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  1. FUNDAMENTALS OF QUALITY IN HEALTH CARE Professor Syed Amin Tabish FRCP (London), FRCP (Edin), MD (AIIMS), FAMS Postdoc Fellowship, Bristol University (England) Doctorate in Educational Leadership (USA)
  2. Quality assurance  QA is a planned and systematic approach to monitoring, assessing and improving the quality of health services on a continuous basis within the existing resources  Forms of QA: Total Quality Management, Continuous Quality Improvement, Clinical Audit or Quality Circles
  3. Quality of care  The degree to which Health Services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge
  4. Healthcare is Constantly Evolving  Physicians, Nurses, healthcare systems, healthcare organizations, are all in a state of evolution  They share the strain of development in a larger world that is changing at incredible speed
  5. Attention to quality  Nearly everyone involved in the practice of Medicine is highly trained, is usually very well educated, and is, for the most part, committed to providing high quality of care.
  6. What is Driving Attention to Quality Today?  Limited Resources  Changes in Insurance Coverage  Shift from paternalism to participation / decision making by patient  Patient demands and expectations  Scientifically sound methods for assessing quality exist and should be employed systematically
  7. Achieving Quality Quality is achieved when:  accessible services are provided in an efficient, cost-effective and acceptable manner that can be controlled by the ones providing it.
  8. What is involved in insuring Quality?  Avedis Donabedian suggests that quality needs to be, assured in three key aspects of healthcare: Structure Process Outcomes
  9. FrameFor Assessing Care  Structure Process Outcome  In which description , measurement, comparison and evaluation of quality of health care can be made.  QUALITY OF:  Building )  Equipments ) STRUCTURE  Systems )
  10. Structure Audit of Structure - assess quality of environment in which care is provided.  The stable elements of the Health Care Delivery System in a community that facilitate or inhibit access to and provision of services.  Community Characteristics (Prevalence of disease)  Health Care Organization Characteristics (# beds per capita)  Population Characteristics (Demographics and insurance coverage)
  11. Audit of process  Process describe the care given by practitioner i.e what the practitioner does , the sum of actions and decisions that describe a persons professional practice.  Treatments  Diagnosis PROCESS  Dr. / Patient Communication Audit of process : describe quality of work done by health professionals.
  12. Process The interaction between the patient and a provider depends on: Technical Excellence:  Appropriateness of Intervention (health benefit to patient significantly exceeds the health risk)  Skillfulness of Intervention Interpersonal Excellence (Intervention is humane and responsive to preferences of the patient.)
  13.  Patient current and future health status.  Definite indicators of health, and describe effectiveness of care.  Success in Preventing the OUTCOME Suffering of Illness Audit of Outcome - assess the benefit achieved by patient. Outcome
  14. Outcome Results of efforts to prevent, diagnose, and treat various health problems. Some possible outcomes:  Clinical Status (Biologic & physiologic aspects of health)  Functional Status (Physical, Mental, Social functioning--how do disorders interfere with these? How does disorder affect everyday life?)  Consumer Satisfaction
  15. Structure, Process, and Outcomes are measured at the levels of:  Health Service Delivery Systems (Systemic Level)  Specific Health Conditions or Services (Clinical Level).
  16. Each of these levels, in turn, has both an Internal and an External Focus:
  17. Each of these levels, in turn, has both an Internal and an External Focus:
  18. What can be done? Focus on highly prevalent conditions with significant effects on Morbidity and Mortality.  Primary prevention (prevent disease from happening)  Secondary Treatment (stop progression, accomplish cure)  Tertiary Treatment (reduce impairment)
  19. A Paradigm Shift: From "Quality Assurance" to "Total Quality" Traditionally, Q A programs have focused on physicians (alone) and changing physicians' behavior by:  Assessing or measuring performance  Determining whether the performance conformed to standards (Clinical Practice Guidelines, HMO)  Improving performance when standards are not met
  20. Total Quality  Total Quality Management (TQM) uses QA as its first step and seeks to implement the results of QA into a more comprehensive and continuous effort to improve Quality.
