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DR. G. ANJANEYULU ORATION
Year : 2013  |  Volume : 57  |  Issue : 3  |  Page : 138-143  

Quality management in healthcare


Adjunct Professor, School of Health Sciences, University of Pune and Former Additional Director of Health Services, Government of Maharashtra, India

Date of Web Publication14-Oct-2013

Correspondence Address:
Subhash S Dodwad
Ramteerth, 302 Sumangal Apartment, 7, Modi Baugh, Near Agri. College 1, Shivaji Nagar, Pune - 411 016, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-557X.119814

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   Abstract 

Clinical governance and better human resource management practices are important planks in the current health policies emphasizing quality of patient care. There are numerous reasons why it is important to improve quality of healthcare, including enhancing the accountability of health practitioners and managers, resource efficiency, identifying, and minimizing medical errors while maximizing the use of effective care and improving outcomes, and aligning care to what users/patients want in addition to what they need. "Quality in health is doing the right things for the right people at the right time, and doing them right first time and every time." Quality can also refer to the technical quality of care, to nontechnical aspects of service delivery such as clients' waiting time and staff's attitudes, and to programmatic elements such as policies, infrastructure, access, and management. In this oration/article quality initiatives like Reproductive and Child Health (RCH) and National Rural Health Mission (NRHM) of Government of India (GOI), which concentrate on improving the quality of infrastructure of vast rural health facilities including sub-center, primary health center, and community health center has been taken into account with focus on improving quality of health services also. United Nation Population Fund (UNFPA) in collaboration with the GOI has proposed introducing quality assurance program for accessing and improving the quality of services at public sector health facilities. It is felt that improving the quality of health services in public sector will attract the client belonging to low economic strata, and surely will help in achieving the goal of the NRHM, that is, "Reaching the enriched with quality of health services."

Keywords: Quality management, Health care, Total quality management, Quality assurance, Quality cycle, Patient focus


How to cite this article:
Dodwad SS. Quality management in healthcare. Indian J Public Health 2013;57:138-43

How to cite this URL:
Dodwad SS. Quality management in healthcare. Indian J Public Health [serial online] 2013 [cited 2019 Aug 25];57:138-43. Available from: http://www.ijph.in/text.asp?2013/57/3/138/119814


   Introduction Top


Clinical governance and better human resource management practices are important planks in the current health policies emphasizing quality of patient care. There are numerous reasons why it is important to improve quality of healthcare, including enhancing the accountability of health practitioners and managers, resource efficiency, identifying, and minimizing medical errors while maximizing the use of effective care and improving outcomes, and aligning care to what users/patients want in addition to what they need.

Quality management models from industry, demands from providers of professional associations, increased focus on clients' perspectives and satisfaction, and emphasis on achieving efficiency in program settings have provided much needed momentum to introducing these interventions.

Rationale for quality improvement

  • Government, business, and households - the three major sources of healthcare financing are demanding more accountability from healthcare providers as evidenced in the Consumers Protection Act.
  • Financial concern of third parties such as insurance companies.
  • It costs no more for providers to treat clients with respect, affordable good-quality care, which means choosing appropriate technology.
  • Good-quality care helps in avoiding unnecessary costs by preventing injuries, infections, and unwanted pregnancies, eliminates costly follow-ups to treat clients who have been harmed.
  • Quality attracts revenue as the improved quality can attract more clients, help programs raise revenue, and attract donor support.
  • Finally, good quality can cost less. Costs of poor quality are: Time spent on complaint handling, costs of claims and legal actions, extra cost of work repeated or wrong work done, duplication, waste, bad reputation, lost referrals, damaging effect on staff, etc.
What is quality?

Quality in healthcare has been defined in many ways.

"Quality" in healthcare is defined as everything the healthcare organization undertakes to fulfill the needs of its customer, be it the patient, the payer, the admitting doctor, the employer, or an internal customer within the organization.

"Quality is doing the right things for the right people at the right time, and doing them right first time and every time."

Quality can refer to the technical quality of care, to nontechnical aspects of service delivery such as clients' waiting time and staff's attitudes, and to programmatic elements such as policies, infrastructure, access, and management.

Quality Management: Quality management is that aspect of the overall management function that determines and implements the quality policy. It includes strategic planning, allocation of resources, and other systematic activities for quality, such as quality planning, operations, and evaluations.

