A brief description on quality management of hospital services. It also includes, Kano Model of service satisfaction

1. Colonel Dr Zulfiquer Ahmed Amin
M Phil, MPH, PGD (Health Economics), MBBS
Armed Forces Medical Institute (AFMI)
KANO MODEL OF SERVICE SATISFACTION

2. A measure of excellence or a state of being free from defects,
deficiencies and significant variations.
Quality is "the totality of features and characteristics of a product or
service that bears its ability to satisfy stated or implied needs.“
Definition of ‘Quality’

5. Quality Management
Quality management is the act of overseeing all activities and tasks
needed to maintain a desired level of excellence. It is management
activities and functions involved in determination of quality policy
and its implementation.
It has four main components:
- Quality planning,
- Quality assurance,
- Quality control
- and Quality improvement.
Quality management is focused not only on product and service
quality, but also on the means to achieve it.

6. - Quality planning:
Quality planning is determining the activities required for
"developing the products, systems, and processes needed to meet or
exceed customer expectations." This includes defining who the
customers are, determining their needs, and developing the tools
(systems, processes, etc.) needed to meet those needs.
- Quality Assurance:
Quality assurance is means of providing enough confidence that
business requirements and goals (as outlined in quality planning) for
a product and/or service will be fulfilled.

7. - Quality Control:
A system of maintaining standards in manufactured products or
services by testing a sample of the output against the specification.
The business confirms that the good or service produced meets
organizational goals, often using tools such as auditing and
inspection.
- Quality Improvement:
"The combined and unceasing efforts of everyone to make the
changes that will lead to better patient outcomes (health), better
system performance (care) and better professional development
(learning)". This may be done with noticeably significant changes or
incrementally via continual improvement.

8. Quality assurance is a way of preventing mistakes and defects in
manufactured products and services and avoiding problems when
delivering solutions or services to customers; which ‘ISO 9000’
defines as "part of quality management focused on providing
confidence that quality requirements will be fulfilled".
QA= QC + GMP
Good manufacturing practices (GMP) are the practices required in
order to conform to the guidelines recommended by agencies that
control the authorization and licensing of the manufacture and sale
of food and beverages, cosmetics, pharmaceutical products, dietary
supplements, and medical devices.
Quality Assurance

9. Purpose of QA
• To meet the rising expectations of consumers of quality of
services
• Help patients by improving quality of care.
• Assess competence of medical staff, serve as an impetus to keep
up to date and prevent future mistakes.
• Bring to notice of hospital administration, about the deficiencies
and in correcting the causative factors.
• Help exercise a regulatory function.
• Restricting undesirable procedures.
• Eliminating medical errors, Adverse Drug Events, and HAI.

10. Principles of Quality Assurance
• QA is a never ending process of continuous improvement, and
continuous updating with rapid advances in science and
technology and medical knowledge.
• The emphasis is on establishing professional excellence and
patients’ satisfaction at reasonable cost.
• Quality is not proportionate to the use of sophisticated
technology or to be expensive.
• Technical imperative should not insist on prolonging life at any
cost, with no consideration to quality of life.
• Decisions must be based on data.
• Customers define the quality.

12. 1. Consistency of purpose:
To stay in business requires that leaders spend time on innovation,
research and education. Everything in life should serve a purpose.
From something as simple as tying a shoelace or as big as changing
the world, purpose is what defines life and drives it forward one
stage after the other. If the purpose is clear and the efforts are
consistent, then the sky is the limit.

13. 2. Adopt new philosophy:
Learn and adopt the new philosophy, one of cooperation to
everyone’s benefit. A new (economic) time offers new chances and
challenges, and management must take responsibility for being open
to such changes. Without change, a company can not sustain itself in
a time when innovation occurs every day.

14. 3. Cease dependence on mass inspection:
Quality does not come from inspection, but from improvement of the
process. It is better to that quality checks take place during the
process so that improvements can be made earlier.
4. End lowest tender contracts:
Price has no meaning without measure of the quality purchased. End
the practice of awarding business on the basis of price tag alone.
Instead, move toward a single supplier for any one item, on a long-
term relationship of loyalty and trust.
5. Improve every process:
Improvement is not a project with a finite end. Instead, think
continuous, never ending improvement. Continuous process
improvement of production and service results in improved quality
and productivity, which in turn leads to cost reduction.

