-Quality assurance and total quality management
philosophy, values and objectives
Quality control (Q, C)
- Refers to a quality related activities associated with the
creation of project deliverables
- Used to verify that deliverables are of acceptable
quality and that they are complete correct
Example: Peer review, Testing process
- Involves performance management and maintenance
- Includes systematic of ensuring conformance to a
desired standard or norm
Quality assurance (Q, A)
- Refers to the process used to create the deliverables,
and can be performed by a manager, client, or even a
third party
Examples: Process checklist, project audits
- Process of establishing a target degree of excellence
- For nursing intervention and taking action top ensure
that each client receives the agreed-on level of care\
OBJECTIVE OF Q.A
- Set standard for nursing care delivery
- Establish criteria as basis to evaluate this standard
Components of Q.A program
- Clear and concise written statement of purpose,
RIGHT IS RIGHT EVEN THOUGH EVERYONE SAYS
WRONG
WRONG IS WRONG EVEN THOUGH EVERYONE SAYS
WRONG
- Standards or indicator for nursing quality of care
Standards (is a need for quality care)
Indicator (if a quality care of pt is below normal)
- Policies and procedures for using such standards in data
gathering
- Analysis and reporting of the data gathered with
isolation of problems and variances
- Use of the results to prioritize and correct problems and
variances
- Monitoring of clinical and managerial performance and
ongoing feedback
- Evaluation of the Q.A system
Quality Improvement (Q.I)
- Concerned with performance development
- On going
- Involved with fixing NOW
- Preventing future costly mistakes
Continuous quality improvement (C.Q.I)
- ON GOING PROCESS of monitoring structure,
process and outcome indicators in order to identify
signal events significant trends and opportunities for
change
- It integrates Q.A, Q.C and CQI
DIFFERENCES BETWEEN Q,A and CQI
Q.A – A goals only aim at maintaining care quality at a present
level
CQI – ON GOING PROCESS through which care standards
and practice behaviors are progressively enhanced
 Current research findings
 Practice
 Patient and public welfare
Nursing care standards
Standard:
The desired quantity, quality or level of performance that is
established as a criterion against which worker performance
will be measured
Purposes
• Guide the provision of nursing care
• Provide the means by which nursing
personnel are evaluated in the provision of
care
• Provide the means by which to measure the
end results of nursing care through patient
outcomes
Standards of Care refers to: ( BOARD EXAM)
- Nurses conducting themselves professionally according to a
generally accepted reasonable practice of nursing care
• Conduct themselves with the degree of care, skill and
knowledge that reasonably competent nurses would exhibit in
any situation.
• Practice that avoid being found negligent.
• Exercise good judgment, education and training to the best of
their ability under any circumstances.
• Conduct themselves with the degree of care, skill and
knowledge that reasonably competent nurses would exhibit in
any situation.
• Practice that avoid being found negligent.
• Exercise good judgment, education and training to the best of
their ability under any circumstances.
Sources of Standard of Care
• Nursing Law
• Professional organizations
• Code of Ethics for Nurses
• Joint Commission on Accreditation of
Healthcare Organizations (JCAH)
• Case Law and Published Opinions by
Judges
• State Statutes and Administrative Codes
• Hospital Policies
• Authoritative Nursing Journals
Total Quality Management
is a management philosophy that seeks to integrate all
organizational functions (marketing, finance, design,
engineering, and production, customer service, etc.) to
focus on meeting customer needs and organizational
objectives.
- views an organization as a collection of processes.
- maintains that organizations must strive to
continuously improve these processes
- by incorporating the knowledge and experiences of
workers.
- infinitely variable and adaptable.
- generic management tool- views an organization as a
collection of processes.
- maintains that organizations must strive to
continuously improve these processes
- by incorporating the knowledge and experiences of
workers.
- infinitely variable and adaptable.
- generic management tool
Objective of TQM
"Do the right things right, the first time every time".
TQM activities include
• Commitment by senior management and all
employees
• Meeting customer requirements
• Reducing development cycle times
• Just In Time/Demand Flow Manufacturing
• Improvement teams
• Reducing product and service costs TQM activities include
• Commitment by senior management and all employees
• Meeting customer requirements
• Reducing development cycle times
• Just In Time/Demand Flow Manufacturing
• Improvement teams
• Reducing product and service costs
TQM activities include
• Systems to facilitate improvement
• Line Management ownership
• Employee involvement and empowerment
• Recognition and celebration
• Challenging quantified goals and benchmarking
• Focus on processes / improvement plans
• Specific incorporation in strategic planning
Principles of TQM
1) Quality can and must be managed.
