2. Introduction
The basic characteristics of service delivery in our hospitals are
characterized by:
– Long waiting time
– Overcrowding
– Unhygienic and disorganized work environment
– Wastage
3. Many Hospitals do not look at patients as human being
●Dignity
•Basic human needs
•Prompt attention in care and treatment
•Confidentiality
•Communication
•Autonomy
4. Disorganized Hospital
•Long waiting time for consultation and other services
•Doctor or nurse cannot be contacted during emergencies
•Wrong administration of drug or infusion
•Hospital acquired infection
•Inaccurate pathological test results
•Test result is lost
•Poor record keeping system
•Failing supply system
•Hospital accidents
5. The ageing of the population, coupled with rising affluence and
greater consumer education has changed consumers' needs and
bargaining power. At the same time, the increasing sophistication of
medical technologies will change the delivery of services even as it
changes the way medicine is practiced. Many developed countries,
like the United States and the United Kingdom, are facing similar
challenges.
6. Situations in developing countries
-To run health facilities, resources are needed. These include
financial, human, materials and infrastructure resources. It is
commonly found in developing countries that both government
health facilities and private health facilities are facing serious
resource shortage.
-There is a chronic shortage of government subsidy funds.
Unavailability of sufficient health insurance cover to the population
compounds the financial resource problem of the health facility.
Cost recovery through cost sharing is insufficient.
-The number and skill mix of the health workers is insufficient.
-The infrastructure is dilapidated.
7. All these chronic constraints lead to deterioration in efficiency &
quality of services manifested by poor preparedness in the delivery
of services, poor standards, poor or no increase of service packages,
inequity in service provision and insufficiency in clients’ satisfaction.
The answer to this lies with how we manage the available resources
and work environment.
8. To address this dilapidation in healthcare, for the past 10 years
global health policy has slowly shifted focus among three areas:
access, cost, and quality of medical care. Each area has successively
received concentrated attention, often at the expense of the other
two. The situation can be viewed as a slowly rotating triangle that
sequentially brings one after another of its vertices into principal
focus.
9. For example, in USA, access to care received primary attention
during the late 1960’s and early 1970s. That period saw the
implementation of major federal initiatives intended to guarantee
that all Americans could easily obtain high-quality health care.
Medicare and Medicaid were introduced, and hospitals and
medical schools were given federal monies for health care and
health education programs of every description.
10. But during the late 1970s the federal government and private health
financiers noted the high and increasing costs that grew from earlier
'access to care' initiatives. The triangle turned. Emphasis shifted
from a primary focus on access to a primary focus on cost. Cost
control efforts were extended to physicians as well as hospitals.
Health budget $3.3 trillion (26% of GDP), or $10,348 per person in 2016 in USA
11. It is not yet clear whether health care costs have been controlled. But
financial risk sharing and competition have placed providers—
physicians and hospitals—in an uncomfortable dilemma: they stand
to gain financially if they lower the cost of the care they deliver, but
that may simultaneously reduce access and quality. A growing chorus
of providers, consumers, and political leaders voice a fear that, due
to cost controls, needed care is
being withheld.
12. In spite of billions of dollars of money spent worldwide, most of the
healthcare is seen to be ineffective, inefficient and inadequate.
Therefore there is a crying need to bring about a paradigm shift in
the quality of health care delivery and to monitor and sustain it.
The triangle is changing—it may no longer be acceptable to
concentrate primary attention on a single vertex. Cost containment
still demands close attention but quality and access are becoming
simultaneous, serious concerns. The value of health care the highest
possible quality at the lowest reasonable cost-is shifting into primary
focus.
13. Quality health care is defined as "doing the right thing, at the right
time, in the right way, for the right person at lowest reasonable
cost—and having the best possible results.'"
19. What Are The Aims Of Healthcare Improvement?
Safety:
It renders a protective shield that avoids the patients from injuries
for the care.
Effectiveness:
Care that, wherever possible, is based on the use of systematically
obtained evidence to make determinations regarding whether a
preventive service, diagnostic test, therapy, or no intervention
would produce the best outcomes.
20. Patient-Focused:
This concept encompasses the following: respect for patients'
values, preferences, and expressed needs; coordination and
integration of care; information, communication, and education;
physical comfort; emotional support (i.e., relieving fear and
anxiety); and involvement of family and friends.
22. Real-time:
Health care that is delivered in a timely manner (i.e., without
long waits that are wasteful and often anxiety-provoking).
