Table of Contents
CHAPTER 1: INTRODUCTION
In this vibrant era of competition in healthcare environment, competition is expected to be hostile with survival of fittest. The rapid growth in population, the rising affluence and increased consumer education brought a dynamic change in customers’ needs and dealing powers. Simultaneously, the rising sophistication in medical technology not only changed the services delivery nevertheless, it has also changed the way medication is practiced. According to Huq.Z, (1996), the challenge of increasing change in medical technology is also being faced by many developed countries including United Kingdom and United States. Along with, the cost and government regulations also pressurize hospitals to reconsider their quality management programs. TQM is considered to be a complete and planned system for the organization management structure that gets superior quality of services and products while using efficient modification in reaction to constant feedback, and utilizing them competently to bring excellent value for the consumer, though achieving long-standing goals of the company.
Therefore, to address these uncertainties healthcare organizations are seeking out for many solutions. For this purpose, hospital managements started to implement Total quality management programs in hospital. Before implementing quality management strategies first it is important to understand what total quality management is. There exist multiple definitions for total quality management. Many scholars of this field including Deming, Crosby, Juran and Ishikawa defined quality management in different ways but the essence behind this concept remains the same. Deming who is known as the father of quality management define TQM as the systematic activities taken by the entire organization for continuous improvement in the quality process towards the achievement of organizational objectives and goals . Another definition by , who describe quality as “fitness for use”. Further, he explained that every individual in the organization should work and involved for the improvement in quality of product that could be fit for use. Crosby (1979), define quality management as conformance to requirements. He describes quality as having “no defect” in the product and doing the right thing at first time.
Ishikawa(1986) classify quality as it does not only mean to have a good quality in the product but also giving after services including sales, quality of management, quality in human resource and the quality in the company itself. The focal point of TQM mainly give an importance to the customer and supplier relation which is known as “quality chains”. Any organization could not afford to break up their prestige relationship with their customers on the base of any incompetency in the product or not meeting up the customer requirement. Failure in the requirements in a single division of the quality chain may result in the breakdown of single part of the whole system which could further results in failure of whole system. The quality management system provide and ensure the quality of the product. The product quality include different aspects including reliability, stability and performance.
By introducing a quality management system, the organization can give their best performance and quality of the certain product. With this system organization not only can improve the quality level of their product but also save the cost and can introduce more designs and innovative products. To implement a quality management system there exists different techniques that help the management to implement a sophisticated management system. These include, standards of ISO, six sigma, Malcolm Bridge model, Good manufacturing practice, EFQM model and so on. Some of these techniques that could be better implemented in a hospital management system are described in detail in the following sections
CHAPTER 2: IMPLICATION OF W.EDWARDS FOURTEEN QUALITY POINT
“The Expert project, a study on external quality mechanisms for healthcare, has identified four principal models and national variants of external quality improvement in healthcare” (Shaw 2000). The models which are being used are the medical specialty driven known as “visitatie” used in the Netherlands, traditional accreditation, European Quality Awards known as “EFQM and national variants” and at last certification using ISO 9001:2000. A similarity has been seen between all four models, (Klazinga 2000). Above of the entire models EFQM- model is seen to be best in accordance to management tool for supporting top management.
The EFQM-model can be best seen as management model to support top management in pursuing the total Quality Management. Further, according to Nabitz (2000), As EFQM, ISO 9001:2000 is also like EFQM a generic model, is giving attention on management of quality and developing quality management systems. The EFQM-model has proved its value and importance in sector of healthcare, 2.1 W. Edwards Deming 14 points of quality:
Edward Deming who is known as the guru of quality management first introduced the basic philosophy of management to the Japanese, which allowed them to conquer the industry without any competition in the industry. An essential change is required in management policies to gain superior quality with low cost. To address this dilemma Deming introduced 14 points to achieve high quality that include: 1. Constant strive for the improvement in services and products. 2. Implementation of total quality philosophy
3. To correct the defects when happens
4. Presenting business on more than price alone
5. Improving constantly the mechanism of service and production 6. Institutionalization of training in jobs
7. Adoption and implementation of Leadership
8. Eliminate fear
9. To reduce the barriers among the staff area
10. Reduce superficial goals and slogans
11. Abolish arithmetic quotes for workforce as well as for management 12. Eliminating barriers that hold up the employees’ satisfaction of workmanship 13. Initializing dynamic educational and self development programs 14. Place each person in a company to work for the innovative work
2.2 TQM in Healthcare:
After defining and understanding the quality management it is important to understand that how healthcare organizations can bring and implement quality in their services, products and outcomes with less cost. In healthcare center implication of quality management system is taking more attention in this time period. In order to execute the management system of hospitals more effectively the UAE public healthcare also has implemented Total quality management philosophy. The vision behind to implement the TQM system in healthcare industry of UAE is to improve their quality, concerning their patients and to cut the cost. The framework to execute this vision includes many standards including change in cultural management system, teamwork strategy, introducing reward system, by empowering the staff to evaluate and solve problems and training and development of staff etc. To understand the quality system of hospitals in UAE this study will consider and study the quality management system of hospital Dubai At Medical Center, it is considered a fundamental phenomenon to build up a good relationship among the patient and doctor.