15. 6. Institute training on the job:
Training must be done on the job, learning by doing; going into the
work and experimenting with work methods and new ideas, studying
the results, and striving for perfection.
7. Institute leadership of people:
Leadership is required, not supervision. Adopt and institute
leadership aimed at helping people to do a better job.
8. Drive out fear:
Fear is paralyzing. Therefore, fear must be eliminated on the work
floor, so that everyone can work effectively for the company, feel safe
and take risks. To achieve better quality people need to feel secure.

16. 9. Break down barriers:
Break down barriers and silos between departments. Traditionally
each silo becomes independent kingdoms, each trying to maximize
their own figures. In other words build a single system.
10. Eliminate exhortations:
Posters ask people to do what they can not do. Eliminate slogans,
warnings and targets for the work force asking for zero defects. Such
urging only creates hostile relationships. Majority of low quality and
low productivity is caused by faulty system.
11. Eliminate arbitrary numerical targets:
No more focus on achieving certain margins; that impedes
professionals from performing their work well and taking the
necessary time for it. Rushing through the work can cause production
errors. Managers should therefore focus on quality rather than
quantity.

17. 12. Permit pride of workmanship:
We need people to have pride in their work, not in their ability to
meet ratings. Barriers to pride (a basic human need) among other
things, results in low morale and absenteeism.
13. Encourage education:
Integrate and promote training, self-development and improvement
for each employee.
14. Top management commitment and action:
Put everybody in the company to work to accomplish the
transformation. The transformation is everybody’s job.

18. Components of Quality Assurance
1. Strategic or organizational level (Dealing with the quality policy,
objectives and management and usually produced as the Quality
Manual);
2. Tactical or functional level (Dealing with general practices such as
training, facilities etc); and
3. Operational level (dealing with the Standard Operating Procedures
(SOPs) worksheets and other aspects of day to day operations).

19. Models of QA
Donabedian's model to analyse quality includes three factors: structure, process, and
outcome. Structure refers to prerequisites, such as hospital buildings, staff and equipment.
Process describes how structure is put into practice, such as specific therapies. Outcome
refers to results of processes, for instance, results of therapy.

20. ANA Model of QA

21. PDCA (plan–do–check–act or plan–do–check–adjust) is an iterative
four-step management method for the control and continual
improvement of processes and products.

22. Approaches of Quality Assurance Program
1. General Approach:
It involves a large governing or official bodies’ evaluation of a
person or agency to meet established criteria or standards at a
given time.
- Credentialing
- Licensure
- Accreditation
- Certification
2. Specific Approach.

23. Credentialing:
Credentialing is the process of obtaining, verifying, and assessing the
qualifications of a practitioner to provide care or services in or for a
health care organization. Credentials are documented evidence of
licensure, education, training, experience, or other qualifications. A
credential is an attestation of qualification, competence, or authority
issued to an individual by a third party with authority to do so.
Examples of credentials include academic diplomas, academic degrees,
certifications, security clearance etc.
Licensure:
Licensing is a non-voluntary process by which an agency of government
regulates a profession. A process by which a governmental agency
grants time-limited permission to an individual to engage in a given
occupation after verifying that he or she has met predetermined and
standardized criteria (Usually education, experience, and examination).
Example: BMDC issues license for practice of doctors.

24. Accreditation:
Accreditation is the process of formally obtaining credibility from an
authorized body, such as the International Organization for
Standardization (ISO), Joint Commission International (USA),
Accreditation Canada International etc.
Certification:
Formal procedure by which an accredited or authorized person or
agency assesses and verifies (and attests in writing by issuing a
certificate) the attributes, characteristics, quality, qualification, or
status of individuals or organizations, goods or services, procedures
or processes, or events or situations, in accordance with established
requirements or standards. eg, certificate of quality issued by BSTI
(Bangladesh Standards and Testing Institution).

25. Specific Approaches

26. Organizations Providing Quality Indexes
USA, Health & Human Service (HHS) Boston, Massachusetts.
Illinois, United States
Chicago

27. Types of QA
External QA:
QA can be evaluated by independent assessors from outside the
hospitals.
Internal QA:
QA can be evaluated by local assessors (Usually by senior persons)
from the same hospitals.
Benchmarking is a way to compare key metrics to other businesses.

