Chapter 1: The Global Evolution of Continuous Quality Improvement: From Japanese Manufacturing to Global Health Services
Outline
Introduction
Definitions
Characteristics / Elements of CQI
Evolution of CQI in Health Care
Broad-Based Approaches to CQI
Introduction
Continuous quality improvement (CQI) has evolved over time and across countries
Substantial progress has been made in the diffusion of CQI in health, e.g., in public heath
The need for greater diffusion of CQI continues, particularly due to greater complexity in health care systems
Quality and safety problems persist in health care and new techniques are available to address these
Definition of Quality in Health
The WHO definition of quality of care is “the extent to which health care services provided to individuals and patient populations improve desired health outcomes. In order to achieve this, health care must be safe, effective, timely, efficient, equitable and people-centered.”
Components of Health (WHO)
Safe. Delivering health care that minimizes risks and harm to service users, including avoiding preventable injuries and reducing medical errors.
Effective. Providing services based on scientific knowledge and evidence-based guidelines.
Timely. Reducing delays in providing and receiving health care.
Efficient. Delivering health care in a manner that maximizes resource use and avoids waste.
Equitable. Delivering health care that does not differ in quality according to personal characteristics such as gender, race, ethnicity, geographical location or socioeconomic status.
People-centered. Providing care that takes into account the preferences and aspirations of individual service users and the culture of their community
Quality Assurance(QA)
QA focuses on conformance quality, which is defined as “conforming to specifications; having a product or service that meets predefined standards” (McLaughlin & Kaluzny, 2006, p. 37).
QA is sometimes the primary goal of accreditation processes.
Definition of CQI in Health Care
CQI is defined as a structured organizational process for involving personnel in planning and executing a continuous flow of improvements to provide quality health care that meets or exceeds expectations
Common Characteristics of CQI
•a link to key elements of the organization’s strategic plan;
•a quality council made up of the institution’s top leadership;
•training programs for personnel;
•mechanisms for selecting improvement opportunities;
formation of process improvement teams;
•staff support for process analysis and redesign;
•personnel policies that motivate and support staff participation in process improvement;
•application of the most current and rigorous techniques of the scientific method and statistical process control.
Societal Cost of Poor Quality
Crosby: Cost of quality (“Quality is free”, 1979)
Cost of (poor) quality = cost of nonconformance
Poor quality care has an impact on the patients directly affected, the services which provide that care, and society at large
unnecessary costs associated with waste and wasted effort when work is not done correctly the first time.
includes the costs of identifying errors, correcting them, and making up for the customer dissatisfaction that results.
This view leads naturally to a broadening of the definition of quality by introducing the concept of adding value, in addition to ensuring the highest quality of care.
Quality/Accountability/Value
Improving quality involves three aims (“The triple aim: Care, health, and cost”: Berwick et. al, 2008: 759):
Improving the experience of care
Improving the health of populations
Reducing the per capita costs of health care
At a more micro level, improving quality also involves professional responsibility and development
An example of the evolution continuing in the 21st Century
These concepts have evolved further in the second decade of the 21st century to include a fourth aim directed at ensuring the well being of health care providers
See Chapter 2 (Bodenheimer & Sinsky, 2014)
Rationale for Implementation of CQI in Health Care
Health care organizations embark on CQI for a variety of reasons, including:
Engagement in true process improvement
Give customers (patients) the quality care they deserve
AND / OR
Accreditation requirements,
Cost control,
Competition for customers, and
Pressure from employers and payers
Characteristics/Functions of Health Care CQI
(1) Understanding and adapting to the external environment;
(2) empowering clinicians and managers to analyze and improve processes;
(3) adopting a norm that the term customer includes both patients and providers and that customer preferences are important determinants of quality in the process;
(4) developing a multidisciplinary approach that goes beyond conventional departmental and professional lines;
Characteristics/Functions of Health Care CQI
(5) adopting a planned, articulated philosophy of ongoing change and adaptation;
(6) setting up mechanisms to ensure implementation of best practices through planned organizational learning;
(7) providing the motivation for a rational, data-based, cooperative approach to process analysis and change; and
(8) developing a culture that promotes all of the above.