In September 1993, Gulf Medical Projects Company established Private Medical Centre. The company provides the modern medical faculties to the expatriate and local population of UAE. Based on the notion to provide complete healthcare facilities under a single roof, this healthcare center provide emergency services in majority surgical and medical areas along with family practice and dentistry. These are accompaniment by a large selection of additional services that includes radiology, clinical laboratory and physiotherapy Hospital show great concern in order to ensure that for treatment and diagnosis of disease best equipments are utilized. Medical Center is the former hospital of its kind which offers full medical services with full support and back up of major private hospitals. This study focuses on the quality concerns of hospital Dubai that includes 1. Customer focus
2. Human resource management
4. Process management
5. Strategy focus
6. Performance management
7. Change management
8. Continuous improvement
The next part of this study focuses on Application of total quality management, application of framework and methodology, application of standards and application of rewards.
2.3 IMPLICATIONS OF TOTAL QUALITY MANAGEMENT
Now a days, Total Quality Management is an integral part of hospitals. In this competitive era, the quality demand has been increased with respect to price. Consumers require quality in an exchange of what they are paying.
Total quality management has its great impact on the hospitals’ performance and efficiency in order to fulfill the customer requirements and to reduce the number of complains. To handle the large amount of population and to tackle the educated customer became itself a huge problem specifically in developing countries. However, the operationalization of total quality management makes it easy for the management and for the consumers. TQM consists of different variables and their application. It includes Leadership
Reduction of Waste
Customer preferences and satisfaction
In this current study, it is assumed that in a Hospital which is aimed at providing basic specialized services. The intensive care and laboratory facilities were expanded with appropriate technology. However, low quality management in department of Emergency and Neurosurgery has been observed in the recent times, which not only increased the overall cost of the hospital but also facing the dissatisfaction and reduction of patients. Further, Hospital is unable to provide the services according to patients’ expectation. The services that are provided by the hospital nicely packaged or offered to the patients. Hospital is facing many complaints regarding death and disabilities because of negligence and inappropriate care Moreover, the hospital management ignore the people non health expectation including dignity, kindness, human needs and proper communication with patients.
To address this glitch and to understanding the desirability and quality of services, especially in complex and dynamic environments such as healthcare systems, there is a need for a systematic evaluation of those services. The lack of assessment and control system means lack of communication with organization’s internal and external environment, which leads to the lack of efficiency, decreased effectiveness, and organizational death. 2.4 Implications of Total quality management using the Fourteen points of Dr Deming philosophy: In order to develop and implement total quality management plan in hospital a conceptual framework has been developed based upon the fourteen points of W. Edwards Deming’s philosophy.
Deming’s principles have been widely and successfully applied in different area including construction, education and healthcare all around the world. In accordance to this successful implementation hospital has planned to implement these successful points in their emergency and Neurosurgery departments.According toDeming, (1986), whenever management think to implement quality management program they need to consider these points. For this reason, to nullify the gaps in the management of Hospital that has been mentioned above selective elements from the Deming philosophy has been discussed separately to implement the TQM techniques at Emergency and Neurosurgery department of Hospital. Here present a table which depicts the overall mapping of Deming 14 points in quality management system.
To implement a successful TQM plan it is required a systematic and planned approach and it can be illustrated briefly by using Ishikawa’s Cause and Effect Diagram as seen in figure 1 Adopted from “The Deming Management Method” by
The above stated diagram signifies and represent an over view of Deming fourteen points and broad implication of Total Quality management at hospital. The necessary elements have been classified according to their congruence with the Fourteen Principles of W. Edwards Deming. The accomplishmentpath adopted by Hospital in reference to the Fourteen Points is constructing upon a consolidation of the teachings of a variety of authorities, including the works of Joseph Juran, Phillip Crosby, Maria G. Naval, Donald M. Berwick. Point 1: Create reliability of purpose for service enhancement, managing the resources to fulfill long-range needs instead of short-term productivity.
The importance of establishing long term goals is essential if hospitals are to overcome. Creating constancy of purpose is, possibly, the only important chore because it particularly addresses the leader’s role in transforming the executive culture towards a common goal. Deming, in 1982, uttered that companies which look for profits in the short term more willingly than strategic planning for the long term endurance will sooner or later fail (Joyce, 1998). Based on fourteen Deming points, the management of Hospital formulates following long-term objectives to create a reliable improvement in these departments; Quality Comes First: The quality of healthcare and hospital services should be the precedence of these departments in order to achieve customer satisfaction. Customers are the hub: Management that includes staff and the doctors should be ambitious to satisfy all of customers both internally and externally.
Public is the customers that look forward to the hospital management to ensure the health and physical inclination. To offer the premier Quality of Patient Care Continuous Improvement is essential: To improve all aspects of healthcare delivery, management should continuously promote innovation and maintain a constancy of purpose. Innovation will be Rewardedand Encouraged: Continuous improvement is likely to happen if innovation is both authorized and encouraged. Educating the Staff is necessary: The highest quality of professional education should be provided by management to every staff member. Management should be familiar with employee professional development that would both increase readiness capability and bring about ever increasing competence in work. Ethical Standards should not be Compromised: The expectations of customers can only be exceeded if each employee will sustain high ethical standards. Point 2: To make better use of all employees, establishment of modern methods of training and retraining on the job should be maintained. The objective of helping the employee to do their job better is only be attained by training them professionals skills to particular job or task, is the main focus of point two. While considering this training conceptually, it will go well beyond the learning. The hospital often receives doctors, nurses, and corpsmen of hospital directly from educational institutions.