Dimensions of quality

  • Technical performance: The degree to which the tasks carried out by health workers and facilities meet expectations of technical quality (i.e., adhere to standards).
  • Effectiveness: The degree to which desired results (outcomes) of care are achieved.
  • Efficiency: The ratio of the outputs of services to the associated costs of producing those services.
  • Access: The degree to which healthcare services are unrestricted by geographic, economic, social, organizational, or linguistic barriers.
  • Interpersonal relations: Trust, respect, confidentiality, courtesy, responsiveness, empathy, effective listening, and communication between providers and clients.
  • Amenities: The physical appearance of the facility, cleanliness, comfort, privacy, and other aspects that are important to clients.
  • Relevance: As appropriate and feasible, client choice of provider, insurance plan, or treatment.
  • Choice: As appropriate and feasible, client choice of provider, insurance plan, or treatment.
Continuous quality improvement

Continuous quality improvement (CQI) is simply a management method. CQI focuses on breaking down your system into processes, and breaking those processes down into inputs. Every process has a list of inputs that can be put into five categories: Man, machine, method, material, and environment.

It views learning as a continual process and provides its members with ongoing professional development opportunities, and it fosters a favorable working environment.

Total quality management

Total quality management (TQM) incorporates the concepts of product quality, process control, quality assurance, and quality improvement. Consequently, it is the control of all transformation processes of an organization to better satisfy customer needs in the most economical way.

Quality assurance process
"Plan-Do-Check-Act" or "PDCA Cycle": It is a work philosophy that emphasizes four phases of activity [Figure 1]. In the planning phase, people define the problem to be addressed, collect relevant data, and ascertain the problem's root cause; in the doing phase, people develop and implement a solution, and decide upon a measurement to gauge its effectiveness; in the checking phase, people confirm the results through before-and-after data comparison; in the acting phase, people document their results, inform others about process changes, and make recommendations for the problem to be addressed in the next PDCA cycle [Figure 2].
Figure 1: Quality cycle

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Figure 2: Quality assurance process

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Principles for good quality management in healthcare

Principle 1 - Patients focus: Our healthcare organization depends on the patients and therefore should understand current and future patients' needs, should meet patients' requirements and strive to exceed their expectations.

Principle 2 - Leadership: Leaders establish unity of purpose and direction of the organization. They should create and maintain the internal environment in which people can become fully involved in achieving the organization's objectives.

Principle 3 - Involvement of people (employees): People at all levels are the essence of an organization and their full involvement enables their abilities to be used for the organization's benefit.

Principle 4 - Process approach: A desired result is achieved more efficiently when activities and related resources are managed as a process.

Principle 5 - System approach to management: Identifying, understanding, and managing interrelated processes as a system contributes to the organization's effectiveness and efficiency in achieving its objectives.

Principle 6 - Continual improvement: Continual improvement of the organization's overall performance should be a permanent objective of the organization.

In routine healthcare delivery, many processes occur simultaneously and involve many professional functions in the organization. Processes can cause inefficiencies due to problems that occur in the execution or the transition of one step to the next. Inefficiency in a process often results from unnecessary steps that add complexity, waste, and extra work to a system, ultimately reducing the overall quality of care.

Building a quality management program

Policies on quality, procedures, and processes are implemented simultaneously, starting at the top and moving down the organization. It typically begins with a review of standards and specifications, if there are any. This is followed by an assessment of healthcare and support services. Priority areas for quality improvement can be identified based on the results of comprehensive monitoring or systems analysis. This approach has three dimensions:

  1. Quality design: Includes setting vision and objectives, allocating resources, and establishing standards and guidelines to ensure effectiveness and safety, monitoring design, training, team building and mechanism for maximizing access increasing clients' satisfaction.
  2. Quality control: Consists of supervising and continuous monitoring activities and staff performance against the set standards to ensure that they meet quality objectives.
  3. Quality improvement: Seeks to keep raising the level of care - no matter what its current level.
It includes problem identification, priority setting, solution development, implementation, assessment, and refinement.

Quality design, quality control, quality improvement-form the three sides of the "quality triangle" also called "Quality management Triad." [Figure 3]
Figure 3: Quality management triad

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Steps of implementation of quality improvement

  1. Creating a supportive environment.
  2. Focus on the user (of services).
  3. Marketing change in the organization.
  4. Motivating people in the organization.
  5. Building teams: An overview.
  6. Data collection and analysis.
  7. Problem solving cycle.
    1. Identify the problem
    2. Describe the problem
    3. Developing strategies
    4. Planning the solution
    5. Defining standards
    6. Implement the solution
    7. Evaluate and monitor the solution
  8. Supervision
Quality initiatives in India

The Government of India (GOI), through its Reproductive and Child Health II (RCH-II) and National Rural Health Mission (NRHM) programs, is committed to improving the quality of RCH services provided through its vast network of rural health facilities, which includes primary health centers (PHCs), community health centers (CHCs), sub-centers, and RCH camps. It aims to improve RCH by identifying and filling gaps in the inputs and processes of RCH service delivery.

