Quality- General overview

1. Quality- General overview NTP managers meeting 2004 Lahore 26-29 April Dr. Samiha Baghdadi EMRO/STB

2. Quality Story • Long way from industry to health. • More than 120 years by now • Japan, USA, Europe • Juran, Deming, Crospy & others

3. What is Quality • Is it doing things in a good/excellent way without deficiency? • Or doing things the best way possible within the available resources? • Or providing 5 star services? • Or meeting customer expectation?

4. Quality definition The degree of conforming to a set of standards. Doing things the best way possible to satisfy your costumer at the lowest possible cost. Totality of characteristics of an entity that bear on its ability to satisfy stated and implied needs [ISO 8402, 2.1:1994]

5. Why do we need Quality • to ensure that NTP (organisation) is providing the best services (processes), aiming to obtain the best results (outcomes) and to maintain the required level of success. So we can ensure that: • Our patients (individuals) are receiving the best care • We will be able to reach the targets .

6. What are the dimensions of quality performance • Technical competence: how much the technical performance is matching with standards [ex. TB diagnosis] • Accessibility: in terms ofcost, distance, transportation, socially accepted, institutional system such as opening times etc.. [DOT accessibility] • Effectiveness: it achieved the desiredresults (output) [community participations increased accessibility to DOT] • Good relations: satisfaction [decreased expenditure on PV in DOTS areas] • Efficiency: best care using available resources [sputum test, DOTS] • Continuity: NO interruption of services [drugs channel] • Safety: for customer, provider and community [safety cabinet III] • Amenities:[HE tools]

7. Perspective of Quality • Customers: concentrate on 2,3,4,6,8 • Providers: concentrate on 1,5,7 • Administrators: concentrate on All dimensions

8. DOTS (Group exercise) To have a high quality DOTS services (ex.lab) we should ensure that the service is • Technically competent: • Accessible: • Effective: • Builds good relations: • Efficient : • Continues • Safe • With additional amenities

9. So what do we need? • We need to have a system of Qualitymanagementof TB services to ensure providing high quality DOTS services/activities and continuously improving these activities

10. Quality System Quality system is the organisational structure, procedures, processes, and resources needed to implement quality management. [ISO 8402, 2.1:1994]

11. Quality Management All activities of the overall management function that determine the quality policy, objectives, and responsibilities, and implement them by means such as [quality planning, quality control, quality assurance, and quality improvement ] within the quality system[ISO 8402, 2.1:1994]

12. Quality Management A process by which the components of the services are analyzedto address costumers needs through improvement of Input, process, output and outcomes

13. Quality Assurance and Quality Control Quality control Operational techniques and activities that are used to fulfil requirements for quality [ISO 8402, 2.1:1994] EX: Lab (safety measures) Quality assurance All the planned and systematic activities implemented within the quality system to provide adequate confidence that an entity will fulfil requirements for quality. [ISO 8402, 2.1:1994] Ex: Lab [EQA]

14. TQM • Quality system = computer  The hardware • Quality management =windows Basic software • QA/QA = office programmes  Application programmes • 

15. Approaches in TQM • Detection approach: Test the product – wait the problem very expensive (in health the cost = the life) ex. False positive • Prevention approach: Test the input & process to ensure the output & outcome – expect the problem High cost but recoverable ex. QA in Lab

16. Characteristics of Quality Management System • Organisational commitment/leadership • Awareness of patients and community needs (task analysis, standards, needs) • Concentrating on systems and processes • Data usage for evaluation • Teamwork (quality is responsibility of everybody)

17. Building Quality Management System Plan Set standards Communicate standards Monitor quality QI Identify problems and select opportunities for improvement Define the problem Identify who needs to work on the problem Analyze and study the problem to identify major causes Develop solutions and actions for quality improvement Implement and evaluate quality improvement efforts

18. 1- Plan • Identify beginning point and methodology (task/level/component) • Review activities, analyze tasks (standards & needs) • Identify quality assurance activities (procedures, processes) • Support/build quality structure [policy, objectives, and responsibilities] • Develop implementation plan • Commit resources

19. 2- Set standards Standard is define as the Statement that identify expected quality So Standard role is to Identify important input, process chains, outcomes needed • Standards are important to: • Identify the quality = how to implement activities/processes • measure quality • reduce differences in performance • Standards types • Practice guidelines [TB manual] • Administrative procedures/protocols [protocol for simple sputum test for TB] • Specifications [ex. Specifications for sputum cup, case definitions] • Performance standards [3 sputum samples for diagnosis, treatment regimen]

20. Characteristics of a good standard • Validity: clear and strong relationship between standard and output/outcome • Reliability: gives same outcome each time the activity is repeated • Realistic: can be applied within available resources • Clarity • Current/updated

21. Group Exercise Ex: Positive Tuberculin test is essential for diagnosis of positive case • Validity: No clear and strong relationship between standard and output/outcome • Reliability: No gives same outcome each time the activity is repeated • Realistic: yes but not always can be applied within available resources • Clarity: yes • Current/updated: No

22. Sources of standards • Previously accepted standards • Locally • internationally • professional or teaching institutions/agencies • Lectures • Consultants

23. 3 - Communicate standards • Aims of communicating standards are to ensure • Full understanding of standards • Commitment • Correct implementation • The Plan of CS should identify: targets, messages, tools, source/distributor, coordination, methods, feedback, evaluation

24. 4 - Monitoring Why: to identify problems, improvement, and impact. Types: regular/periodic - exceptional Planning : concentrate on major indicators/standards/criteria, collect needed data only, provide feed back Main gabs: data more than needed, incomplete, inaccurate or not updated. Bad interpretation, not utilized in decision making.

25. 5 - Identify problems/select opportunities for improvement • Select service (Diagnosis) or area (District X) • Review all problems and list them • Select problem/opportunity for improvement with in a service/area

26. % tested among suspects in Syria by province

27. How to select opportunity for improvement / problem: Criteria :important, could be solved, solution costs more than efforts Tools: Brain storming, Prioritization tool Sources: data, workers, costumers Types of data : quantitative, qualitative

28. 6 - Define the problem operationally • Define the problem what, data support the presence of problem, impact of problem on health care, frequency or continuity, needed solution, data needed to answer the questions, how to ensure the solution • Determine boundaries: the activity, the field, timing and effectiveness.

29. 7 - Choose the team • Team composed of: customers, workers, decision makers, consultants. • Types of teams: Creative, work, quality improvement

30. 8 - Analyze and study the problem to identify its root causes • How • Review step 6, (who, what, where, when, frequency) • Understand the activity that has the problem process chain:[ suspects are selected in registration section] • Puthypothesis [brain storming, check list] • Test hypothesis [data collection tools] • Select causes [problem tree] Methods: process chain, cause and result drawings, data collection tools

31. 9 - Identify/develop solutions and actions for QI • Put all solutions List • Put criteria for best solution using available resources, does note effect workers or processes negatively, applicable, supported by DM and community, efficient, solve the problem completely, time for implementation • Select solution • Types of solutions: develop process chain as a standard, correct/ modify process chain, improve designing, improve input • Formulate solution in a practical statement.

32. 10 - Implement and evaluate QI efforts

33. Where we are - EMRO • Some countries began different activities related to improving Quality (Egypt, Iran, Syria, Jordan) • The main concentration is on Lab Quality system • We need to have the quality system for all the components