A short note on Quality Management of Hospital Services for Public Health students at Post Graduate level

1. Brig Gen Dr Zulfiquer Ahmed Amin
M Phil, MPH, PGD (Health Economics), Advance Course HA (AIIMS, Delhi), MBBS
North South University 1

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’
2

3. 3

4. 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,
-Quality improvement.

5. - 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. It needs to
address all the dimensions of quality of healthcare services.
- 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.

6. - 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.

7. 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

8. 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 to correct the causative factors.
• Help exercise a regulatory function.
• Restricting undesirable procedures.
• Eliminating medical errors, Adverse Drug Events, and HAI.

9. 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.

10. Models of QA
•Donabedian's Model
•PDCA Cycle
Donabedian's Model
Donabedian's model to analyze quality includes three factors:
structure, process, and outcome. Structure refers to inputs, such as
hospital buildings, staff and equipment. Process describes how
structure is put into practice, such as specific therapies, intangible
patient-factors, and competency of managerial functions. Outcome
refers to results of processes, for instance, patient recovered,
patients’ satisfaction, death averted etc.

11. Donabedian Model directs
attention to three essential
components of quality care: inputs,
process, and outcome, and collects
feedback for corrective measures.

12. Plan, Do, Check, and Act/Adjust Cycle
PDCA (plan–do–check–act or plan–do–check–adjust) is an iterative
four-step management method for the control and quality
improvement.
The PDCA/PDSA cycle is a continuous loop of planning, doing,
checking (or studying), and acting. It provides a simple and effective
approach for solving problems and managing change.

13. 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.

14. Credentialing:
Credentialing is the process of obtaining, verifying, and assessing the
qualifications of a practitioner to provide care or services for a health
care organization. Credentials are documented evidence of licensure,
education, training, experience, or other qualifications.
Examples of credentials include MBBS/FCPS/MPH/diplomas
certificate, certifications, security clearance etc.
Licensure:
Licensing is a mandatory 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.

15. 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, Accreditation Council of
Bangladesh (For education) etc.
Certification:
Formal procedure by which an authorized person or agency assesses
and verifies the quality, qualification, or status of individuals or
organizations, goods or services, in accordance with established
requirements or standards and attests in writing by issuing a
certificate. eg, Certificate of quality issued by BSTI (Bangladesh
Standards and Testing Institution).

16. Specific Approaches of QA

17. Organizations Providing Quality Indexes

18. 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 managers)
from the same hospitals.

19. QA Cycle

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

21. Factors Affecting Quality of Healthcare in Bangladesh
-Lack of resources
-Deficiency of manpower
-Improper maintenance of electro-medical equipment
-Patients number beyond capacity
-Excess and uncontrolled attendants
-No report of incidents
-No policy of accreditation requirements
-People are not informed about their right
-Lack of use of ICT in medical practices
-No survey on Patients’ Satisfaction
-Lack of proper maintenance of medical records
- Gap in medical education (not emphasizing on psycho-social aspects
of care)
- Lack of ethical practices

22. Quality Control
Quality control (QC) is a 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.

25. 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)

27. KANO’s Model in Healthcare

29. 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.

30. 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.
Improving the performance of these attributes far above base level,
do not guarantee increased customer satisfaction and may only add
to the cost of product.

32. Performance Attributes (Satisfiers or Performance Needs):
Standard characteristics (Intangible dimensions of quality of
healthcare) that increase or decrease satisfaction by their degree of
attainment. 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, 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.

34. 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
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.
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, colour TV.

36. Kano Requirements Type Definitions: A Summary
Requirements Type Definition
Must Be (Expected Quality)
Requirement that can dissatisfy
(Expected, but cannot increase
satisfaction by adding more attributes).
eg, availability of doctor.
One-Dimensional (Desired Quality)
The more of these requirements that
are met, the more a client is satisfied.
eg, less waiting time, more
consultation time, behavior of doctor
Delighters (Excited Quality)
If the requirement is absent, it does
not cause dissatisfaction, but it will
delight clients if present. eg, most
modern equipment, robotic surgery.
A competitive product meets basic attributes, maximizes
performances attributes, and includes as many “excitement”
attributes as possible at a reasonable price to the customer.

37. Sources of Quality Attributes
Leading Edge Forum (LEF) is a global research and thought leadership program

38. TQM
Total Quality Management, or TQM, can be summarized as a
management system for a customer-focused organization that
involves all employees in continual improvement.
TQM is based on the participation of all members of an organization
in improving inputs, processes, products, services, and the culture in
which they work.
TQM is a process which embraces the conscious striving for zero
defects in all aspects of an organization's activities or management
with workforce co-operating in the processes, developing, producing
and marketing quality goods and services which satisfy, customers'
needs and expectations first time and every subsequent time.

40. Conclusion
Overall improving the quality and performance in the healthcare
environment can help providers with reliable, cost-effective and
sustained healthcare processes and enable them to achieve their
goal of improving care delivery and enhancing patient outcomes.