The NRHM of the Ministry of Health and Family Welfare (MOHFW), [Figure 4] Population Council, and UNFPA jointly proposed introducing a quality assurance (QA) program for assessing and improving of the quality of services at public sector health facilities. In the first round, 89 facilities in Ahmadnagar and 100 facilities in Tumkur were selected for QA visits. Sixty-four percent were of good quality, about one-third were average, while a small proportion (6%) were of poor quality.
Figure 4: Structure of QA

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An analysis of all the facilities covered until the end of December 2007 revealed substantial gaps in the infrastructure and human resources available to provide good quality services, as well as adherence to standards for providing the services. The analysis of CHC/PHC inputs shows that 75% of facilities in Ahmadnagar and 94% of facilities in Tumkur were in grade B or C. Regarding the process of service delivery, more than two-thirds of facilities in Ahmadnagar (67%) and about 45% of the facilities in Tumkur scored C or D grade. This clearly points to the existing poor quality services provided by these facilities and need for improvement. The key gaps identified at facilities in both the districts are similar, including training of different providers, shortage of essential equipment and supplies, general cleanliness, infection prevention practices, repair and maintenance of buildings, updating of records, poor waste management, availability of protocols and job aids, display of information at facilities, among others [Table 1].
Table 1: Common observations during QA

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A majority of the facilities in both the districts scored higher grades during the second visit as compared with their corresponding grades obtained in the first visit [Figure 5]. Average scores of the facilities visited increased by 13 percentage points in Ahmadnagar (from 68% to 81%) and 26 percentage points in Tumkur (from 53% to 79%). This indicates that QA is making difference in the quality of services [Figure 6].
Figure 5: Change in quality grading of all facilities between fi rst visit and fourth visit

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Figure 6: Changes in quality grades by district

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It was observed that there was an overall improvement of grades of healthcare quality of health institutions from:

  • (A) 24-72%, (B) 69-25%, (C) 7-3% (I) during first to second visit for SDH/RH/PHC.
  • It improved from - (A) 9-39%, (B) 48-58%, (C) 43-3% ( from first to second visit) in case of sub-centers [Figure 7].
Figure 7: Change in quality grading of facilities by type of facility between first and fourth visit

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Let me share a case study from Mohadi, a remote PHC in Nashik District of Maharashtra. We see the commitment of the Medical Officer displaying leadership qualities, changes in the patient oriented services such as the environment, waiting time, waiting place, provision of safe drinking water to the patients and their relatives, provision of information, privacy, examination place, provision of all essential drugs, provision of surgical services with well-equipped labor room and operation theatre, laboratory services, safety precautions, indoor patient care with all required IV fluids and drugs, etc.



From these pictures, we see how a change can be brought about in the existing healthcare delivery system, with the existing health staff.

Every year, NRHM funds are made available to PHCs in Maharashtra for development of infrastructure and other developmental activities as follows:

  1. Untied Funds; Rs. 25,000/-
  2. Annual Maintenance Grants: Rs. 50,000/-
  3. Rugna Kalyan Samiti: Rs. 1,00,000/-
  4. IPHS Rs. 5,00,000/-

   Summary and Conclusion Top


Making quality a top priority can require changes in goals, guidelines, attitudes, and activities that are difficult to make. Organizations typically do not change themselves overnight but rather one step at a time. Internal process for QA can be successfully driven in large public health systems. It is feasible and effective. It can be supported financially by the states.

Commitment and persistence are crucial. Traditionally, most healthcare education from undergraduate through to postgraduate training is offered within specific professional groups. Most training is focused on the care of individual patients with specific conditions and little attention and time goes to educating healthcare professionals on wider professional issues such as how patient care depends on contributions of colleagues from other disciplines; working in teams; organizational behavior and change; and clinical audit or CQI. Nurses and doctors will therefore learn separately about the care of patients with, for example, diabetes from their own professional viewpoints, but often do not learn about the organizational aspects of care of people with diabetes. Although these aspects of care are not about individual people and individual treatments, getting them right impacts on both the quality and the safety of the care patients receive.

I would like to end the article by quoting the statement of our H'ble Prime Minister, Shri Dr Manmohan Singh. While inaugurating the NRHM Project in April 2006 he ended his speech by saying that NRHM is meant for the poor; we would like to reach the unreachable with quality of health services.


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1]


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