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)

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

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

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

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.

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

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.

What is involved in insuring Quality?
 Avedis Donabedian suggests
that quality needs to be,
assured in three key aspects
of healthcare:
Structure
Process
Outcomes

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 )

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)

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.

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.)

 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

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

Structure, Process, and Outcomes
are measured at the levels of:
 Health Service Delivery
Systems (Systemic Level)
 Specific Health Conditions
or Services (Clinical
Level).

Each of these levels, in turn, has both
an Internal and an External Focus:

Each of these levels, in turn, has both
an Internal and an External Focus:

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)

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

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.

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"

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

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

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

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

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

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

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

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

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.

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.

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

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

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

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

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.

Perspectives on quality
All QA systems should
encompass three
perspectives on quality:
 Clinical standards
 Performance
management
 Patient satisfaction

What is EBM ?
EBM is the integration of
1- Best research
evidence, with
2- Clinical expertise,
and
3- Patient values.

It is the SYSTEMATIC,
SCIENTIFIC and
EXPLICIT use of current
best evidence in making
decisions about the care
of individual patients.
EBM

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.

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. ?

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.

The stages of clinical audit
National Institute for Clinical Excellence. Principles for best practice in clinical audit. Oxford: Radcliffe Medical Press, 2002.

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

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.

Thank you
very much