Now, as they have no working experience so they are not fully trained to work and understand within the processes that function here but it is true that these people hold exact technical education to the level that is essential to perform well in their new job. The initial coaching of these employees helps them more effectively to adjust to the new system and includes a discussion with other people of the organization so that their particular work may cope with the larger processes of the organization. Integral parts of the quality process are cross training, skill training and job training. The training program of Hospital will provide fresh and inexperienced people with the skills to do well in their new job. The demands of the quality process are not fulfilled by the traditional approach to training, which was restricted to infrequent professional and management forums and on-the-job instruction. Training has always been a basic part of the lives of administrators, physicians, nurses and hospital corpsmen. The revolution in the field of medicine day by day requires a dedication to remain up-to-date personally. The Total Quality Management in hospitals follows the same policy. Apart from the traditional training, the framework of additional training can be build by orientation to the Hospital mission, goals, values and the introductory training in the philosophy of TQM. There is no long-term training program offered by Hospital as we take a start to the transition to Total Quality management.
As the revolution challenged us to master new skills and as our people became well aware of their own training needs, most part the program began to develop. Furthermore, Hospital employees are frequently pressured to do more work in the environment with less human and material resources due to personnel shortages and industrial downsizing in some professions. The hospital is fated to surrender to its environment without sufficient, ample, and particular training in quality. The quality improvement of processes is greatly influenced by training to the employees. Point 3: Set up leadership, focus supervision on helping people do a better job; make sure that abrupt action is taken on reports of unfavorable condition to quality. According to Deming, traditional activities such as supervising or managing must be replaced with leadership, throughout the organization.
In recent years, huge quantity of literature has been written on the subject of leadership that mostly focuses on the personal characteristics of effectual leaders, which facilitate them to direct the actions of others. Adjectives were often endorsed to leaders that have shown noticeable behavior. Adjectives such as reliable, creative, audacious, sympathetic, convincing, affectionate, and enigmatic are often used. The conversion of TQL needs a swing from imprudent to proactive management. The picture of the manager should be modified from the idea of supervisor (person who reins and directs the actions of others) to a picture of a leader (person who helps others in attaining a common objective). Most managers in health care institutions and managers in other different industries are almost alike in sharing qualities. They are likely to perceive their job as one of inspiring inadequate employees to perform at superior levels. The initiative of Total Quality Leadership is to provide new and stimulating roles for the hospital leaders. The new leader practices TQM leadership in every day efforts. At Hospital Pendleton, the valuable leader must: expand and sustain a system of teamwork which focuses on the our customer’s desires, expectations, and requirements; and fully support the staff through assets, personal dedication to quality and training; develop individual commitment to the values of Total Quality Leadership; institute an atmosphere of trust and respect for all employees in which continuous quality improvement is anticipated; develop and amplify personal understanding of professional literature and quality. Management begins at the climax of the Hospital but it is obvious that it is not restricted to top leadership. Most often, the principles are applied to at least three levels in which: Top supervision (Executive Officer, Commanding Officer, and seven Directors) drives, defines and distributes the message of constancy of purpose to all over the organization.
The principal importance to this purpose is the struggle towards constant quality improvement. According to Deming (1986), the foremost responsibility of management is to framework a system and to accomplish its mission, it should provide a plan as well as resources for it. The implementation of that mission of the organization should be the priority of the top leadership. Leaded by personal example, departmental and mid-level managers (administrative and clinical heads of department, nursing supervisors), under their supervision, must know how they fit into overall mission of the hospital by having a comprehensive perceptive of the processes. Mid-level managers intend to improve the processes of the organization and support in eradicating the obstacles to communication. The philosophy of leadership must be adopted by the First-level supervisors (Chief Petty Officers, departmental leading petty officers, charge nurses, and officers). Their new responsibility is mostly one of serving (coaching) their employees to perform improved work that can only be done by providing them the training, instructions, good tools, assets, equipment, and other resources which are essential to create a quality product.
Point 4: Eliminate barriers that hinder the employee’s conceit of workmanship The fact that the work an employee performs is appreciated by the hospital is its own incentive. The annual performance evaluations within the Department of the Neurology are one of the most fearsome barriers. The employee is often judged by what they have accomplished personally, whereas in a composite organization like a hospital when an employee is appraised, the concept of team is a vital factor that is commonly ignored . The existing system of performance appraisal used throughout the department is opposing to the philosophy of the teaching of Demings. According to Demings advises the removal of those elements of performance evaluation which spotlight on judgment of results. Moreover, he warns that the future or upcoming development in performance does not contribute to ranking or rating of employees. Employees are rated and ranked with their peers in this department performance assessment process and in promotion opportunities, this rating serves as critical factors. Doctors are looking for ways to state positively on group achievements, team hard work, artistic and innovative thinking, risk taking and other elements of TQM while ensuring evaluation of the person remains viable in the promotion cycles until the performance evaluation process is modified to reflect current thought in the TQM philosophy.
