EXERCISE ON

FORMULATING
QUALITY OBJECTIVES
AND USE OF QUALITY
TOOLS
Dr R Shankar Shanmugam., PhD,DSc,MBA,CCHQ,RN.,
Associate Professor/Reader in Nursing
 INTRODUCTION
Quality

Quality itself has been defined as fundamentally relational:

'Quality is the ongoing process of building and sustaining
relationships by assessing, anticipating, and fulfilling stated and
implied needs.‘

Quality is the totality of features and characteristics of a

product or service that bear on its ability to satisfy given
needs.
 Contn..
Quality in healthcare

Health care quality is "the degree to which health

care services for individuals and populations
increase the likelihood of desired health outcomes
and are consistent with current professional
knowledge."
•
 Quality objectives are measurable CONTN…
goals relevant to enhancing customer
satisfaction and are consistent with
the quality policy. These objectives
are initially established when planning
your QMS and redefined in
management reviews as needed.
Examples can include goals to improve
on time delivery, defects, or scrap.
Exercise on formulating
quality objectives
 Steps in QI
Step 1: Identifying a problem, forming a team and
writing an aim statement
Step 2: Analyzing the problem and measuring quality
of care
Step 3: Developing and testing changes
Step 4: Sustaining improvement
 Identifying a problem to solve
Data-based decision: Review local health facility data and
identify gaps related to quality of care

Simple, easy to fix & amenable to change

Value for patient outcomes

Does not need many new resources

Short turn-around time: early success is motivating

Avoid long-term projects initially

Decreasing maternal mortality in a small facility:

Decreasing hemorrhagic disease in newborn (vitamin K related): since onset

is late follow up after discharge is required to capture this
 SELECT YOUR TEAM
Look for volunteers who are:

� Enthusiastic - they want to make changes

� Involved - they are already doing the work that needs

change

� Influential - others people listen to them and they can

get things done

 SELECT YOUR TEAM
Identify who should be in the team:
⮚ Need people from every level: from administrators to
cleaners
⮚ From all involved departments
⮚ Assign some key roles
⮚ Leader
⮚ Recorder
⮚ Communicator
 CHARACTERISTICS OF A GOOD AIM
STATEMENT
 States a clear, specific aim –’what’ are we improving
 Linked to specific patient population – ‘who’ will be affected
 Should include a goal – ‘how much’ will we improve
 Neither too difficult nor too long to achieve

 Includes a timeline – ‘by when’ will the goal be achieved

 SMART AIM

Specific

Measurable

Achievable (but challenging)

Relevant and recorded

Timely
 Aim statement
Problem: All babies are not dried immediately after
birth
We will increase immediate drying at birth in all 100% of
births from current 60% within 4 weeks, from May 1st to June
1st.
Who (which patients)- Newborn
What (the process)- Immediate drying
How much (the amount of desired improvement)- from 60% to 100%
By when (time over which the improvement will occur)- within 4 weeks
 AIM STATEMENT
PROBLEM: BABIES ARE COLD AT ONE HOUR
FOLLOWING BIRTH
We will reduce the percentage of newborns with low
temperature (<36.5 C ) from current 50% to <10% within 6
weeks, from 15th June to 30th July.
�Who (which patients) - Newborns
�What (the outcome) - Hypothermia (<36.5 C)
�How much (the amount of desired improvement) - from baseline of 50% to
<10%
�By when (time over which improvement will occur)- within 6 weeks
 Is this a good aim statement

To establish skin to skin contact after delivery in low risk mothers

admitted in Labour Room

To establish skin to skin contact immediately after delivery for at

least one hour from 0% to 25% within two weeks for newborns of low
risk mothers admitted in Labour Room
USE OF QUALITY
TOOLS
 QUALITY TOOLS
• Quality tools are defined as an instrument or technique to
support and improve the activities of quality
management and improvement.
• Quality improvement tools are standalone strategies or
processes that can help you better understand, analyze,
or communicate your QI efforts
WHY DO WE NEED TO KNOW THESE QUALITY
TOOLS?
Extracting information from data collected.
identifies patterns and focus areas

