Introduction

More than 40 years ago, Donaldian proposed measuring the quality of healthcare by observing its structure, process and outcomes.

 

Structure:

1. Measures
2. asses the accessibility
3. availability and quality of resources such as health insurance
4. Bed capacity of hospital
5. No of nurses with advanced training

 

Process:

Measure access of delivery of healthcare services by clinicians & providers, such as using guidelines for care of diabetes patients.

 

Outcomes:

1. Measures indicate the final result of healthcare and can be influenced by environmental and behavioral factors. Eg: Mortality & patient satisfaction improved health status.
2. 20 years later, healthcare leaders borrowed techniques from the work of Deming, The father of Total Quality Management (TQM) promoted “consistency of purpose” and systematic analysis and measurement of process steps in relation to capacity or outcomes.
3. The TQM Model is an organizational approach involving management, teamwork, defined process, systems thinking & change to create an environment for improvement. This approach incorporated the view that the entire organization must be committed to quality and improvement. This approach incorporated the view that the entire organization must be committed to quality and improvement to achieve the bet result.
4. TQM is a management strategy aimed embedding awareness of quality in all organizational.

 

Quality Control

1. TQM enjoyed widespread attention during the late 1980s & 1990s before being overshow by ISO, Lean six manufacturing and six sigma.
2. In healthcare Continuous Quality Improvement (CQI) is used interchangeably with TQM.
3. CQI has been used as a means to develop clinical practice and is based on the principle that there is an opportunity for improvement in every process and every occasion.

 

Quality Assurance:

Programma’s of hospital generally focus on issue’s identified by regulatory or accreditation. Reviewing the work of oversight committees and studying credentialling process.

 

PDCA

The Deming cycle is a model of a logical sequence of four representative steps continuous quality improvement and learning.

1. Concept of PDCA is based on the specific method “hypothesis – experiment – evaluation.”
2. Shewart cycle- Specification production in function in 1939. PDCA, “Deming cycle” developed in Japan on 1950 by Dr W. Edward Deming.

The Deming Cycle – Procedure

1. Plan: Plan ahead for change, analysis and predict the results.
2. Do: Execute the plan, taking small steps in controlled circumstances.
3. Study: Check, Study the result.
4. Act: Take action to stimulate or improve the process.

When to Use Plan – Do – Check act

1. As a model for continuous improvement.
2. When starting a new improvement project.
3. When developing a new or improved design for a process product or service.
4. When defining a repetitive work process.
5. When planning data collection and analysis is order to verify a prioritize or root cause.
6. When implementing any change.

ISO (International Organization for Standardization)

1. A network of National standard bodies makes up the ISO membership and represent ISO in their country.
2. ISO have different acronyms in different language (IOS in English, OIN in French). So, founder decided to give it short form.
3. ISO derived from Greek word ISOs means “equal”, whatever the language, the short form is ISO.
4. ISO International Standard ensure that product & services are safe, reliable & of good quality.
5. For business, they are strategic tools that reduce costs by minimizing waste and errors and increasing productivity. For companies, to access new market and facilitate free and fair global trade.

 

Six Sigma

1. It measures how many defects errors in a process.
2. Then figure out how to systematically eliminate them.
3. Finally get us close to perfection as possible.
4. Six sigma is a set of technique and tools for process improvement.
5. It improves the quality of process outputs by identifying & removing the cause of defects (error & minimizing variability in manufacturing and business process).
6. Six sigma combines established methods such as statistical process control, design of experiments, failure mode & effect analysis in an overall form.
7. Six sigma structure creates a special infrastructure of people within organization.

a. Champions

b. Black Belts

c. Green Belts

d.  Yellow Belts

 

Lean:

1. Maximize customer value while minimizing waste. The ultimate goal is to provide perfect value to the customer through a perfect value creation process that has zero waste.
2. Lean eliminates waste along entire value streams.
3. Creates processes that need less human efforts, less share, less capital, and less time.
4. Provides services at less costs & with much fewer defects, compared with traditional business system.
5. Lean focuses on eliminating of waste process such as

a. overproduction

b. Unnecessary stock

c. Inefficient transportation

d. waiting times

e. Rejects & defects

f. Inappropriate processing

 

Quality Circle:

Groups or people oriented. A quality circle is a participationary management technique that insists the help of employees in solving problems related to their own job.

