1. Healthcare Quality
Concepts
Prepared by: Dr. Alber Paules

2. Evolution of Quality Management
Walter Shewhart (1891-1967):
o He was an American physicist, engineer, and statistician.
o He is called the “Grandfather” of quality movement (the
fathers are Deming and Juran, since much of their works
was influenced by Shewhart’s ideas).
o Also known as the “Father of Statistical Quality Control”;
he introduced the concept of Statistical Process Control
(SPC) in manufacturing.
o Developed the run charts and the control charts (known
as “Shewhart Charts”) in order to aid managers in making
scientific and economical decisions.

3. Evolution of Quality Management
William Edwards Deming (1900-1993):
o He was an American engineer and statistician. He is the
student of Walter Shewhart.
o Post WWII, Deming’s ideas lost popularity in the US, mainly
because demand for all products was so great that quality
became unimportant; any product was snapped up by the
hungry consumers.
o He taught statistical process control methods and quality
concepts to Japanese business leaders, returning to Japan
for many years to consult and to witness economic growth.
Deming’s message to the Japanese leaders was “improving
quality will reduce expenses while increasing productivity
and market share.”

4. Evolution of Quality Management
William Edwards Deming (1900-1993):
o Deming made a significant contribution to Japan's later
reputation for high-quality products and its economic
power.
o Despite being considered something of a hero in Japan,
he was only just beginning to win widespread
recognition in the U.S. at the time of his death
o Deming’s quality ideas went far beyond SPC to include a
systematic approach to problem solving and continuous
process improvement with the PDCA cycle, which he
developed (it is also called the “Deming Cycle”).

5. Evolution of Quality Management
William Edwards Deming (1900-1993):
o Deming also believed that management is ultimately
responsible for quality and must actively support
and encourage quality “transformations” within
organizations. He then developed his famous 14 key
principles to guide the management how to achieve
such transformation.

6. Evolution of Quality Management
Joseph Juran (1904-2008):
o He was born in Romania and later immigrated to the US
with his family when he was 8 years old.
o He was an engineer.
o Working independently of Deming (who focused on the
use of statistical quality control), Juran (who focused on
managing for quality) went to Japan and started courses
(1954) in Quality Management. During his life he made
ten visits to Japan, the last in 1990.
o Juran’s Quality Handbook was first published in 1951 and
remains a standard reference for quality.
o Juran was one of the first to define quality from the
customer perspective as “fitness for use”.

7. Evolution of Quality Management
Joseph Juran (1904-2008):
o The training started with top and middle management.
The idea that top and middle management need training
had found resistance in the United States.
o During the 1970s and 1980s, the Japanese automobile
industry gained higher popularity in the US and
threatened the national automobile industry. The
Japanese products were famous for lower prices and
higher quality.
o In 1941, Juran stumbled across the work of Vilfredo
Pareto and began to apply the Pareto principle to quality
issues.

8. Evolution of Quality Management
Joseph Juran (1904-2008):
o Juran is widely credited for adding the human dimension
to quality management. He pushed for the education and
training of managers. For Juran, resistance to change—
or, in his terms, cultural resistance—was the root cause
of quality issues.
o Juran's vision of quality management extended well
outside the walls of the factory to encompass non-
manufacturing processes.
o He also developed the "Juran's trilogy”.
o During his 1966 visit to Japan, Juran learned about the
Japanese concept of Quality Circles (Quality Teams)
which he enthusiastically spread in the West.

9. Evolution of Quality Management
Philip Crosby (1926-2001):
o He was an American businessman.
o In 1979, he issued groundbreaking book “Quality Is Free”.
In this book, he popularized the idea of the "cost of poor
quality", that is, figuring out how much it really costs to
do things badly.
o He promoted the phrase “right first time”.

10. Definitions of “Quality”
If we look to some famous experts in the subject, we
find that they define “quality” in the following ways:
• “Meeting of customers’ needs” (W. Edwards Deming);
• “Fitness for use” (J.M. Juran);
• “Conformance to requirements” (Philip B. Crosby).

