Ozcan: Chapter 12 Quality Assurance and Quality Control Part 1 Dr. Joan Burtner, Certified Quality Engineer Associate Professor of Industrial Engineering and Industrial Management

Fall 2009ISE 491 Dr. Joan Burtner Ozcan Chapter 12 Part Topics  Part 1  Quality in Healthcare  Quality Experts  Quality Certification  TQM & CQI  Six-Sigma  Part 2  Monitoring Quality through Control Charts Control Charts for Attributes Control Charts for Variables  Process improvement  Methods for Generating New Ideas  Tools for Investigation

Fall 2009ISE 491 Dr. Joan Burtner Ozcan Chapter 12 Part Two Broad Definitions of Quality in Healthcare  Classic Definition  Quality refers to the ability of a product or service to consistently meet or exceed customer expectations.  Issue: Who is the customer?  Institute of Medicine (1990) Definition  “Quality is the extent to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

Fall 2009ISE 491 Dr. Joan Burtner Ozcan Chapter 12 Part Stakeholder Perspectives  Quality of care depends upon who is making the assessment  Clinician-- technical components, adequate skills, resources, conditions  Patients-- outcomes, interpersonal processes, amenities, overall satisfaction  Health Facility Managers- appropriate and effective utilization  Community-- availability, access, reputations, general health status of community

Fall 2009ISE 491 Dr. Joan Burtner Ozcan Chapter 12 Part Adaptation of Donebedian’s Model for Quality Structure Process Outcome Inputs Conversion Process (Throughput) Outputs Patient, provider labor equipment supplies, etc. Various hospital and medical services transform poor health to wellness for patients (diagnosis, procedures, treatments) Treated Patient Source: Figure 12.1 OZCAN, Quantitative Methods in Healthcare Management

Fall 2009ISE 491 Dr. Joan Burtner Ozcan Chapter 12 Part 1 6 Yasar A. Ozcan 6 Quality as Avoidance of Mistakes Principles:  Avoid mistakes by looking at the maintenance of quality.  Reduce undesired outcomes by designing mistake- proof processes.  Deliver safe, effective patient care by reducing variance in diagnostic and therapeutic interventions and the associated errors.  Work toward completely eliminating errors in healthcare systems.

Fall 2009ISE 491 Dr. Joan Burtner Ozcan Chapter 12 Part Quality Gap Categories: Chassin (1998)  Over-utilization exists when the potential benefit of a therapy is less than its risk.  Pressure comes from providers as well as patients  Under-utilization of necessary healthcare may be caused by lack of insurance or insurance that has high co-payments and deductibles.  Miss-utilization is characterized by avoidable complications, negligent care, mistakes, and mishaps.  Harms the overall quality of patient care  Produces poor outcomes  Wastes the organization’s resources  Increases lengths of stay

Fall 2009ISE 491 Dr. Joan Burtner Ozcan Chapter 12 Part Quality Experts  Deming  poor quality caused by the system, not employees  management’s responsibility to correct system  use Fourteen Points to reduce variation caused by special causes (correctable) and not common causes of variation.  Juran: 80% of defects can be corrected by management through planning, control, and improvement  Crosby:  zero defects  quality is free (the cost of achieving higher quality also reduces costs)

Fall 2009ISE 491 Dr. Joan Burtner Ozcan Chapter 12 Part  Organizations can earn awards or achieve certification or accreditation by international organizations or by their own trade organizations.  Baldrige Award, Deming Prize  International Organization for Standardization (ISO), American National Standards Institute (ANSI)  Hospitals are evaluated periodically by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).  For the medical group practices, the Medical Group Management Association (MGMA) is the principal voice. Quality Certification

Fall 2009ISE 491 Dr. Joan Burtner Ozcan Chapter 12 Part Quality Certification – ISO 9000  Set of international standards on quality management and quality assurance, critical to international business  ISO 9000 series standards require firms to document their quality-control systems at every step (incoming raw materials, product design, in-process monitoring and so forth) so that they’ll be able to identify those areas that are causing quality problems and correct them.  Quality Management System - ISO 9000 requires companies to document everything they do that affects the quality of goods and services.  It is estimated that it takes one to one-and-a-half years to go through the entire process of documentation and on-site assessment for certification.