CQI: Philosophy and Process
CQI is simultaneously two things: a management philosophy and a management method.
It is distinguished by the recognition that customer requirements are the key to customer quality and that customer requirements ultimately will change over time because of changes in evidence-based practices and associated changes in education, economics, technology, and culture.
In health care such changes, in turn, require continuous improvements in the administrative and clinical methods that affect the quality of patient care and population health.
Elements of CQI in Health Care
Philosophical Elements
Structural Elements
Health Care Elements
Philosophical Elements of CQI
Strategic Focus
Customer Focus.
Systems View
Data-driven (evidence-based) Analysis
Implementer Involvement
Multiple Causation
Solution Identification
Process Optimization
Continuing Improvement.
Organizational Learning
Structural Elements of CQI
Use of process improvement teams
Use of CQI tools
Creation of parallel organization (Quality Council) to monitor CQI
Gain commitment from top management
Utilize statistical analysis
Develop and review customer satisfaction measures
Use benchmarking
Engage in redesign of processes
Examples of CQI Tools
Flow charts
Run charts
Control charts
Cause and effect diagrams
Frequency
charts
Checklists
Pareto charts
Healthcare Elements of CQI
Use of epidemiological and clinical studies (evidence based medicine)
Involvement of staff in governance and peer review
Use of risk-adjusted outcome measures
Use of cost-effectiveness analysis
Use of quality assurance and risk management data and techniques
Evolution of CQI
From Japan(post-WW II) to US (1960s) to the World (21st century)
Most recently: to low and middle income countries
From TQM to CQI
Pioneers
Deming (14 points)
Shewhart
Juran
Feigenbaum
Crosby
Donabedian
Continuing Evolution in Japan
Taguchi
Ishikawa
Deming’s 14 Points
Deming’s 14-Point Program
Reprinted from The New Economics for Industry, Government, Education by W. Edwards Deming by permission of MIT and W. Edwards Deming. Published by MIT, Center for Advanced Engineering Study, Cambridge, MA 02139. Copyright © 1993 by W. Edwards Demig.
Cross Disciplinary Thinking
Cross-Disciplinary Strategic Thinking
Industrial Versus Health Care Quality
Cons
Ignores complexities patient-practitioner relationship;
Downplays competencies and motivation of the practitioner;
Ignores quality-cost trade-offs;
Gives less to clinical activities than to supportive ones;
Limited perspective on mechanisms for influencing professional behavior such as “education, retraining, supervision, encouragement and censure”
Pros
Importance of health care quality traditions.
Greater attention to consumers
Greater attention to system designs and processes
Expansion of self-monitoring, self-governing tradition to all staff
Greater role by management in CQI
Development of appropriate applications for health care monitoring.
Greater education and training in CQI for all staff
Evolution of CQI in Health Care
From hospitals to all segments of healthcare
From doctors and managers to all staff
From specialized knowledge to generalized competencies
From localized activities to national and international regulatory and accrediation agencies
The Big Bang of CQI
Institute of Medicine
To Err is Human (2000)
Crossing The Quality Chasm (2001)
Data already know, but these report galvanized the press, the public, professional groups and regulators
Increased demands for accountability and professional responsibility
Transfer of concerns from managerial responses, to across the board responsibility
Revised Boynton & Victor Model for Health CareFrom Industrialization to Personalization
Revised Boynton and Victor Model for Health Care
Mass Personalization
Personalization must not be mixed up with customization. While customization relates to changing, assembling or modifying product or service components according to customers’ needs and desires, personalization involves intense communication and interaction between two parties namely customer and supplier. Personalization in general is about selecting or filtering information objects for an individual by using information about that individual (the customer profile) and then negotiating the selection with the individual….