11. Definitions of “Quality”
• Other definitions of quality include:
o Doing the right thing right the first time it is done
o Conformance to relevant requirements/standards
o Satisfying the needs and the expectations of
customers
o Freedom of deficiencies (less costly because the
presence of deficiencies will cause customer
dissatisfaction which will need to be reduced or
eliminated through correction)

12. Definitions of “Quality”
in Healthcare
• Institute of Medicine (IOM) defines “Quality of Care” as:
“the degree to which health services for individuals and
populations increase their likelihood of desired health
outcomes and are consistent with current professional
knowledge.”

13. Definitions of “Quality”
in Healthcare
• Joint Commission defines “Quality” as
“the optimal achievement of therapeutic benefit
and avoidance of risk and minimization of harm”.
• Another definition: “degree of conformity with
accepted principles and practices (standards),
the degree of satisfying the patient’s needs, and
the degree of attainment of acceptable
outcomes, while making appropriate use of
resources.”

14. Benefits of Providing
Quality Services
• Increasing customer satisfaction and/or
decreasing customer dissatisfaction; with
subsequent increase in market share and
revenues/profits.
• Reducing the cost of poor quality.
• Increasing staff productivity; due to
increased morale and the standardization
of the work processes.

15. The 3 Aspects of Quality Care
1. Measurable Quality:
• is the aspect of care which can be judged by the provider
through comparative measures between the actual
performance versus the standard one.
2. Appreciative Quality:
• is the aspect of care which can be judged by the
experienced practitioners who rely not only on standards
but on their personal judgments and experiences as well.
Peer review is an example.
3. Perceptive Quality:
• isthe aspect of care which is perceived/judged by the
recipient of care.

16. The 3 Aspects of Quality Care
Perceptive Quality:
Quality perceived by the patient is generally based on the
degree of care expressed by health care providers rather
than on the physical environment and technical
competence. The latter two are essential to prevent
dissatisfaction but do not necessarily lead to patient
satisfaction.

17. Key Dimensions of
Quality of Care
1. Appropriateness:
• The degree to which the care and services provided are
relevant to the individual's clinical needs, given the
current state of knowledge.
2. Availability:
• The degree to which the care and services are accessible
and obtainable to meet the individual's clinical needs.
3. Competency:
• The practitioner’s ability to achieve both desired clinical
outcomes and patient’s satisfaction.

18. Key Dimensions of
Quality of Care
4. Continuity:
• The provision of a seamless care through the
coordination among all practitioners and across all the
involved settings over time.
5. Effectiveness:
• The degree to which care achieves the desired outcomes.
6. Efficacy:
• The potential capacity or the capability of care to
produce the desired outcomes.

19. Key Dimensions of
Quality of Care
7. Efficiency:
• The optimum utilization of resources to produce the
desired outcomes.
8. Prevention:
• The degree to which care promote health and prevent
disease.
9. Respect and Caring:
• The degree to which those providing care and services do
so with sensitivity for the individuals’ needs, expectations,
and differences.
• This may also include the provision of equitable care to
all patients.

20. Key Dimensions of
Quality of Care
10. Safety:
• The degree to which the risk of an intervention and risk in
the care environment are minimized for patients, visitors,
and staff.
11. Timeliness:
• The degree to which care is provided to the individual at
the most beneficial or necessary time.

21. The Concept of “Value”
• Nowadays, consumers and insurers are demanding
proof that the quality of the purchased care is
worth the dollars paid.
Value = Quality of care (service usefulness perceived by the patient)
Cost
Assume that a patient can have a surgery (X) at either hospital A or
hospital B. The level of care provided is the same and the same
surgery team will perform the surgery in either of the two hospitals.
If there is charges vary significantly between the two hospitals;
then the patient will feel that he has received greater value for the
price paid if he has the surgery done at the lower price hospital.