CHAPTER 3: APPLICATION OF 6 SIGMA METHODOLOGY
The Six sigma is a method that blends many elements of previous quality initiatives and adding its own unique approach to business management. The main aim of six sigma is to reach to the opportunities that help in attaining the long term goals. Six sigma methods mainly focus on the information providing by customers by knowing their needs and expectations for improvement in areas. Six sigma is considered to be a mathematical concept that evaluate a method in terms of faults. To adopt the six sigma it means that processes are particularly perfect. Six sigma is a philosophy that possesses well defined and established techniques to decrease process inconsistency plus expels irrelevant material by utilizing different statistical techniques and tools from business process (Antony and Bañuelas, 2002). The six sigma term is related to the eliminate the faults and imperfections, if the organization now this process very well so it can help them in increasing their profits by detects their faults and shortcomings. Banuelas, Antony (2004), conclude that many organization use six sigma as a new business strategy for making improvement in their process by eliminate the differences using proper methodology. 3.1 TQM vs. Six Sigma:
Antony (2007), in his study discussed that six sigma is a management trend and reality. It concluded that six sigma capitulate the computable end results in organization. While different applications of six sigma process are not working as big deal in manufacturing companies but in other areas like finance, healthcare, IT, banking it worked drastically in recent years. According to (Al-Musleh, 2010). There is logic behind the five phases, as Six Sigma involves a number of statistics and equations but it not like that it is not a statistical process but it tells how use the statistical procedures and know their values, in order to make an rational decisions about business processes. Many companies and organizations of all types in all our the world achieve the highly recommendable enhancement in different area f fields including customer satisfaction, market shares service quality and financial savings due to the implementation of Six Sigma. In contrast researchers have opposed the Six sigma improve, control, incremental and radical approach. 3.2 Six Sigma In Health Care:
(Barry in 2002; Thomerson 2001; Sehwail 2003; Christianson et al. 2005; Van den Heuvel et al. 2004), they are all suggest the six sigma application in healthcare system. In health care system six sigma is work effectively especially in reducing costs and improve quality (Kooy and Pexton 2002). In order to compute the specified process performance, six sigma project initiated by implementing important statistics and measures that is described as critical to quality characteristics. Six sigma undertake process issues in five following phase, which are known as (DMAIC): 1. Define the projects, aims, purpose and deliverables to customer both internally and externally 2. Measure the existing performance of the process
3. Analyze and detect the main cause of defects and shortcomings 4. Improve the eliminated defects of the process
5. Control the performance of the process
In addition to this according to Bandyopadhyay et.al, (2005), stepwise approach ofsix sigma project contains the organizational structure. In this scenario leaders of the certain projects who are named as green belts or black belts are trained according to project management and with inductive methodology. In this strategy leaders who are known as black or green belts facilities them to diagnose the facts and solve the problem properly. In six sigma tools that are used including pareto analysis and quality function operation creates a link between their customers and the product features to establish the importance of the product. In the study, it is assumed that hospital has mismanagement in its emergency department. The hospital management receiving a lot of complains about the services, quality, and resources constraints. To address these management problems the hospital decided to implement the six Sigma control process.
3.3 Six sigma in Hospital:
The six sigma technique is widely applied now to the non manufacturing areas. In this article we discuss the health care which focusing on the decision making process. Here we specific to our application of six Sigma process at hospital. In this section we review pre-Six Sigma quality initiatives. Then we discuss implementation of it followed by the example of successful Six Sigma Projects and in the final section, we come up with a conclusion. 3.4 Pre-Six Sigma quality improvement initiatives
In initial pre-Six Sigma Stage quality improvement, approach work very effectively. A large number of quality improvement projects were completed successfully on their hand the managerial control on projects was not up to the mark. Along with, the goals of the project was poorly aligned with the core strategic goals of the hospital.The problem was in the systematic section of the project that was actually determining the project contribution and relevancy with the long-term strategies. The big hurdle against the efficiency of the project was the lack in the standardized process that was assessing the cost effectiveness of project and one more thing was against tonus that we face a difficulty in making a go on go decision of project. The main aim behind the initialization of project was their contribution for the improvement in the quality care. The hospital management was also unable to determine the saving for alternative projects. Once the project has initiated, the management do not possess any authentic and reliable information to known the status till its completion.
This, of course, was the result of not having a standardized project management approach. Each project had its own and different milestone from other project and thus development of the project cannot be compared and evaluated with other projects. In summary, management of the hospital was neglecting the darker side. The team along with the employees was eager and annoyed due to the low standards of project management approach. Moreover, the time consumption was in a large quantity. Every time the project approach, planning and documentation need to be arranged from scratch. Management did have organized training and trainers but have disappointing results. Another problem of our employees was that management expects more work from them more than their regular duties in completion of project. At first time, this approach appears to be cost effective. However,actually this approach delayed potential savings. Sarcastically, at first the management was unaware of situation due to the lack of management control. Afterwards, the management maintained to arrange the time allocation of the employees of the project. Luckily, management also quickly realized that there were many more potential savings and we were just missing them because of a our poor project management system. 3.5 The implementation of Six sigma
Six sigma is like a system that integrates a large number of techniques of quality management. The problem defined in previous section would be resolved with its help. Followings would be considered as main success stories: 3.5.1 Philosophy
The scientific principle of six sigma is that, decisions are mainly based on details and data and fewer on intuition and feelings. When the estimated savings are not meeting the point of thresholds, there would be no use to start new projects. 3.5.2 Project management
To manage the project the project in accordance to the five stage of Define-Measure Analyse-Improve-Control (DMAIC). Every phase is finished simply at time particular milestones are attained (Harry 1997). At the given time, it is likely to identify specific project’s growth in an integrated method inside departments and crosswise the whole organization. 3.5.3
Well-defined roles and responsibilities
Six sigma would involve different type of roles, like Green, yellow, blackbelts winners and black beltmaster. It would really important that how a role reacts and bring his part in during the change process of organization. Roles that would have been clearly defined could be a milestone in completion of a project. 3.5.4 Tools and techniques
Plenty of tools and techniques will be applied by six sigma. Tools that would require no trainings or ease of access would be applied by software tools. 3.5.5 Classifiedinterfacesfor the existing organization
Six sigma would provide anexclusive blue print, which interlinks it with existing organization in a matrix like fashion. Six sigma would be implemented in the organization thoroughly to get the expected results. all the related information and tasks would be composed on a single platform without effecting the ongoing operations of business. At the end it would be considered that six sigma is far more than just an idea. It is a set of tools those are well managed to improve the results of projects to achieve the vital perspective of organization by maximizing the performance. Six sigma has vast areas of management concepts, to achieve the full results we would implement this six sigma at Hospital, by molding it with respect to the healthcare industry. By keeping in view the size of our organization, we would make few alterations with respect to the service industry as all Dubai hospitals are organized as a non-profit organization, so it would have no major impact during the implantation phase. Culture of our respective organization would be a little of concerns only if we would compare it with the profit oriented organizations particularly in finance department.