2) Everyone has a customer to delight.
3) Processes, not the people, are the problem.
4) Every employee is responsible for quality.
5) Problems must be prevented, not just fixed.
6) Quality must be measured so it can be controlled.
7) Quality improvements must be continuous.
8) Quality goals must be based on customer
requirements.
Issues & Concerns of TQM
• Management Commitment
– Plan (drive, direct)
– Do (deploy, support, participate)
– Check (review) The Concept of Continuous Improvement by TQM
– Act (recognize, communicate, revise) - TQM is mainly concerned with continuous improvement in
all work,
• Employee Empowerment - from high level strategic planning and decision-making,
– Training - to detailed execution of work elements on the shop
– Suggestion scheme floor.
– Measurement and recognition
– Excellence teams
The Concept of Continuous Improvement by TQM
• Fact Based Decision Making - It stems from the belief that mistakes can be avoided
– SPC (statistical process control) and defects can be prevented.
– DOE (Design Of Experiment) , FMEA (Failure Modes and - It leads to continuously improving results, in all aspects
Effects Analysis) of work, as a result of continuously improving
– The 7 statistical tools ( SPSS, R, MatLab, MS Excel, SAS, capabilities, people, processes, technology and machine
GraphPad Prism, Minitab) capabilities.
– TOPS (FORD 8D - Team Oriented Problem Solving)
The Concept of Continuous
Improvement by TQM
• Continuous Improvement It stems from the belief that mistakes can be avoided and
– Systematic measurement and focus on COQ (Cause on defects can be prevented. It leads to continuously improving
Quality) results, in all aspects of work, as a result of continuously
– Excellence teams improving capabilities, people, processes,
– Cross-functional process management
– Attain, maintain, improve standards  Continuous improvement must deal not only with
improving results, but more importantly with improving
• Customer Focus capabilities to produce better results in the future.
– Supplier partnership
 A central principle of TQM is that mistakes may be
– Service relationship with internal customers
made by people, but most of them are caused, or at least
– Never compromise quality (hindi pwedeng, pwede lang)
permitted, by faulty systems and processes.
– Customer driven standards
  This means that the root cause of such mistakes can be
identified and eliminated, and repetition can be
prevented by changing the process.1
The five major areas of focus for capability improvement
1. demand generation (Demand for online class)
2. supply generation
3. technology (LABS)
4. operations
5. people capability.
There are three major mechanisms of prevention
• Preventing mistakes (defects) from occurring (Mistake -
proofing or Poka-Yoke).
• Where mistakes can't be absolutely prevented, detecting them
early to prevent them being passed down the value added chain
(Inspection at source or by the next operation).
• Where mistakes recur, stopping production until the
process can be corrected, to prevent the production
of more defects. (Stop in time).
Implementation Principles and Processes
A preliminary step in TQM implementation is to assess the
organization's current reality.
- If the current reality does not include important
preconditions, TQM implementation should be delayed
- until the organization is in a state in which
TQM is likely to succeed.
- If an organization has a track record of
effective responsiveness to the environment,
and if it has been able to successfully change
the way it operates when needed,
- People need to feel a need for a change.
Kanter (1983) addresses this phenomenon
be describing building blocks which are
present in effective organizational change.
Steps in Managing the Transition
Beckhard and Pritchard (1992) have outlined the basic steps in
managing a transition to a new system such as TQM:
- identifying tasks to be done,
- creating necessary management structures,
- developing strategies for building commitment,
- designing mechanisms to communicate the
change, and
- assigning resources.
TQM and CQI Processes
The Continuous Quality Improvement
Cycle
• PLAN
– Plan for CQI and build team to do the following.