22. A Value-based Health Care System
• Value-based purchasing is increasing, whereby
consumers and insurers utilize those healthcare
facilities that embrace quality improvement efforts
and hence have better outcomes.
• Transparency allows consumers to compare the
quality of health care services and make informed
choices.

23. Quality Management
• Definition: “A planned, systematic, and
organization-wide approach to monitor, analyze,
and improve the organizational performance;
thereby continually improving the quality of care
and services provided”
Quality Management (QM) includes efforts to
develop and maintain programs to keep it at an
acceptable level (quality planning and control) and
to institute improvements when the opportunity
arises or the care does not meet standards (quality
improvement).

24. Total Quality Management
• Total Quality Management (TQM): It is an
organization-wide management strategy / philosophy /
program aiming at embedding awareness of quality
among all staff and at involving every process of the
organization in a cycle of continuous improvement with
the aim of satisfying the customers’ needs and
expectations.

25. Continuous Quality Improvement
• Quality Improvement (QI): the sum of all activities
which create desired change in the quality.
An effective QI system results in a stepwise increase
in quality of care. QI approach emphasizes reducing
the variability in the entire process and shifting the
process in the desired direction; rather than just
taking actions whenever thresholds are exceeded.
Continuous Quality Improvement (CQI): implies the
continuity of the improvement efforts (i.e.) whenever
an improvement is achieved, we might seek another
opportunity to achieve further improvement.

26. TQM/CQI
• A hospital with TQM/CQI philosophy will, for example,
set specific quality goals, choose a number of high
priority QI projects, make quality improvement part of
job descriptions throughout the organization, provide
necessary resources (dedicated time, financial
resources, etc…) for QI efforts, and provide essential
training for staff involved in QI efforts.

27. QA vs. QI
• Quality Assurance (QA) is a conformance quality
(i.e.) ensures that the performance meets
standards/requirements, rather than continually
improving performance beyond standards/requirements
(e.g.) reducing infection rate at the neonatal ICU to a
specific level is a QA project.
The new QI approach involves not being satisfied with
meeting a specific goal but rather having the
organization making continual progress toward 100%
compliance (e.g.) reducing infection rate at the neonatal
ICU with a systematic continuous effort till reach 0% is a
QI project.

28. QA vs. QI
• QA has traditionally been performed by the QA
staff who collaborate with the involved
department, but the QI paradigm moves the
responsibility to all stakeholder departments
(through the multi-disciplinary QI team) who
get support from the QM staff.

29. QA vs. QI

30. Basic Principles of
Quality Management
1. The active participation and the commitment of Top
Management is crucial.
2. Establishment of new organizational structures, which
are responsible for all quality-related issues, can help
achieve quality improvement (e.g., the quality council).
3. Work is accomplished through processes; the main
source of quality defects is problems in the process.
4. Understanding the variability in the process is crucial.
5. Poor quality is costly.

31. Basic Principles of
Quality Management
6. Scientific statistical methods and proper quality
tools/techniques should be used to improve care.
7. Total employee involvement is critical. Employees
should be provided with appropriate education
and training. Quality is everyone’s responsibility.
8. Recognition and reward systems.
9. Customer focus.
10. Corporate culture should be transformed to that of
quality.

32. Deming’s 14 points for
Management
1. “Create constancy of purpose for continual improvement of
products and services, with the aim to become competitive
and to stay in business”: this is achieved through proper
strategic planning, investment in education/training,
listening to all customers, and responding to their needs.
2. “Adopt the new philosophy that quality must become the
new trend”: providers have to realize that the era of cost-
based retrospective reimbursement, when they were paid
whatever they charged, is over. During that era, efforts to
improve efficiency and effectiveness of care were minimal.
The introduction of new prospective payment methods,
with their financial constraints, has forced the providers to
adopt the quality principles in order to provide a “value”
care, which is both effective and efficient.