(Tseng and Piller, 2003, p.7)
Examples of Personalization in Health Care
Increased accessibility of data and information leading to increased patient and family participation in decision making
Possibility of personalized medicine – right drug at the right dose at the right time
Focus on individual rather than (chronic) condition, including evidence based medicine and self management
Recent Evolutionary Trends in CQI
The integration of CQI into public health activities
The integration of CQI into nursing education (QSEN)
The expanding role of accreditation.
The global spread of CQI across countries and health services
Greater understanding and use of broad–based applications and methods
PDSA/PDCA
PDSAPlan-Do-Study-Act
Shewhart (PDSA) cycles “provide a structure for iterative testing of changes to improve quality of systems…The pragmatic principles of PDSA cycles promote the use of a small scale iterative approach to test interventions, as this enables rapid assessment and provides flexibility to adapt the change according to feedback to ensure fit-for-purpose solutions are developed” (Taylor et al. 2014, pp.290-291).
PDCA is an alternate definition of PDSA
Used interchangeably
C:Check is equivalent to S:Study
Shewhart (PDSA) Cycle
Shewhart (PDSA) Cycle
Reprinted from The New Economics for Industry, Government, Education by W. Edwards Deming by permission of MIT and W. Edwards Deming. Published by MIT, Center for Advanced Engineering Study, Cambridge,
MA 02139. Copyright © 1993 by W. Edwards Demig.
Key Features of PDSA
The use of repeated iterative cycles
Prediction-based test of change (developed in the plan stage)
Small-scale testing (build as confidence grows – adapting according to feedback and learning)
Use of data over time (to understand the impact of change)
Documentation (to support local learning and transferability to other settings)
Source: Taylor et al. 2014, p.293.
FOCUS-PDCA
The FOCUS–PDCA Cycle
FOCUS-PDCA
FOCUS-PDCA creates common language and an orderly sequence for implementing CQI. It focuses on the answers to 9 questions (Batalden and Stoltz, 1993):
1.What are we trying to accomplish?
2.How will we know when that change is an improvement?
3.What changes can we predict will make an improvement?
4.How shall we pilot test the predicted improvements?
5.What do we expect to learn from the test run?
6.As the data comes in, what have we learned?
7.If we get positive results, how do we hold onto the gains?
8.If we get negative results, what needs to be done next?
9.When we review the experience, what can we learn about doing a better job in the future?
Model for Improvement
Model for Improvement
Reproduced from Langley, G.L., Nolan, K.M., Nolan, T.W., Norman, C.L. and Provost, L.P. (2009), The
Improvement Guide: A Practical Approach to Enhancing Organizational Performance, 2nd ed., Jossey Bass, San Francisco.
Guidelines for StrengtheningPDSA Applications
Four questions to ask when applying or reviewing PDSA applications:
Is the quality improvement study pertinent and relevant?
Are the results valid?
Are appropriate criteria used to interpret the results?
Will the study help you with your practice or organization of care?
(Source: Speroff et.al., 2004, p.36)
Conclusions
Since the advent of the new millennium CQI has continued to evolve in an exponential manner
Globally and across sectors of health care, leading to innovations and paradigm shifts
Examples
Broader applications in low and middle income countries
Institutionalization of CQI in Public Health
Broad-based CQI approaches/methods continue to be used successfully and help account for these trends
PDCA/PDSA
Focus PDCA
The Model for Improvement
However, continued success in using these methods requires care
Recommendations have been presented for greater emphasis on the fidelity of the applications and fuller understanding, and consideration of the context, in which project-specific results are obtained and generalized
Conclusions
The need for greater diffusion of CQI continues, particularly due to greater complexity in health care systems
Quality and safety problems persist in health care and new techniques are available to address these
The evolution of CQI will continue in a broader manner
Future health improvement models will address the questions of quality and cost and the issues of “value-added” care.
