medical
and health care contexts, despite its industrial beginnings. Clinical teams can utilize root
cause analysis to review all of the processes leading up to a damaging incidence or near
miss, determine the root and develop strategies to prevent recurrence. Root cause analysis
is a technique for determining the root causes of errors that cause harm or injury.
However, it has a larger use that is it also looks into “potential adverse events,” which are
errors that could have caused harm but didn't because of luck or because something or
someone in the system intervened. To do a root cause analysis, there are five fundamental
stages. First, while an incident report is necessary and it is insufficient, gather everyone

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who was engaged in the occurrence, such as clinicians, family members, maintenance
workers, and office employees, as quickly as possible when a mistake happens, such as a
patient fall. Secondly, make a list of all steps that appear to be linked to the mistake. To
keep track of your observations, use a white board or a wall, as well as index cards or
post-It notes. Everyone should be able to contribute something, regardless matter how
insignificant it may appear. Thirdly, begin to organise the events in chronological order
as they are listed, using the "5 Whys" technique: To get to the fundamental cause—or
causes—of the occurrence, ask “why” 5 or more times. Then, a cause-and-effect diagram
can aid in visualizing the event's equipment, people, process, materials, environment, and
management difficulties. The team can determine the incident's root cause or causes.
Lastly, staff can establish prevention strategies, implementation plans, and metrics for
monitoring progress after the root cause has been identified (Sherwin, 2011).

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4.
A quality improvement program is a set of actions targeted at monitoring, analyzing,
and improving process quality in order to improve an organization's healthcare outcomes.
System, structure, measurement, and adaptive action must all be improved in healthcare
quality improvement projects. The success of quality improvement projects is also
dependent on the development of positive working relationships among healthcare
workers. The microsystem approach strives to promote an emphasis on small, repeatable,
functioning service systems that enable people to provide patients with high-quality
clinical and patient-centered care in a timely and efficient manner.
Quality improvement affects how services are delivered, how satisfied patients are,
how efficient they are, and how successful they are. Four essential ideas that healthcare
systems may examine for quality improvement are work as systems and processes, focus
on the patient, focus on the use of data, and emphasis on care coordination. Failure modes
and effects analysis, Plan-Do-Study-Act, Six Sigma, Lean, and root-cause analysis are
examples of quality-improvement methodologies and tools that have been used to
improve health-care quality and safety.
Overall, improving the quality and performance of the healthcare environment can
assist providers in developing dependable, cost-effective, and long-lasting healthcare
processes, allowing them to achieve their aim of improving care delivery and patient
outcomes.
(2974 words)

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5. REFERENCES
Agency for Healthcare Research and Quality. (2013, May). Module 4. Approaches to
quality improvement. Agency for Health Research and Quality.
https://www.ahrq.gov/ncepcr/tools/pf-handbook/mod4.html

Agency for Healthcare Research and Quality. (2020, January). Section 4: Ways to
approach the quality improvement process.
https://www.ahrq.gov/cahps/quality-improvement/improvement-guide/4-approach-qi-
process/index.html

Bartunek, J. M. (2011). Intergroup relationships and quality improvement in healthcare.

BMJ quality & safety, 20(Suppl 1), i62-i66.

Batalden, P. B., & Davidoff, F. (2007). What is "quality improvement" and how can it
transform healthcare?. Quality & safety in health care, 16(1), 2–3.
https://doi.org/10.1136/qshc.2006.022046

Deming, W. E. (2021). PDSA cycle. The W. Edwards Deming Institute.

https://deming.org/explore/pdsa/

Hughes, R. G. (2008). Tools and strategies for quality improvement and patient safety -
Patient safety and quality - NCBI bookshelf. National Center for Biotechnology
Information.
https://www.ncbi.nlm.nih.gov/books/NBK2682/

Improta, G., Cesarelli, M., Montuori, P., Santillo, L. C., & Triassi, M. (2018). Reducing
the risk of healthcare‐associated infections through Lean Six Sigma: The case of the
medicine areas at the Federico II University Hospital in Naples (Italy). Journal of
Evaluation in Clinical Practice, 24(2), 338–346.
https://doi-org.newdc.oum.edu.my/10.1111/jep.12844

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Institute for Healthcare Improvement. (2017). Failure modes and effects analysis
(FMEA) tool. Improving Health and Health Care Worldwide | IHI - Institute for
Healthcare Improvement.
https://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx

Ipatientcare. (2016, November 25). Why quality improvement in healthcare is important?

IPatientCare.
https://ipatientcare.com/blog/why-quality-improvement-in-healthcare-is-important/

Mahoney, K., & Simmonds, W. (2020). Using a health improvement methodology to

standardise leg ulcer management. British Journal of Community Nursing, 25(Sup9),
S20–S25.
https://doi-org.newdc.oum.edu.my/10.12968/bjcn.2020.25.Sup9.S20

Sherwin, J. (2011). Contemporary Topics in Health Care: Root Cause Analysis. PT in

Motion, 3(4), 26–31.

Smith, D. L. (2015). FMEA: Preventing a failure before any harm is done. iSixSigma.
https://www.isixsigma.com/tools-templates/fmea/fmea-preventing-failure-any-harm-
done/

Xuxia Yu, Tieer Gan, Yuexian Zhu, Junmin Cao, Xuejing Yang, Bo Jin, Ying Zhang, &
Weijiang Zhan. (2020). Healthcare failure mode and effect analysis (HFMEA) for
improving the qualification rate of disinfection quality monitoring process. Journal of
Infection and Public Health, 13(5), 718–723.
https://doi-org.newdc.oum.edu.my/10.1016/j.jiph.2020.02.040

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