33. Deming’s 14 points for
Management
3. “Eliminate the need for mass inspection”: a better approach
is that inspection should be used to see how we are doing,
and not be left to the final product, when it is difficult to
determine where in the process a defect took place. When
this principle is applied to the healthcare services, it can be
achieved through considering process review/re-design
when the outcome(s) is/are not favorable.
4. “End the practice of awarding business solely on the basis of
price tag”: vendors of pharmaceuticals, medical equipment,
supplies, software…..etc must be chosen based on quality
and reliability of the products they provide, in addition to
the timeliness. Mechanisms should be in place to ensure
that products selected to be utilized inside the organization
undergo a sort of scrutinizing before being chosen.

34. Deming’s 14 points for
Management
5. “Improve constantly and forever the system of production
and service”: improvement is not a one-time effort —
management is obligated to improve quality continuously.
6. “Institute modern methods of training on the job for all,
including management”: healthcare practitioners must be
provided with continuing education and training especially
with the emerging demands that care provided be based on
current, scientific, and valid evidence. Web-based
education, specially the one depending on multimedia tools,
is a good practical solution (e.g., www.cmeweb.com).
Providing the practitioners with access to professional sites
is another solution (e.g., www.cochrane.org).

35. Deming’s 14 points for
Management
7. “Adopt and institute leadership aimed at helping people to do a
better job”: top management should optimize output from
people (i.e.) increase productivity, while maintaining or
increasing quality of the care provided. One way to achieve this
is through establishing reward and recognition systems.
8. “Encourage effective two-way communication and other means
to drive out fear throughout the organization”: in some
organizations, suggesting new ideas is too risky; people are
afraid of losing their raises, promotions, or jobs. Fear robs
people of their pride in their jobs and of the chance to
contribute to the organization (i.e.) decreases productivity.
Empowering staff and seeking their contributions through the
QI teams are approaches that improve fear in the organization
and improve productivity.

36. Deming’s 14 points for
Management
9. “Break down barriers between departments”: there are
numerous problems when departments have different goals
and do not work collaboratively to solve problems. Alignments
of the goals and functions of different departments through
essential to achieve the ultimate organizational goals.
10. “Eliminate the use of slogans, posters, and exhortations for the
workforce that do not provide methods”: Slogans never helped
anybody do a good job. Setting goals (through slogans) without
describing how they are going to be accomplished is pointless.
Rather than generate slogans, the organization should change
the work environment and develop policies and procedures
through which goals will be achieved and productivity will be
increased.

37. An Example to Explain “Principle 10”
− The administration at XYZ hospital was becoming
progressively more concerned about dropping patient
satisfaction scores in the ED. Qualitative surveys were
conducted to identify the reasons of dissatisfaction and the
results were depicted on a Pareto chart.
− The figure demonstrates that long waiting times and staff
discourtesy were among the most prevalent reasons for
patient dissatisfaction.
− The administration placed a number of signs around the ED
staff rooms, with slogans such as “The Patient Is Our First
Priority” and “Rapid Care Is Excellent Care”.
− Over the next few months, administrators noted that
satisfaction survey scores actually dropped slightly, rather
than rising in response to the slogans campaign.

38. Pareto Analysis
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Waiting Staff Facilities Amount of Availability Others
Time Courtesy Bill of Foods
and Drinks
38

39. An Example to Explain “Principle 10”
− At this point, the administrators decided to poll the staff at
the ED, who noted that the scheduling pattern left the
department understaffed during the early evening hours.
− Administrators delegated scheduling to the department
manager, and over the next several months, patient
satisfaction survey scores improved by 30%, and the ranking
of waiting time and staff courtesy complaints, in the Pareto
analysis, changed.
− Therefore, we can see how the ED staff identified and
corrected scheduling problems with better distribution of the
workload. This caused staff satisfaction improvement leading
to better scores on staff courtesy. Additionally, diminished
waiting time was associated with improved satisfaction
scores.