So it would not much difficult to present that money would play an important role towards the happiness and health of our patients and here again we would have to exempt few doubts. After completion of BB course, with the help of external consulting company specific employees was registered in the in-house Green Belt (GB) training program. During the green belt training period, every participant was requisite to contribute in thesix sigma project. Along with, the hospital director also took part in the first section of green belt projects. Meanwhile, throughout the course work that contains two different sections of three days each member was asked to maintain documented results. Without the completion of preceding stage, it was not allowed to pass on the subsequent stage. In each section every member need to present the outcomes in front of the whole group twice a day. The second thing was the presentation of the outcomes. As the size of the hospital is large, the management of the project tried to utilize the green belts as their team members from that each of the member spend their two days twice from a week on the project. The management utilized approximately estimated savings of $ 25,000 to imitate the project. This amount was appropriate considering the budget and savings potential of our organization. After the completion of first section, the management immediately enrolled a group of 15 green belts, then 13 green belts and so on. The members were divided in five groups and after the completion of first group the second group training started immediately. In hospital, this approach could be well established.
This approach helped and supported the team members throughout the whole process. Data driving approach considered very helpful and provided support for the successful implication of the end results. The gathered data was credible and helped at many times to reduce the emotional resistance from the members. At initial stages, the black belts presented the function of master black belts on temporary basis. As the time pass the number of green belts increased that proved inadequate. For this sake and as the management wants to implement the six sigma quickly, the hospital management decided to hire master black belts from outside. Successfully employing a master black belt with thepractice from the other sectors did not create any problem to implement the project, as the language of six sigma is universal and irrelevantfrom the type of industry. 3.5.6 Improved checks on invoices from temp aegis
From the past thorough investigations, the result was found that extensive number of invoices from temporary agencies was not right. Moreover, the mistakes were continuousafter hiring thetemporaryagency favors that could cost the hospital a huge amount. It was decided that management arranged and executed an enhanced program by all agencies contracting with the management of the hospital. 3.5.7 Revision of the terms of payment
The investigation discovered that there were different other conditions for the payment to the suppliers of the hospital.The reason was known dueto the lack of reliable payment policy standards. To address this problem a standards of policy was established and a improved quality system was implemented. The sum of the savings could increase and goes on with an increase. 3.5.8 Reduction in the amount of mistakes in invoices
Hospital managementissued a large amount of invoices every year to their patients and insurance companies. Unfortunately, due to the mismanagement of hospital every time few number of invoices were rejected by the insurance companies. However, during this project a large amount of mistakes regarding the invoices were recognized and which resulted in the accuracy in the statistics of the invoices. The management of the hospital started working on it, which in returns benefits in the form of reduction in the invoices turn down and the savings amount increased. 3.5.9 Reduction in the patients due to intravenous antibiotics Oral medication cost less than the intravenous antibiotics. The results showed that it is possible to reduce the number of patients by shifting them from intravenous antibiotics to oral medication. Results also showed that to run this process internal medical department is a good approach rather than surgical department. Additionally, different analysis also recognized that internal medical department follow strict protocols (SOP) while shifting from intravenous antibiotics to oral medication instead of surgical department.
Thus, the management could develop and follow the SOP, which could be used by internal medicine department. This results in the cost saving of the hospital. Even though each of the savings independently may appearreserved, which jointly added by sum amount. Additional, management asked differentchanges in the hospital management. Significantly, all of these development projects endowedfewerbut vital benefits to both management and patients. This projects show that a minimum level of revenues per project of $25.000 is relatively easily met. However, it was found that much better amounts (e.g. $200.000) were feasible. Projects are possible in patient care as well as in the administrative departments. Since employees are relatively easy to give ideas regarding the project, management look forward to an improved selection of projects can more enhance revenues. Certainly, we are very optimistic about the future. 3.6 Conclusion:
The Hospital could introduced Six Sigma as a major quality management approach. The results have been encouraged. Expect major difficulties, Six Sigma was implemented and made operational. Management practiced no reasonable issues while implementing six sigma in a non-profit service organization. Employees functioning with Six Sigma were passionate and considered it a foremost benefit to mange and execute improved projects. The savings far exceeded initial prospect. There is no hesitation that the Hospital will continue to Six Sigma in its organization.