Helps identify and prioritize problems more quickly and in an efficient

manner.
 - Discuss causes and effects

For communication to others for solving business problems

Help in decision making process
For CQI
 WHERE TO BEGIN

Data based decisions

To identify problems and suggest solutions
Lack of training
Is not covered in my JD!!
 REMEMBER: FOCUS
F – Find a process that needs improvement
O – Organize a team that knows the process
C – Clarify the current knowledge of the process
U – Understand the process and learn the causes of
variation
S – Select the improvement opportunities
 DATA…
• Quality/outcome measures
• Utilization/workload measures
– Unplanned readmission rates < xx days
– No of inpatients
– Infections Patient falls
– No of outpatients – Unplanned returns to operating theater
– No of procedures (surgical etc.) – Needle-stick injuries
– No of tests – Pressure sores

• Efficiency measures – Complications rate

– Deaths
– Average length of stay
– Sentinel events
– Bed occupancy rate
– Patient complaints
– Day care rate
– Patient satisfaction
– Operating theater utilization
 Methods

Observation
One-on-one interviews
Document review
 7 QUALITY TOOLS- BY KAROU
ISHIKAWA
1. Process Flow Chart/Process mapping
2. Histogram
3. Check sheet
4. Fish Bone Diagram
5. Control Charts
6. Pareto Charts
7. Scatter Diagram
8. Stratification
 Additional Tools
1. Gantt Chart
2. Brainstorming
3. PDCA
4. 5 Why Analysis- Root Cause Analysis(RCA)
5. Control Matrix Chart
6. Action Plan Tracker
Flow Chart/Why Map
Processes?
What we think process is What actually process is

What process should be

What process could be
 PROCESS FLOWCHART/
PROCESS FLOW DIAGRAM
 Picture of the separate steps of a process in sequential order.
 Elements:
sequence of actions,
materials or services entering or leaving the process (inputs and
outputs)
decisions that must be made
people who become involved
time involved at each step and/or process measurements
 USES
To study a process
how a process is done.
for improvement.
Documentation
For better communication with team members in the
same process/to others how a process is done.
When planning a project.
 HISTOGRAM

A frequency distribution

how many times each different value have occurred

in a set of data
 USES
 Data are numerical.

 To communicate the distribution of data quickly and easily to

others.
 Process change has occurred from one time period to another.

 To see the shape of the data’s distribution.

 The outputs of two or more processes are different.

EXAMPLE
 CHECK SHEET
 Structured form for collecting and analyzing data.

USE
 Data observed and collected repeatedly by the same person or at the
same location.
 Data collection on the frequency or patterns of events, problems,
defects, defect location, defect causes, etc.
 PARETO CHART/DIAGRAM
 It is a bar chart which visually shows which are more significant
situations.
 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 your data

EXAMPLE: PATIENT SATISFACTION: PATIENT
COMPLAINTS : LIST OF PROBLEMS
 Long waiting time in OPD Department
 Shortage of medicines
 Delay in discharge process
 Doctors not in OPD during OPD hours
 Long billing process in TPA cases
 MRI equipment not functioning
 Shortage of Nurses
 Surgery not happening on time in OT.
PROBLEMS TO FOCUS: PARETO
CHART
 BRAIN STORMING

Brain Storming is a technique to obtain

creative ideas from a group of persons in a shortest
possible time on an effect. Brain Storming plays an
important role to build a Cause & Effect Diagram.
 DOS AND DONTS
 Let all the members speak freely & give ideas

 Encourage wild ideas

 Focus on Quantity rather quality of ideas

 Suspend judgment on good or bad

 Never criticize other persons’ opinions

 Never prohibit a person from different angles / facets

 Write down all the view points

 List to causes / ideas

 The Leader / facilitator needs to guide the members in generating ideas

 BRAINSTORMING SESSION- CAUSE &
EFFECT ON DISCHARGE DELAY
• Errors in indenting drugs
• Delay in refund for drugs
• Lack of induction for New staff
• Lack of motivation
• Server problems
• Doctors rounds are at irregular times
• Discharge summary not prepared on the previous day
• Doctor not available for correction in summary.
• Lack of training in staff for new processes
• Patient’s money not ready
• Delay in transfer of file to billing
• Rate of procedures not explained
• Handwriting not legible.
• No standardization
• No automation
 FISHBONE OR CAUSE & EFFECT
DIAGRAM
Maps out a company’s process/problem to get better
understanding of the situations
Looks “like fish skeleton”

No statistics involved

Ishikawa Diagram.
 WHERE TO USE IT?