Efficiency:
It avoids certain wastes that include effort, idea, supply as well as
equipment. (i.e., uses resources to obtain the best value for the
money spent).
Equitability:
Basing on personal characteristics, the rendered healthcare quality
mustn’t differ. (i.e., care should be based on an individual's needs,
not on personal characteristics--such as gender, race, or insurance
status-- that are unrelated to the patient's condition or to the
reason for seeking care).
23. Quality improvement (QI) consists of systematic and continuous
actions that lead to measurable improvement in health care services
and the health status of targeted patient groups.
A successful QI program always incorporates the following four key
principles:
• QI work as systems and processes
• Focus on patients
• Focus on being part of the team
• Focus on use of the data
System: A set of things working together as parts of a mechanism.
Process: A series of actions or steps taken in order to achieve a particular end
24. QI Work as Systems and Processes
To make improvements, an organization needs to understand its own
delivery system and key processes. The concepts behind the QI
approaches in this toolkit recognize that both resources (inputs) and
activities carried out (processes) are addressed together to ensure or
improve quality of care (outputs/outcomes).
25. key components of healthcare delivery system comprises inputs,
processes, and outputs/outcomes:
27. Activities or processes within a health care organization contain two
major components:
1) what is done (what care is provided), and
2) how it is done (when, where, by whom and by what standard care
is delivered).
Improvement can be achieved by addressing either component;
however, the greatest impact for QI is when both are addressed at
the same time.
28. Focus on Patients
An important measure of quality is the extent to which patients’
needs and expectations are met. Services that are designed to meet
the needs and expectations of patients and their community
include:
• Systems that affect patient access
• Care provision that is evidence-based
• Patient safety
• Support for patient engagement
• Coordination of care with other parts of the larger health care
system
• Cultural competence, including assessing health literacy of
patients, patient-centered communication, and linguistically
appropriate care
29. Focus on Being Part of the Team
At its core, QI is a team process. Under the right circumstances, a
team harnesses the knowledge, skills, experience, and perspectives
of different individuals within the team to make lasting
improvements. A team approach is most effective when:
• The process or system is complex.
• No one person in an organization knows all the dimensions of an
issue.
• The process involves more than one discipline or work area.
• Solutions require creativity.
• Staff commitment are needed.
30. Focus on Use of the Data
Data is the cornerstone of QI. It is used to describe how well current
systems are working; what happens when changes are applied, and
to document successful performance.
Using data:
● Separates what is thought to be happening from what is really
happening
● Establishes a baseline (Starting with a low score is acceptable)
● Reduces placement of ineffective solutions
● Allows monitoring of procedural changes to ensure that
improvements are sustained
● Indicates whether changes lead to improvements
● Allows comparisons of performance across sites Both quantitative
and qualitative methods of data collection are helpful in QI efforts.
31. 5S-CQI (Kaizen)-TQM is a management technique to improve
productivity and quality on a continuum scale. It was introduced in
Japan after the World War II in a war-ravaged country to revive
economy. It is mostly suitable in resource strained situations, like
the third world countries. In Bangladesh, this approach was
introduced in 2011, and the process is now being implemented in
more than 120 hospitals. 5S-Kaizen-TQM is a Govt program
supported by JICA, UNICEF, WHO and GIZ
5S-CQI (Kaizen)-TQM
34. 5s
5S is a system, uses a list of five Japanese words for organizing
spaces, so work can be performed efficiently, effectively, and safely.
This system focuses on putting everything where it belongs and
keeping the workplace clean, which makes it easier for people to do
their jobs without wasting time or risking injury.
There five 5S phases are translated to:
In some quarters, 5S has become 6S, the sixth element being safety.
5S is the initial step towards establishing Total Quality Management
(TQM).
37. Sort (Seiri)
-First step towards 5S journey.
-Make work easier by eliminating obstacles.
-Reduce chances of being disturbed with unnecessary items.
-Remove all parts or tools that are not in use.
-Segregate unwanted material from the workplace.
-Define Red-Tag area to place unnecessary items that cannot
immediately be disposed of. Dispose of these items when possible.
-Need fully skilled supervisor for checking on a regular basis.
-Waste removal.
-Make clear all working floor except using material.
-Floor will be Epoxy Flooring (If possible).
39. Set in order (Seiton)
-Arrange all necessary items so that they can be easily selected for
use.
-Prevent loss and waste of time by arranging work station in such a
way that all tooling / equipment is in close proximity.
-Make it easy to find and pick up necessary items.