28. QA Cycle

29. QA Committee
- Medical Administrator
- Two Senior Clinicians
- Pathologist
- Radiologist
- Matron (Senior Nurse)
- Medical Record Officer (Secretary)
- Additional Personnel: eg Super-Specialists, consultants

30. Factors Affecting QA in Healthcare

31. Quality Control
Quality control (QC) is a procedure or set of procedures intended to
ensure that a manufactured product or performed service adheres to
a defined set of quality criteria or meets the requirements of the
client or customer.
Quality Control is a system of maintaining standards in manufactured
products or services by testing a sample of the output against the
specification.

32. Although QA and QC are closely related concepts, and are both
aspects of quality management, they are fundamentally different in
their focus:
- QC is used to verify the quality of the output;
- QA is the process of managing for quality.

37. The Kano Model of Customer satisfaction conceptualizes that
satisfaction of clients depend on functionality of three attributes of
products or services:
- Threshold,
- Performance,
- and excitement.
These classifications are useful for guiding design decisions in that
they indicate when good is good enough, and when more is better.
KANO MODEL OF SERVICE SATISFACTION
(1984 by Professor Noriaka Kano)

39. The Kano Model addresses three types of requirements:
- Satisfying basic needs (Threshold attributes): Allows a company to
get into the market.
- Satisfying performance needs (Performance attributes): Allows a
company to remain in the market.
- Satisfying excitement needs (Excitement/delight attributes): Allows a
company to excel, to be world class.

41. Threshold attributes (Dis-satisfiers or Basic Needs):
Expected features or characteristics of a product or service (basic
functionality). These needs are typically “unspoken.” If these needs
are not fulfilled, the customer will be extremely dissatisfied. Example:
Cleanliness of a hotel. This includes a clean bathroom, clean linens
and a pleasant, fresh aroma in the air. When a person books a
reservation at a hotel, they do not request a clean room. They expect
it. If this basic need is not met, they will be extremely dissatisfied.
Improving the performance of these attributes do not guarantee
increased customer satisfaction and may only add to the cost of
product.

42. Performance Attributes (Satisfiers or Performance Needs):
Standard characteristics that increase or decrease satisfaction by their
degree (cost/price, ease of use, speed). These needs are typically
“spoken.” Using the hotel example again, “spoken” needs could be
Internet access, a room away from the elevators, a non-smoking
room, the corporate rate, waiting time at a hospital etc.
The better fulfillment leads to linear increment of customer
satisfaction and absence or poor performance of these attributes will
diminish the customer satisfaction. The price for which customer is
willing to pay for a product is closely tied to performance attributes.

43. Delighters or Excitement Needs:
Unexpected features or characteristics that impress customers and
earn the company “extra credit.” These needs also are typically
“unspoken.” Example: Those who stay in a hotel, are delighted by a
free wi-fi, internet access in TV, HD TV etc; which are not expected
normally.
The presence of these attributes delights the customer and results in
high satisfaction. The absence of these attributes however does not
cause dissatisfaction. The excitement attributes are seen to meet the
latent needs of the customers. The marketers can build on these
attributes to delight the customers and gain competitive advantage. A
point to be noted here is that today’s excitement attribute would
evolve into performance attribute in near future and finally could end
up as a threshold attribute. An example could be power steering in a
car.

44. Examples for the Kano Model
Excitement attributes: Online access via TV, paying via smartphone
Performance attributes: Display resolution, battery life of smart
phones.
Threshold attributes: Customizable ring tones, TV channel search.
Indifferent qualities: Adding emoticons to instant messaging apps,
Capacity of more than 1000 stations in TVs.
Reverse qualities: Displaying apps when changing channels, rust on
motorcycle wheel rims.
Paradoxically, customer expectations for characteristics and features
of products, systems, and services vary greatly. One feature may
excite a customer while another person may take it for granted or
even reject a product because of it.

45. Kano Requirements Type Definitions: A Summary
Requirements Type Definition
Must Be (Expected Quality)
Requirement that can dissatisfy
(expected, but cannot increase
satisfaction)
One-Dimensional (Desired Quality)
The more of these requirements that
are met, the more a client is satisfied
Delighters (Excited Quality)
If the requirement is absent, it does
not cause dissatisfaction, but it will
delight clients if present
Indifferent
Client is indifferent to whether the
feature is present or not
Reverse Feature actually causes dissatisfaction
A competitive product meets basic attributes, maximizes
performances attributes, and includes as many “excitement”
attributes as possible at a cost the market can bear.

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