Fall 2009ISE 491 Dr. Joan Burtner Ozcan Chapter 12 Part Ozcan’s View of Total Quality Management  A philosophy that involves everyone in an organization in the quest for quality, with customer satisfaction as the driving force  TQM involves:  finding what customers want  designing services to meet customer needs  designing mistake proof delivery process “pokayoke”  monitoring results and continuous improvement  benchmarking through comparisons to peer providers

Fall 2009ISE 491 Dr. Joan Burtner Ozcan Chapter 12 Part Achieving TQM  Successful TQM requires  Standardized problem-solving techniques  Attitude of continual improvement  Competitive benchmarking  Employee empowerment  Team approach that creates synergy among clinicians, administrators, and support staff  Failure of TQM projects  Lack of motivation, communication, leadership, plan, or dedication  Hodgepodge implementation

Fall 2009ISE 491 Dr. Joan Burtner Ozcan Chapter 12 Part Plan DoAct Check The Deming Wheel/Shewhart Cycle

Fall 2009ISE 491 Dr. Joan Burtner Ozcan Chapter 12 Part CQI is a detailed version of a PDCA cycle that comprises: 1) selecting a process that needs an improvement 2) studying and documenting the current process seeking ways to improve it 3) designing an improved process 4) implementing the new process 5) monitoring and evaluation 6) documenting the process if it worked successfully and publicizing it through the healthcare organization 7) re-starting from step 1, if necessary Continuous Quality Improvement (CQI)

Fall 2009ISE 491 Dr. Joan Burtner Ozcan Chapter 12 Part Six Sigma Six Sigma is an important quality improvement concept that emerged during the 1990’s. Its name comes from the measure of variation from the normal distribution (six standard deviations). Adopting a six-sigma strategy as a quality goal sets tolerance levels for errors (defectives) to levels that occur only 3.4 times per million observations. Example: Healthcare organizations have reduced the deaths caused by anesthesia from per million cases to 5 per million cases since the 1980s through improved monitoring techniques, adaptation of practice guidelines, and other systematic approaches to reduce errors.

Fall 2009ISE 491 Dr. Joan Burtner Ozcan Chapter 12 Part Deployment of Six Sigma  Healthcare and delivery performance focus areas such as:  Clinical excellence  Service delivery  Service costs, and  Patient satisfaction.  Two methodological sequences:  DMAIC: define, measure, analyze, improve, and control  DMADV: define, measure, analyze, design, and verify.  DMAIC is generally used to improve existing systems that have fallen the below six-sigma levels.  DMADV is used to design and develop new processes or products at six-sigma levels.

Fall 2009ISE 491 Dr. Joan Burtner Ozcan Chapter 12 Part Training for Six Sigma The essence of six-sigma methodologies is both improvement of the knowledge and capability of employees, and also changes behavior through training. Thus six-sigma employs a classification system that identifies education and training for employees, project managers and executives. Emulating karate honors, certification is granted at Green Belt (GB), Black Belt (BB) and Master Black Belts (MBB) levels.

Fall 2009ISE 491 Dr. Joan Burtner Ozcan Chapter 12 Part Green Belts (GBs) are the employees who have taken the training courses on implementing the projects. Black Belts (BBs) are the project leaders, whose training may be more intensive; they may complete several projects a year depending upon their size and scope. Master Black Belts (MBBs) are generally assigned to an area that needs improvement (for example, human resources), to ensure that objectives are set, targets are identified, plans are made, and resources are secured to implement the projects in their assigned area. MBBs may oversee many six-sigma projects at a time, working with various BBs. Deployment of Six Sigma Training

Fall 2009ISE 491 Dr. Joan Burtner Ozcan Chapter 12 Part  Six-sigma projects require BBs and MBBs to have expertise in basic statistical techniques, higher level statistics including regression, and statistical modeling techniques.  In addition to statistical concepts, they are expected understand project management, finance, leadership, measurement through socio-metric (survey) analysis, reliability and validity.  Examples of successful six-sigma deployments in healthcare include:  reduction of emergency room diversions  fewer errors in operating rooms ’ cart materials  reduced bloodstream infections in an ICU, and  improved radiology turnaround time Application of Six Sigma

Fall 2009ISE 491 Dr. Joan Burtner Ozcan Chapter 12 Part Dr. Joan Burtner Quality Engineering Contact Information