-Ensure first-in-first-out (FIFO) basis.
-Make workflow smooth and easy.
-All of the above work should be done on a regular basis.
-Place components according to their uses, with the frequently used
components being nearest to the work place.
- Use 5s-tools to set the working place.
54. Shine/Sweeping (Seiso)
-Clean your workplace on daily basis completely or set cleaning
frequency time to time
-Use cleaning as inspection.
-Prevent machinery and equipment deterioration.
-Keep workplace safe and easy to work.
-Keep workplace clean and pleasing to work in.
-When in place, anyone not familiar to the environment must be
able to detect any problems within 50 feet in 5 sec.
58. Standardize (Seiketsu)
-Establish procedures and schedules to ensure the consistency of
implementing the first three ‘S’ practices.
-Develop a work structure that will support the new practices and
make it part of the daily routine.
-Ensure everyone knows their responsibilities of performing the
sorting, organizing and cleaning.
-Use photos and visual controls to help keep everything as it should
be.
-Review the status of 5S implementation regularly using audit
checklists.
-Ensure standardizing color codes for usable items.
61. Sustain (Shitsuke)
-Also translates as "do without being told".
-Perform regular audits.
-Training and discipline.
-Training is goal-oriented process. Its resulting feedback is necessary
monthly.
-To maintain proper order, ensure all defined standards are being
implemented and heard.
-Follow the process, but also be open to improvement
63. Targets of 5-S principles are:
• Zero changeovers
• Zero defects leading to higher quality
• Zero waste leading to lower cost
• Zero delays leading to on-time delivery
• Zero injuries thus promoting safety
• Zero breakdowns bringing better maintenance
• Zero customer complaints, i.e., client satisfaction
• Zero red ink, i.e., betterment of organization’s image
65. Kaizen (Kai„Zen) is a Japanese term taken from words 'Kai', which
means continuous and 'zen' which means improvement. Kaizen (or
‘continuous improvement’) is an approach of constantly introducing
small incremental changes in a business in order to improve quality
and/or efficiency. This approach assumes that employees are the best
people to identify room for improvement, since they see the
processes in action all the time.
74. PDCA Cycle
KAIZEN process is divided into four sequential categories: plan, do,
check, and act (the PDCA cycle). In the planning phase, people
define the problem to be addressed, collect relevant data, and
ascertain the problem's root cause; in the doing phase, people
develop and implement a solution, and decide upon a measurement
to gauge its effectiveness; in the checking phase, people confirm the
results through before-and-after data comparison; in the acting
phase, people document their results, inform others about process
changes, and make recommendations for the problem to be
addressed in the next PDCA cycle.
77. TQM
Total Quality Management (TQM) is a management approach that
aims for long-term success by focusing on customer satisfaction.
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 comprehensive and structured approach
to organizational management that seeks to improve the quality of
products and services through ongoing refinements in response to
continuous feedback.
78. Total Quality Management (TQM)
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.
79. Principles of TQM are:
The Theme: TQM must be grounded in a continuous improvement
philosophy. It is geared to the continuous improvement of quality in
a hospital.
The Focus: TQM is customer-focused. It is based on customer
expectations and on meeting customer needs.
The Control: TQM requires analytical knowledge and skills and an
organization's long-term commitment. The use of analytical tools
and techniques to evaluate and improve processes.
80. The Approach: TQM requires a structure and organization that must
be tailored to the unique internal and external culture and
environment. A supportive culture and organization should be
established to ensure the success of a wide range of quality
improvement efforts.
The Scale: TQM involves interpersonal or people skills. As work is
accomplished by people, the involvement of everyone in the
organization and the empowerment of staff are critical to success in
a highly competitive healthcare environment. Better ideas are
generated and changes implemented faster if staff closer to the
process are involved in the analysis and decision-making process.
The Scope: TQM's focal point is leadership and collaborative
teamwork.
96. As customers’ expectations rise, patient care becomes more
complex, and resources continue to shrink, hospitals are finding that
traditional approaches to defining, organizing, and staffing quality
assurance functions are no longer adequate.
97. In a resource poor set-up, 5S-CQI-TQM approach for continuous
quality improvement is the most cost-efficient, lasting and easy to
materialize approach for quality improvement. “Continuous quality
improvement” or “total quality management” are names for a
philosophy of management that aims to help organizations of all kinds
improve performance through eliminating poor quality during
production or delivery of the product or service rather than through
trying to fix the results after the product has been made or the
service given.