CHAPTER 4: IMPLEMENTATION OF ISO 9001 STANDARDS
Healthcare organizations are likely to bring an ample level of quality of care. Moreover, proficient handling of public endowment, society demands precision and responsibility (Relman 1988). However, the Institute of Medicine (IOM) affirms that healthcare nowadays often damage that usually fall short which brings about its possible remunerations (IOM 1999, 2001). Dire quality and consequently the chance to develop quality is generally associated to the blueprint of multifaceted production processes and not to be deficient in of determination, ability, or being intention of workers (Berwick 1989).
To improve the quality of care, the IOM also accentuate the requirement to redesign the healthcare delivery system, because it is highly shredded and methods of care are inadequately planned. So, the foremost obligation of any organization of hospital is quality supervision and the execution of a system of quality management that stress on the processes of control, development, (Casparie 1993). In this editorial, we will illustrate the methods we implemented and intended a system of quality management in the Red Cross Hospital in Beverwijk, The Netherlands that is based on the standards provided by ISO 9000. 4.1 ISO 9000
On behalf of quality management systems (ISO 2000a) (ISO 2000b), the ISO 9000 strings are principles that characterize necessities (9001) and procedure (9004). These standards (principles) were first issued in 1987 by the International Organization for Standardization (Geneva, Switzerland). The ISO 9000 series were revised in 1994 and in 2000. The principles are generic (non-specific), that means the same standards can be practically useful to any organization, a civic organization or a commanded sector, whether it is a business endeavor or it is huge or miniature, whatsoever its result or servings, in every subdivision or movement.
The declaration of reliable creation or serving quality is top attained by quality management system principles and synchronized relevance of product standards is the central idea of institution of the ISO 9000 standards (Marquardt 1999). The standards signify a global consent on good quality administration performance with the intention of assurance that the association can constantly distribute the service or product that:
Fulfill the quality expectations of customers;
Fulfill relevant dogmatic necessities;
Improve consumer approval; and
Accomplish constant perfection of its presentation in chasing these objectives. To develop managerial and economic presentation with a definite emphasis on quality administration, process management and quality assertion methods to attain designed results non-conformance or avert unsatisfactory performance, ISO obtains a system and process advancement. In worldwide industries and service organizations, ISO 9000 values are effectively adopted and used (Marquardt 1999). In 159 countries, more than 560,000 conformities to ISO 9000 standards have been issued, at the end of December 2002 This is more than 10 percent increase as compared to 2001 (ISO Survey). An ISO 9000 certificate of conformity have been acquired by many companies in Dubai.
The implementations of the ISO standards, however, are not yet very centre of attention and common in healthcare. The effectiveness of ISO 9000 standards are lately been outlined in healthcare (Carson 2004). Until recently, the implementation of ISO 9000 standards in hospitals was restricted to certification of departments (Van den Heuvel et al. 1998). Information about the international appliance of ISO 9001:2000 can only be obtained by organizations through announcements by the hospitals themselves or hospitals that are permitted to perform certification.
In most European countries an inadequate number of hospitals have obtained an ISO certificate by a survey on the internet shows. BUPA, a healthcare insurance company has an ISO 9001:2000 certificate (BUPA website) have related ten smaller (around fifty beds) hospitals in Great Britain. Successful certifications in hospitals (www.ics.sgsna.com; www.qualityparadigms.com; www.tuvamerica.com) have been claimed to achieve by several US certification organizations. The first acute care hospital in North America to be certified to ISO 9002 (ISO 2001a) is assumed to be the American Legion Hospital in Crowley, Louisiana, USA., In Hospitals of Dubai trend to acquire the ISO 9001 certification have increased according to report of (http://www.iso-uae.ae). Furthermore, the Dubai health authority recently received ISO certification in 2011 (http://www.dha.gov.ae). 4.2 ISO requirements
According to the requirements of the American National Standard for quality management systems, an organization looking for ISO certification must demonstrate and execute a quality management system. This primarily involves the implementation of the principles to inscribe a quality manual, quality policy and quality objectives, and then utilizing the process approach to deal with other standard requirements. Conventionally, ISO says that you: Manuscript (document) what you do
Institute a process for the service
Execute your documentation (“Do what you say”)
Present the service based on the process
Record the consequences of your work (“Record information”) Properly sustain all recorded information
Inspect the documentation for effectiveness (“Audit effectiveness”) Audit by means of the process approach
Eight quality management principles are the basis of ISO 9001 requirements. For the development of quality system, these principles propose the use of a process approach and are intended to enhance satisfaction of customer/patient. Continuous development is essential for quality system. The eight principles are: 1. Customer center of attention
3. Public involvement
4. Process approach
5. Management for System approach
6. Frequent improvement
7. Accurate approach to assessment making
8. Equally useful supplier relationships
The eight clauses of ISO 9001:2000 are imbedded within these principles, together they describe the quality management system and include the quality manual for an organization. After successful application of a quality management system, an organization may seek out certification. After passing an audit by an accredited registrar, certification or registration is awarded to the organization. Worldwide network of governing bodies qualify registrars which are independent companies. 4.3 Implementation:
In Dubai, the Al Zahra Hospital is a general hospital with 200 beds that have a budget of 72 million dollars annually. We will begin our project by writing a global implementation plan. The department heads will investigate and explain the processes within their own departments. In process of improvement, these investigations are first used to recognize and execute quick wins. Once the process will be improved, it will be described in a homogeneous manner called a procedure. Approximately sixty procedures will be needed to explain all core processes in our hospital. The subsequent step would be the protocols making, associated with each procedure. Protocols will give a detailed depiction of a particular task in our quality system i.e. how to enter specific data in the computer or how to remove stitches. If the provision of adequate quality assurance is essential then processes and activities will only be described. The number of activities and procedures that actually had to be documented will be limited to a minimum.