– Set standards
– Monitor current quality level and identify problem/s
– Analyze root causes of problem/s
– Generate solution/s
• DO
– Implement chosen solution/s
• CHECK
– Monitor success of solution
• ACT
– Adjust solution/s to ensure success
– Standardize effective solution/s
Quality Problem Solving Tools
• Generating ideas --Brainstorming
• Generating consensus on ideas -- Nominal group technique
• Clarifying processes --Flowcharting
• Analyzing cause and effect -- Cause-effect diagram
• Organizing data– Check sheets
• Prioritizing -- Pareto chart
• Showing patterns in data -- Histogram
• Showing changes
Principles for Involving People in CQI
• Involve those who do the work as leaders in
developing better and better ways to do the
job
• Make sure they understand customer needs
• Partner with specialists or other knowledgeable people who
understand how the process does or should work--people who
can teach you and other employees about the underlying theory
or principles that guide the work
• Designate an “owner,” a person
responsible for keeping visible the
documentation, for updating the standard
and documentation as improvements are
identified, and for assuring that
newcomers and others are trained
Quality Circles/Teams
• Quality circles = Quality teams,
• circle is a small group of employees who voluntarily meet at
regular times to
• Identify, analyse and solve quality and other problems in their
working environment
• recommend and implement improvement strategies and be a
useful reservoir for the generation of new ideas.
• members face and share similar problems in their daily work
lives and
• create a programme to tap human creative
energy that is capable of generating handsome
rewards.
Activities in Quality Circles/Teams
1. LIST the project name, goal, reasons for the
project,
2. CREATE an activity schedule. The entire
team will compose an action plan, deem how
to implement it, and then evaluate the results.
Title the sections as research, compilation,
analysis, investigation, action plan,
implementation and evaluation, with relevant
volunteer names and notes written under
each section.
3. The quality circle team works with management to
DECIDE specific goals against which to measure the data. then
analyze the results again against project goals so that the
company can prevent future excess scrap and its consequent
monetary loss.
4 . DEVELOP a quality circle ACTION PLAN based on the
team's analysis and work with management to implement it.
5 . Work with management to EVALUATE the quality circle
activity.
QI Team process using Deming Cycle (FOCUS-PDCA)
• F – ind a process to improve
• O- rganize a team that knows the process
• C- larify current knowledge of the process
• U- understand causes of process variation
• S – elect the process improvement
• P- lan the improvement
• D-o data collection, data analysis and improvement
• C- heck data fro process improvement and customer
outcome
• A-ct to maintain and continue improvement
Clinical Practice Guidelines
 Clinical pathways - are standardized, evidence-based
multidisciplinary management plans, which
identify an appropriate sequence of clinical
interventions, timeframes, milestones and
expected outcomes for an homogenous
patient group (Queensland Health Clinical
Pathways Board definition 2002).
2. Nursing Audit, (Joint Audit)
- a review of the patient record designed to identify,
examine, or verify the performance of certain specified
aspects of nursing care by using established criteria.
Types:
A concurrent audit - performed during ongoing nursing
care.
A retrospective audit - performed after discharge from the
care facility, using the patient's record. Often a nursing
audit and a medical audit are performed collaboratively,
resulting in a joint audit.
Purpose of Nursing Audit
• (1)Evaluating Nursing care given.
• (2)Achieves deserved and feasible quality of
nursing care.
• (3)Stimulant to better records.
• (4)Focuses on care provided and not on care
provider.
Utilization review
- is a health insurance company's opportunity to review a
request for medical treatment.
The purpose of the review is to :
- Confirms that the plan provides coverage for your medical
services.
- Minimizes cost and determine if the recommended treatment
is appropriate.
- Gives opportunity to confirm that your health plan provides
adequate coverage for your particular condition.
Types of Utilization Review
1) concurrent reviews are used for approval of medically
necessary treatments or services, happen during active
management of a condition, for in-patient/outpatient care.
- The focuses on ensuring patient that they get the right care in
a timely and cost-effective way.
2) retrospective review involves the review of medical records
after your medical treatment.
- Staff looks into the results to approve or deny coverage you
have already received, and the information can also be used in
a review of the insurance company's coverage guidelines and
criteria for a particular condition.
Complaint Analysis
• Comments, feedbacks coming from
dissatisfied customer
• A customer's complaint is a blessing in
disguise
• Prompt resolution of a complaint often
generates more customer loyalty than
trouble-free service.
Facts about Complaints
 While the average customer doesn't complain to the
company, he will tell ten people or more about the problem,
and these people in turn will tell others;
 A complaint identifies an area of your business that might
need improvement;
 If you suddenly see several customers with the same
complaint, then you have a functional problem that needs
analysis, discussion, and correction;
 Complaints are a great tool to fine-tune your customer
service, to get better at what you do. Facts about Complaints
 While the average customer doesn't complain to the
company, he will tell ten people or more about the problem,
and these people in turn will tell others;
 A complaint identifies an area of your business that might
need improvement;
 If you suddenly see several customers with the same
complaint, then you have a functional problem that needs
analysis, discussion, and correction;
 Complaints are a great tool to fine-tune your customer
service, to get better at what you do.