 

Kaizen

1. It is a concept in which we practice continuous improvement in order to refine each and every process, making it more efficient and easier along the way.
2. Kaizen in Japanese means “change for the better.”
3. Kaizen in English means “continuous improvement.”

 

FOCUS – PDCA

1. F= Find a process/opportunity for improvement
2. O= Organize a team
3. C= Classify a current knowledge of process
4. U= Uncovers cause of process variation
5. S= Select improvement

 

FEMA

1. Failure mode effect analysis.
2. Select a high-risk process & assemble a team
3. Diagram the process
4. Brainstorm potential failure modes
5. Estimate the probability of detection
6. Calculate the risk priority number
7. Prioritize failure mode
8. Identify contributing factors of failure mode
9. Redesign process
10. Analyze and test the new process

 

SIX SIGMA           

Six sigma at many organizations simply means a measure of quantity that strives for near perfection. It is a disciplined data-driven approach and methodology for eliminating defects (driving towards six standard deviations between the mean and the nearest specification limit) in any process – from manufacturing to transactional and from product to service.

The statistical representation of six sigma describes quantitatively how a process is performing. To achieve six sigma, a process defect is defined as anything outside of customer specifications. A six sigma opportunity is then the total quantity of chances for a defect. Process sigma can easily be calculated using a Six Sigma Calculator.

Six Sigma has 2 key methodologies. DMAIC and DMADV. DMAIC is used to improve an existing business process. DMADV is used to create new product designs or process designs in such a way that it results in a more predictable, mature & defect free performance. Sometimes, a DMAIC project may turn into a DFSS project because the process in question requires complete redesign to bring about the desired degree of improvement.

 

DMAIC

1. Define: The process improvement goals that are consistent with customer demands and enterprise strategy.
2. Measure: The current process & collect relevant data for future comparison.
3. Analyze: To verify relationship & causality of factors. Determine what the relationship is, and attempt to ensure that all factors have been considered.
4. Improve: Or optimize the process based upon the analysis using techniques like Design of Experiment’s.
5. Control: To ensure that any variances are corrected before they result in defects. Set up pilot runs to establish process capability, transition to production and thereafter continuously measure the process & institute control mechanisms.

DMDAV

Basic methodology consists of the following steps:

1. Define: The goals of the design activity that are consistent with customer demands & enterprise strategy.
2. Measure & Identify: CTQs (critical to qualities), product capabilities, production process capability & risk assessments.
3. Analyze: To develop & design alternatives, create high-level design and evaluate design capability to select the best design.
4. Design Details: Optimize the design, and plan for design verification. This phase may require simulations.
5. Verify the design: Set up pilot runs, implement production process and handover to process owners.

Some people have used DMAICR(Realize). Others contend that focusing on the focusing on the financial gains realized through Six Sigma is counter-productive & that said financial gains are simply by products of a good process improvement. Another additional flavor of design for six sigma is the DMEDI methods.

This process is almost exactly like the DMDAV process, utilizing the same toolkit, but with a different acronym. DMEDI stand for define, measure, explore, develop & implement.

 

Process Capability

Process Capability = 6s

This represents a more pragmatic & realistic definition of process capability, since covering the population and measuring the quality characteristic to determine sigma is almost impossible, given the volumes of production and the like.

To process planners the figure of process capability is probably not as useful as the measure which indicates how well the process is doing with respect to the specifications indicated for the quality characteristic in question. Therefore, if the Upper Specification Limit (USL) & the Lower Specification Limit (LSL) are fixed for a certain important quality characteristic, then it is important to know whether the process can ‘hold tolerance’ or not. This ability determined by the Process Capability Index, Cp, defined as:

Cp= USL-LSL/6s

 

5- M Checklist

The important resources or inputs of the organization are the following if these are checked & controlled, there can be process control also. What will be the methods of control or how the mechanism of control can be devised has been given below:

1. Man
2. Machine
3. Material
4. Method
5. Measurement

Men

1. Does he know what to do?
2. Does he have standard?
3. Is he following his standard?
4. Is he adequately trained and qualified?
5. Is his rate of work acceptable?
6. Is he assigned to the right task?
7. Is he willing to improve his standards?