The hospital management will assemble the Quality Manual as soon as we will describe all the necessary processes and activities of our organization. Descriptions of the organization, our quality system, the divisions, the policies of our hospital and our existing status of performance indicators will be included in this manual. We will implement an internal audit system to complete our system of quality management. We will coach fifty co-workers approximately to audit procedures and protocols in different departments. These internal audits will end up with a excessive progress and improvements to our quality management system. The system will have to “come alive” when all mandatory elements of our ISO quality management system will be designed and executed. We will be taking curative actions if the processes will not be performing in right way. Our improvement of system will require a flow of opportunities that will direct to the actual improvements. Then we will have to see either the internal and external audits would confirm that the system will be running properly or will be providing input to further improvements.
We will be able to execute ISO 9001:2000 without the reference of external consultants or an increase in human resources. External audits and consequent certification will cost approximately US$50,000 on the survey itself, according to the report of (www.thenational.ae). And we will have to pay for the flight and adjustment of a team of two to five people for a few days from the accrediting body. In total, it would come to about $100,000 to $150,000. To get the ISO 9001 certification following steps need to pursue by the hospital Management accountability: This applies to both clinical managerial operations. The intention is to institute the quality policy for the whole health care quality system; for example, the hospital, clinic, nursing home or sanatorium and to endow with the leadership, resources, and composition. Quality system: Health care providers must set up a quality manual; establish how the organizational procedures, frameworks, and processes will assure quality objectives; generate a documented quality management system (QMS); and. Quality planning propose incessant development, as with other ISO 9001 applications. The ISO 9001 quality system requirement is, at least once a year, intended to lodge current external and internal audits of the quality system, and more often when it is required to sustain the integrity of the QMS.
Contract review: The intention of this requirement is to make sure that all written materials generating the expectations of patient are accurate. It means that before engaging in a contract, customer requirements are established, and some being in the organization must be there who is accountable for considering that contract requirements are accomplished. The centre of attention of ISO 9001 4.3 is the fact that the patient realizes and acknowledge ethical issues such as discretion, security, confidentiality, interactions in considering anesthesia strategies, orders (such as admittance and discharge), approvals and officially agrees with any contracts that affects his or her privileges as a patient. Design control: For health care providers, design control has a wide application. It describes the steps that should have been taken by the hospital when additional or further services are considered for accomplishment. It could engage off-site human immunodeficiency virus (HIV) treatment facility or prolonged oncology program, designing a plan to control patient flow or a specific service such as a new neonatal care facility. Document and data control: The requirement of this section is that for the precise and timely provision of patient care and support functions, the quality system provides appropriate access to approved instructions. The accurate documents must be indexed and accessible so they are readily available. The section requires that providers institute and sustain documented procedures and those relevant documents and data are accessible at all areas where operations important to the effectual functioning of the quality system are executed. All charges must be permitted, and outmoded documents must be detached at the appointed time.
Health care providers frequently thrash about when at different locations in a health care facility, they locate as many as 30 dissimilar versions of a similar form. Purchasing:Purchasing often considered second position in expenditures for health care providers after employee health care benefits. This section covers up the whole lot from subcontractors to medical tools to pharmaceuticals. It is required that the QMS guarantee the exact and suitable procure of materials and provisions from official vendors. If not efficiently controlled, it also is a area that can produce runaway expenses Control of customer supplied product: Any objects that are used in the deliverance of services, but are not the assets of the health care provider must be recognized and forbidden. This area deserves serious attention, given the combination of internal and external customers in health care settings. Product identification and traceability:This clause has a particular application in health care settings. Through the use of exclusive recognition numbers, patient records and patient activities are usually related to a particular patient. Each admission still is treated as exceptional and not efficiently associated with preceding admissions or tests for some providers who act together with patients in outpatient settings.
This can make a paper blunder along with the patient service that is unproductive but costly. Process control:In health care settings, this section puts forward a broad range of services. Pulaski Community Hospital in Pulaski, VA, illustrates process control as the provision of “personalized, designed patient care in the locating that most properly supports the patients’ requirements “.It could comprise proscribed conditions regarding to the use of appropriate tools and working atmosphere or supervising, and organizes appropriate process parameters and service situation to clearly declared criteria for workmanship. Particular processes could contain areas such as obstetrics, surgery, oncology, physical therapy, radiology, anesthesia and respiratory therapy. Inspection and testing: This clause comprises the idea of supervision of all supporting functions that affect that care and the precision and suitability of patient care. It consists of evaluation, quality checks and scrutiny at all process stages, from admittance through patient discharge. This clause includes the areas like pre-admittance testing and admittance, in-dispensation of patients and yields (for instance, is this we ordered? Has it been tested to establish if it meets purchasing needs and final scrutiny?), and patient discharge and liberated. Records are required to be reserved and uncharacteristic products must be properly quarantined. Clause 4.10 can create an influential and effectual impact in setting of health care.