How to Analyze Customer Complaints
There are three primary tools for analyzing complaints.
1. Customer survey.
2. Policy technicians who always tell management about
complaints.
3. Customer complaint form.
The form documents the complaint, and forces corrective
action.
 Use the files for training: How could we have prevented this
service problem? How would you have handled it differently?
Could we have responded better to the customer? Complaints
should be considered not as an inconvenience, but as a tool to
be used to improve service.
Effective Questions to analyze complaints
• How could we have prevented this service
problem?
• How would you have handled it differently?
• Could we have responded better to the
customer?
Note: Complaints should be considered not as an
inconvenience, but
as a TOOL to be used to IMPROVE SERVICES.
Morbidity and Mortality Review Meetings
 are a requirement of all medical departments within the
hospital. These guidelines have been prepared to assist
departments conduct effective meetings and set the minimum
standard expected.
Preparation
 • Identify clinicians who will form the core group for the
department meetings, taking into account: o the benefits of a
multidisciplinary approach involving the ‘working group’
 Provide potential to broaden the group for specific cases,
where significant input to care occurred from other clinical
areas.
 • Appoint a senior consultant to be the Chair and to have
responsibility for meeting management.
 • Appoint a registrar or fellow with responsibility for case
coordination and minute taking, outlining expectations.
 • Book a regular meeting time. It is a requirement that
meetings are held monthly.
Purposes:
• discussing management decisions
• providing a learning opportunity
focused on system thinking
• identifying opportunities to improve
patient safety and quality of care.
Case analysis Morbidity review
• Cases should be summarized and reviewed
using the standardized format ;
• Issues should be identified and, where
appropriate, recommendations for system
change made. It is important that the person
responsible for implementing the change is
identified and a due date established;
Sentinel Events Monitoring
• Sentinel Events are defined as serious
adverse events that cause death or severe
injury to the patient and result in loss of trust
in the healthcare system by clients/patients.
The surveillance of sentinel events , is an
important role of public health; It is an
indispensable tool for the prevention of such
events and for the promotion of patient
safety.
Sentinel Event List
 Procedure performed to wrong patient
 Surgery performed to wrong part of body (side, organ or part)
 Erroneous procedure to correct patient
 Instruments or other material retained in surgical site which
requires successive interventions or ulterior surgery
 Transfusion reaction consequent to ABO incompatibility
 Death, coma or severe harm originating from error in
pharmacologic therapy
 Maternal death or severe illness correlated to labour and/or
childbirth
• Death or permanent disability in healthy
newborn weighing > 2500 grams not
correlated to congenital illness
• Death or severe bodily harm due to patient
fall
• Suicide or attempted suicide by patient in
hospital
Credentialing
• is the process of obtaining, verifying and
assessing the qualifications of a healthcare
practitioner to provide patient care services in
or for a healthcare entity.
• Re-credentialing is the process of obtaining
and evaluating data to support the continued
competence of the healthcare practitioner to
provide patient care services in or for a
healthcare organization.
Clinical privileging
• is the process used to identify, document,
and approve the specific procedures and
treatments that may be performed in a
specific setting.
• Privileges are granted based on the findings
of the credentialing function and should only
be granted for services that are currently
offered by the hospital.
Credentialing and Privileging are required for increased
patient
safety, reduction of medical errors and the provision of high
quality health care services.
Variance Reporting and Analysis
• is usually associated with a manufacturer’s product costs;
• In the health setting, variance analysis attempts to identify the
causes of the differences between a services provided:
– 1) standard costs of the inputs that should have
occurred for the actual products it manufactured,
and
• The price variance identifies whether the
company paid too much for each unit of
input— or if they paid more per actual input
than it had planned.
• The quantity variance identifies whether the
health institution used too much of the
 input— • Histograms
perhaps it • Run Charts and Control Charts
used too • Scatter plots and Correlation Analysis
many
FLOWCHARTS
materials for
• Remember system theory:
the number
- Input
of services it
- Output
renders to
- Customer supplier
client.
- Interactions.