If all these parameters in respect of the manpower deployed in the organization is taken care of the human error in process can be reduced to the significant level.

 

Machine

Does it meet the requirement of production?

Does it meet the requirement of process capability?

Is it appropriately laid down?

Is it easy to maintain and operate?

Is it easy to set up?

Does it exhibit any drift over time?

There is need of designing, procurement and installation of the right kinds of machines. These machines are maintained well, there is no down time. These machines are utilized adequately. The quality can be ensured.

 

Material

Is the material of the right (desired) physical and chemical (or other) properties?

Is the volume, and the manner of receipt appropriate?

Is it free from impurities?

Is it stored appropriately prior to production/processing?

Is it likely to be mixed up with the ‘material-in-process’?

Is the material suitable for processing changes?

Is it liable to stock-outs/deterioration prior to processing?

The materials management and inventory control is an important aspect of the management. The materials are important resources for any process.

 

Method

Is the appropriate method documented?

Does the method ensure the desired outcome?

Is the method safe?

Is it efficient?

Does it dovetail with other methods/ processes in the organization/ prior or next process?

Is there a means to improve the method?

Is the working environment appropriate?

The quality assurance depends much upon the right methods of doing things are at the right place. There are available, understood and being practiced rightly will ensure the process control.

 

Measurement

Is there a clearly defined unit of measurement?

Is there an appropriate standard?

Are the right means of measurement available?

Is there a provision of calibrating all measurements devices? And regularly?

Are the measurement devices easy to read?

Are the measurement stimulate improvement or corrective action, where needed?

Are the measuring devices suitably stored?

There should be standard methods of measurements, not only that: the tools which are being used for the measurement of all other activities are also measured and calibrated for their accuracy. This is important aspect of the process control.

 

Variance in Quality

If we accept that the system is combination of these five elements, and any process exhibits a certain amount of variation on account of randomness in the elements of system itself. the variation will be acceptable as long as the system is able to deliver its output as planned and the system as a whole does not show any drift in consistency.

If the system has to be stable, exhibiting minimum of variation, the focus must be on the five elements as enumerated above. The figure above indicates the relationship between the variation of each of the five elements. If we are able to reduce the variation of each of these elements, we will bring our system into a state of control. The required output will be consistent over the time.

 

Application of “5 S” Technique for Quality Assurance in Housekeeping Services of the Hospital

The housekeeping is an important component of any hospital. It is not only important from the point of view of the patients or their attendants but also from the point of view of the service providers. The work environment improves, the efficiency of the employees, is a proven fact. The “5S” technique is very useful for any health care organization, for improved housekeeping.

“5S” stands for Japanese words- all starting with ”S”, these can be translated into English words also starting with ”S”. Therefore it is not necessary to remember “5S” in Japanese, what is important is to understand what it conveys, and practice it, rather than just memorizing the words.

Japanese in their language call these steps as SEIRI (Sorting), SEITON (Segregating), SEISO (Shine/sweep), SEIKETSU (Standardize) and SHITSUKE (Sustain/ self-discipline).

SEIRI (Sorting):  Sorting is about separating the things which are necessary for the job from those that are not, keeping the number of necessary ones as low as possible and at a convenient location.

SEITON (Segregating): It is a question of how quickly you can get the things you need and how quickly you can put them away. Just making an arbitrary decision on where things go is not going to make you any faster. Instead, you to analyze why getting things out and putting them away takes so long. You have to study this for both the people using the things frequently and those who seldom use them.

SEISO (Shine/Sweep): Everyone is a sweeper. Cleaning should be done by everyone in the organization, from the managing director to the sweeper. This is why in japan, they do not need street sweepers in residential areas. Every family is responsible for cleaning the pavement in from of their houses. Therefore, what they need are rubbish collectors.

SEIKETUS (Standardization): Standardization means continually and repeatedly maintaining organization through neatness and cleaning. As such, it embraces both personal cleanliness and the cleanliness of the environment. The emphasis here is on visual management and “5S” standardization.

SHITSUKE (Sustain/Self-discipline): Self-discipline means instilling the ability of doing things the way they are supposed to be done. The emphasis here is on creating a workplace with good habits. By teaching everyone what needs to be done and having everyone practicing it.

In industries the “5S” has been applied for better housekeeping and it is equally relevant for the health care organizations.