40. Deming’s 14 points for
Management
11. “Eliminate work standards that prescribe quotas for the
workforce and numerical goals for people in management”:
Quotas or other work standards, such as measured day
work or rates, impede quality.
12. “Remove the barriers that rob people of their right to pride
of workmanship”: Delegate responsibility to the staff to
seek out quality and do whatever it takes to accomplish it
(empowerment). Receptionists, housekeeping workers,
nurses’ aides, and transport staff all spend copious time
with patients and their attitudes and behavior can have
significant influence on patient perceptions of a provider.

41. Deming’s 14 points for
Management
13. “Institute a vigorous program of education and encourage
self improvement for everyone”: change requires education.
Education not only facilitates change, it also promotes
personal growth and development because workers who
learn more about their professions tend to be more
satisfied, productive, and empowered.
14. “Take Action to Accomplish the Transformation”: Top
management should ensure that quality is embedded as a
cultural value within the organization. Senior managers
must make sure that the organizational structure, the
organization's policies and procedures, and the incentives
system altogether support everybody’s commitment to
quality.

42. Juran Model of QM
(Juran Trilogy)
1. Quality Planning: concerned with the
development of services/products to meet
customer needs, through the following steps:
• Definition of the project.
• Identification of the customers.
• Discovery of customer needs.
• Development of the product and processes to meet the
customer’s needs.

43. Juran Model of QM
(Juran Trilogy)
2. Quality Control: involves the developing and
maintaining of operational methods in order to ensure
that the processes work as they are designed to work
and that the target levels of performance are being
achieved, through the following steps:
• Set performance goals.
• Develop performance measures.
• Measure and analyze.
• Compare actual performance to target performance.
• Take action in case of difference.

44. Juran Model of QM
(Juran Trilogy)
3. Quality Improvement: an approach that improves
the level of performance of the process. After
ensuring that the new levels of performance are
achieved, quality control mechanisms are in place
to sustain that effectively. This is achieved through:
• Collaboratively studying the process.
• Analyzing causes of process failure, dysfunction, and
inefficiency.
• Systematically developing optimal solutions to the chronic
problems in the process.

45. “Avedis Donabedian” Paradigm
Structure, Process, and Outcome
Biography of Prof. Avedis Donabedian:
• He was born in Beirut, Lebanon in 1919
• He studied at the faculty of Medicine, AUB.
• He then migrated to the US, where he joined the
public health school.
• Donabedian authored 16 books and more than 100
articles that focused on quality assessment and
improvement in the HC sector.
• He published his famous article about the
classification of methods for quality assessment:
structure-process-outcome in 1966.

46. “Avedis Donabedian” Paradigm
Structure, Process, and Outcome
• Donabedian was one of the first to view healthcare as
a system composed of structure, process, and
outcome.
• He believed that quality of care is not only related to
each of these elements individually, but also to the
relationships among them.

47. Structure
• Structure component of Donabedian’s Paradigm
designates the conditions under which health care is
delivered. The conditions included may be
material/physical resources, such as facilities and
equipment; human resources and intellectual capital,
such as the number, variety, and qualifications of
professional and support personnel; and
organizational characteristics such as the
organizational structure and the hierarchy.

48. Process
• Process component of Donabedian’s Paradigm refers to the
procedures, methods, means or sequence of steps that are
followed in order to provide care and produce outcomes.
• The “process” is a series of activities that transform inputs
(resources from suppliers) into outputs (services/products to
customers). Those who perform those activities are called
“processors” or “process owners”.
• Viewing healthcare services as processes is the first step in
applying techniques/methods for improving care.
• In health care settings, processes have the following 3 types:
1. Patient flow processes
2. Information flow processes
3. Material flow processes

49. Outcomes
• According to Donabedian, structures combine with processes
to produce outcomes (i.e., S + P = O)
• Outcomes refer to the results of care, whether adverse or
beneficial.
• Classification of Outcomes:
1. Clinical: (e.g.) mortality, complications, and adverse
events.
2. Functional: (e.g.) ability to perform Activities of Daily
Living
3. Perceived: (e.g.) patient satisfaction
4. Financial: (e.g.) cost savings
5. Utilization: (e.g.) productivity, LOS