 The diagram is useful to help organize ideas and to identify

relationships.
 It is a tool that encourages open brainstorming for ideas.

 For better understanding all the causes were categorized under main
categories : Manpower, Methods, Machine, materials.
 CONTROL IMPACT MATRIX
High Medium low
In Control -Poor training/No Less team members Lack of motivation
induction -Doctors rounds are
-No quality processes at irregular times
-Unavailability of
doctors for correction
--Discharge summary
not prepared on the
previous day
-Handwriting not
legible.

Not in Control Server problems Lack of automation Lack of system

performance
 FIVE WHYS/TWO YEAR OLD
TECHNIQUE
Developed by Sakichi Toyoda

questioning process designed to drill down into the

details of a problem
 peel away the layers
 EXAMPLE
 Problem: I am not able to meet deadlines of my project
 Why( 1 st): Why do you think you are having trouble meeting
your deadlines?
 Answer: Because I have so much to do
 Why ( 2 nd): Why do you have so much to do?
 Answer: Because I didn’t prioritize as per importance. I did
what was easy first.
 EXAMPLE
 Why( 3 rd): Why did you not prioritize you work based on importance?
 Answer: I normally do one project at a time so it was easy to know what
to do. I never had so many project at one time.
 Why ( 4 th): Why do you have to do so many projects at once?
 Answer: I thought I could handle more projects and prioritize. But I now
realize I do not know how to prioritize.
 Ok we’ll work together on next steps to meet your goals.
CAUSAL TREE
 EXAMPLE

Group O patient almost given

Group A blood

WHY?
A positive unit was Transfusing nurse didn’t check
hanging on the infuser blood type on hanging unit

A positive unit not Nurse was busy & distracted

removed from prior case

Replacement nurse unclear about Other nurses Replacement

procedure on sick out nurse needed help
 CONTROL CHART
 Graph used to study how a process changes over time and to predict
expected product outcome. ( process variation)
 Is a tool for statistical process control

 Process in control or out of control (routine or Special causes of

variation).
 Two categories depending on type of data i.e. Attribute data or
variable data
 VARIATION & CUSTOMER
SPECIFICATIONS
Expected Customer
Variation Specs

Expected Customer
Variation Specs
 VARIATION

Fans Cheer!

Fans Groan! Fans Groan!

Customer
Specification
Limits

53
 WHEN TO USE IT

 When controlling ongoing processes by finding and correcting

problems as they occur.
 When determining whether a process is stable (in statistical control).

 When analyzing patterns of process variation from special causes

(non-routine events) or common causes (built into the process).
 CONTINUAL QUALITY
IMPROVEMENT : PDCA
 CONTINUAL QUALITY
IMPROVEMENT : PDCA
When to use:
 As a model for CQI

 Starting an improvement project

 On implementation any change

 On designing a new or an improvement in a process/service.

 STRATIFICATION
• When data from a variety of sources or categories have been lumped
together, the meaning of the data can be impossible to see. This
technique separates the data so that patterns can be seen.
• Useful in surveys
• Eg. Medication error study
 EXAMPLE
No. of Births per year
No. of Births per gender per year
No. of births by mother’s economic strata per gender
per year
No. of deliveries /week
No. of deliveries /day/week
No. of deliveries/hour/day/week
Caution: please use where relevant/value add
 GANTT CHART
• Gantt chart is a bar chart that shows
 the tasks of a project,
 when each must take place
 how long each will take.
 People assigned to each task
• As the project progresses, bars are shaded to show which tasks have
been completed.
 WHEN TO USE
Scheduling and monitoring tasks within a project.

Communicating plans or status of a project.

Steps of the project or process, their sequence and

their duration are known.
 CONCLUSION
Quality helps to boost reputation, brand value and meet the
industry standards. Quality control is a product-based process and
quality assurance is a process-based process. When it comes to our
focus, we understand that quality control is a product-oriented
process. When it comes to quality assurance, it is a process-oriented
practice.