• Variance
analysis for
• Divide complex processes into simple sub-processes.
manufacturing • A Qualitative tools FLOWCHARTS
overhead costs is more complicated than the • Remember system theory:
variance analysis for materials. However, the - Input
variance analysis of manufacturing overhead - Output
costs is very important as manufacturing - Customer supplier
overhead costs have become a very large - Interactions.
percentage of a product’s costs • Divide complex processes into simple sub-
processes.
TOOLS OF TQM
• A Qualitative tools
INTRODUCTION
• Data-Driven Methodology
• Data generated by processes
THE ‘SEVEN SIMPLE TOOLS’ Types of Flowcharts
• Flowcharts • LAYOUT FLOWCHART
• Cause and Effect (Ishikawa / fishbone) Example Staff movement
Diagrams • DATA FLOW DIAGRAMS
• Check sheets Leave approval process
• Pareto Charts
ISHIKAWA DIAGRAMS money), and are arranged with longest
 Also known as Fishbone or Cause-and-Effect Diagrams bars on the left and the shortest to the
 Non-quantitative tools (Qualitative) right. In this way the chart visually depicts
 Sometimes called the 5M Diagram which situations are more significant.
- Men When to Use a Pareto Chart
- Machine • When analyzing data about the
- Materials frequency of problems or causes in a
- Measurements and Methods process.
CHECKSHEETS
• Central tool for Quality Assurance
programs
• Specially useful for operational
procedures
• Could be derived from the flowchart and
fishbone diagrams

Pareto chart
• is a bar graph. The lengths of the bars
represent frequency or cost (time or
• When there are many problems or
causes and you want to focus on the
most significant.
• When analyzing broad causes by looking
at their specific components.
• When communicating with others about
Pareto Chart Procedure PDPC simply extends this chart a couple of
• Decide what categories you will use to group items. levels to identify risks and countermeasures
• Decide what measurement is appropriate. Common for the bottom level tasks, as in the diagram
measurements are frequency, quantity, cost and time. below. Different shaped boxes are used to
• Decide what period of time the Pareto chart will cover: One highlight the risks and and countermeasures
work cycle? One full day? A week? (they are often shown as 'clouds' to indicate
• Collect the data, recording the category each time. (Or their uncertain nature).
assemble data that already exist.)
• Subtotal the measurements for each category.
• Determine the appropriate scale for the measurements you
have collected.
• Construct and label bars for each category.
• Calculate the percentage for each category:
• Calculate and draw cumulative sums
Process Decision Program Chart (PDPC)
The Process Decision Program Chart (often
just called PDPC) is a very simple tool with
an unnecessarily impressive sounding name,
possibly derived from the Japanese name, How do you do it?
from where it came as one of the 'Second 1. Break down the task into a Tree
seven tools (also known as the 'Seven tools
for management and planning').
How does it work?
• A useful way of planning is to break down
tasks into a hierarchy, using a Tree Diagram.
Diagram. The bottom 'leaves' on the tree
will now indicate the actual tasks to be
carried out.
2. For each bottom-level task 'leaf',
brainstorm or otherwise identify a list of
possible problems that could occur.
3. Select one or a few of the risks
identified in step 2 to put on the diagram,
based on a combination of probability of
the risk occurring and the potential
impact, should the risk materialize.
4. For each risk selected in step,
brainstorm or otherwise identify possible
countermeasures that you could take to
minimize the effect of the risk.
5. Select a practical subset of
countermeasures identified in step 4 to
put on the chart.
6. Continue building the chart as above,
finding risks and countermeasures for
each task. If there are a large number of
tasks, you can simplify the task by only
doing this for tasks that are considered to
be at risk or where the impact of their
failure would be felt.
10 Steps of Quality Improvement
1. Commitment
2. Improvement teams
3. Education
4. Measures, Display and Review
5. Cost of Quality
6. Communication
7. Corrective/Preventive actions
8. Recognition
9. Event
10. Goal setting and continuous improvement6.
Communication
7. Corrective/Preventive actions
8. Recognition
9. Event
10. Goal setting and continuously improve
Credentialing
• Credentials = certification;
• Process by which an agent qualified to do
so grants formal recognition to and records
such status of entities (individuals,
organizations, processes, services, or
products) meeting pre-determined and
standardized criteria.
Accreditation
Voluntary process by which a nongovernmental entity grants a
time-limited recognition to an organization after verifying that
it has met predetermined and standardized criteria
Portfolio
- a portfolio is a collection of investments;
- evidentiary documents;
- information intended to expand and provide
evidence of accomplishments;
- it included skills and experiences, in the
academe, workplace, and community service