  21. Practice Guidelines  Are systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances  Rely on qualitative reasoning and emphasize clinical content  Are written to influence practitioner behavior  Are like "expert opinion"
  22. Theories of QM  CQI and TQM are based on the work of pioneers in industrial management such as Deming, Juran, Fiegenbaum, and Ishikawa.  These people helped transform Japan's industrial sector in the 1950s by applying statistical methods to management of production processes, by making client satisfaction the focus of all operations, and by empowering employees through teamwork and shared decision-making
  23. Patient-Centered Care  Putting patients first is key to improving the quality of health  Patients are considered first and foremost at every point in the planning, implementation, and evaluation of service delivery
  24. What Do Patients Want?  Respect: be treated with respect and friendliness  Understanding: value individualized service and prefer providers who make the effort to understand their particular situation and needs
  25. What Do Patients Want?  Technical competence of the services they receive  Access to services  Fairness: to offer thorough explanations and examinations to everyone alike  Results: services for a specific purpose
  26. Principles of Quality Management  Strengthen systems and processes  Encourage staff participation and teamwork  Base decisions on reliable information  Improve communication and coordination  Demonstrate leadership commitment
  27. Quality Design QA Triangle:  Quality design  Quality control  Quality improvement. Quality Design can help assure good care and prevent problems from arising by designing quality into every aspect of a program
  28. Quality Control  Quality control ensures that a program's activities take place as designed  Quality control includes day-to- day supervision and monitoring to confirm that activities are proceeding as planned and staff members are following guidelines
  29. Measurable Indicators of Quality  Input indicators measure whether a program has the needed resources for example, the number of doctors/nurses  Process indicators measure how well program activities are being implemented. Examples include waiting times
  30. Measurable indicators of Quality  Output indicators measure results at the program level. Examples include the number of patients served, the percentage of STD cases successfully treated.  Outcome indicators measure the program's short-term effects and long- term impacts on the general population—for example, the incidence of STDs, and the fertility rate.
  31. Approach to Q Management One of the most widely used paradigms for QA management is the PDCA (Plan-Do-Check-Act) approach, also known as the Shewhart cycle.
  32. Data Collection  Direct observation  Clinical audits  Inspections and accreditation visits  Peer review and individual self- assessment  Operations Research  Service statistics and Management Information Systems  Situation Analysis
  33. Supervision  Effective supervision is the cornerstone of quality control because it gives front-line workers the direction and support they need to apply guidelines to their day-to- day work
  34. Quality Improvement  Quality improvement (QI) is a revolutionary idea in health care. The idea is to raise the level of care—through a continuous search for improvement.  QI asks not just to meet the standards but rather to exceed them—indeed, to raise the norms
  35. The Problem-Solving Process  Step 1: Identify problem areas  Step 2: Analyze the root causes of the problem  Step 3: Design and implement solutions  Step 4: Evaluate and refine the solution
  36. Continuous quality improvement (COI):  The use of incremental and breakthrough quality management techniques to constantly improve processes, products, or services provided to patients to achieve higher levels of customer satisfaction.
  37. Perspectives on quality All QA systems should encompass three perspectives on quality:  Clinical standards  Performance management  Patient satisfaction
  38. What is EBM ? EBM is the integration of 1- Best research evidence, with 2- Clinical expertise, and 3- Patient values.
  39. It is the SYSTEMATIC, SCIENTIFIC and EXPLICIT use of current best evidence in making decisions about the care of individual patients. EBM
  40. The argument for EBM 1- Stay up to date with the current literature. 2- Communicate effectively with consultants. 3- Make the best use of other sources of information, such as pharmaceutical representatives & colleges. 4- Make the best use of information, from the history, physical examination and diagnostic testing. 5- Avoid common pitfalls of clinical decision making.
  41. 5 steps are required : Step 1 : Converting the need for information (about prevention, diagnosis, prognosis, therapy, causation … etc) into an answerable question. Step 2 : Tracking down the best evidence with which to answer that question. How do we actually practice EBM. ?
  42. Step 3 : Critically appraising that evidence for its validity (closeness to the truth), impact (size of the effect) and applicability (usefulness in our clinical practice). Step 4 : Integrating the critical appraisal with our clinical expertise and with our patient's unique biology, values and circumstances. Step 5 : Evaluating our effectiveness and efficiency in excuting steps 1-4 and seeking ways to improve them both for next time.
  43. The stages of clinical audit National Institute for Clinical Excellence. Principles for best practice in clinical audit. Oxford: Radcliffe Medical Press, 2002.
  44. 1- Become : Life – Long learners. 2- Shift : a- From authority and opinion to evidence. b- From intermediate effects to outcomes. 3- Help our patients to become “informed” consumers. We have to
  45. Hadith: Saying of Rasool (pbus)  ‫أحدكم‬ ‫عمل‬ ‫إذا‬ ‫يحب‬ ‫هللا‬ ‫إن‬ ‫يتقنه‬ ‫أن‬ ‫عمال‬ Indeed Allah likes that whoever does a job, he should do it perfectly.
  46. Thank you very much