Control of assessment, test equipment and determination: The intention of this clause is to build up training process and an ample system to pledge that all equipments and devices affecting quality health care have been appropriately standardized. Test status and inspection: This clause involves confirmation that evaluations, tests and scrutiny have been executed, and a medical record of patient depicts what measures, lab tests, outcome and appraisals have been completed. The information should be retrievable (a dilemma for a number of providers who documents current information) and voluntarily available (a dilemma for a number of multisite health care providers). In brief, this information should be a fundamental part of a QMS. Control of nonconforming product: Nonconforming product also involves nonconforming service in health care settings.
Nonconforming products could be an in-vitro analytical computer that is out of calibration, in-vitro reagents that do not meet up purchasing requirements, an inappropriately operating magnetic resonance imaging (MRI) machine or sterilized hangings in packaging that was perforated in transit. Nonconforming services could be a loss of decisive patient records, electrical outages that blackout a surgical room, amateur recruits conducting a patient testing process. ISO 9001 involves that health care providers pursue established measures to avoid installation or unintentional use. Nonconforming product or service must be assessed and its basic source must be resolute to avoid a repetition of the nonconformity. Remedial and defensive action: Special attention is required in health care settings. Nonconformities can emerge in both products and services as it is eminent. Luckily, remedial and defensive action in ISO 9001 systems is also determined by the internal audit process, which recognizes nonconformities, reports corrective actions and impels corrective and preventive action, processes and any quality inclinations to administrative review on a intermittent basis. It is one of the potency of an ISO 9001 QMS. Managing, storage, casing, preservation and deliverance: This covers matters such as packaging and sterilizing medical devices for use in the operating room, storing medical supplies postoperative instructions handling of patients and medical supplies, conserving and disposing of medical supplies and delivering supplies to hospital employees and patients.
Control of quality records: This varies from 4.5 document and data control because it apprehend quality records like which records must be set aside and how they are stored are at issue. For accountability purposes, administration should regard as dictatorial requirements and what is stock up for liability rationale. The dearth of key records can be tremendously detrimental to liability exposure. Internal quality audits: An ISO 9001 QMS is inspected repeatedly. Audits can be internal (foremost party), insurance underwriters (succeeding party) or competent health care registrars (third party). Also they could be state licensure audits. It is impossible to have an ISO 9001 registered QMS without competent health care registrars. One of the strengths of ISO 9001 is the existence of the three-tiered audit system determined by internal audits on a regular basis. Training; The spotlight of training narrates to quality. It means that health care providers must guarantee that recruits have the essential abilities to do their jobs. In house training programs, the hospital requires to commence following which comprises CME with compensated annual stipend
Enduring Professional Improvement
Life sustaining Courses (ACLS, BLS, PALS, NRP)
Compulsory aptitude Courses for Nurses and other personnel
Communication Courses and Consumer Service
Security and Fire Training
Disease management Training
Moreover, internal auditors must have quality training credential on documentation. Training must be acknowledged and a vital training records catalog must be conserved. Auditors assess to notice if people have been trained to do their job with the improved hiring of temporary staff. Servicing:This clause includes internal suppliers as well as servicing equipment or providing services to consumers. Statistical techniques: Statistical technique might seem inaccessible that is first thing to be blushed. Statistical process control has been used with immense effect in health care administration. It can endow with momentous insight to the effectiveness of the system and areas that should be concentrating on. ISO 9001 registration is comparatively innovative to health care providers. In January 1996, the first hospital registered an ISO 9001 QMS certification.
Registration to ISO 9001 by a competent health care registrar provided the obligatory third party endorsement that contented state licensing, certification requirements and compensation by state and federal agencies. Undoubtedly, ISO 9001 registration presents some authoritative improvement to other endorsement programs. Although others are better acknowledged and documented among health care providers, it should be eminent that ISO 9001 registration presents a regimented and logical approach to health care as it has to other service and manufacturing industries. At first, it might seem intimidating. An acknowledged, internally administered ISO 9001 quality management system focus on recurrent external review ,once documented, is easier to sustain, economically less challenging and competent of submitting better service to its customers 4.4 Benefits of ISO Implementation:
The foremost benefits of the ISO process are associated with the consumption of the process management approach. The process approach primarily was used in designing the medical and surgical patient care process maps that were incorporated into the ISO system during the first six months. As we improved and evaluated the care processes and incorporated them into the ISO framework, these maps were obliging in understanding the process steps. The process approach was also used in the improvement of policy map for the organization and balanced scorecard. PCI undertake these documents biannually that were developed as a result of the strategic planning process. The balanced scorecard and strategy maps clearly support the ISO management principles and complement the management review activities of the ISO quality management system although they are not an ISO requirement.
The process approach was used to build up a payer template for executing payments on projected insurance contracts. This template or matrix is engaged to a document of important elements of a projected contract and allocate each contract an overall score. Electronic transmission, one of high value elements is awarded extra points and the resultant score allows us to evaluate the overall contract and assessment of contracted rates to other payers. A request for proposal (RFP) process was also written and integrated into the ISO quality management system as a methodology that is required to acquire information from vendors. For both internal and external auditing are ISO requirements, PCI is presently evaluating electronic medical record systems that has been used. Our internal auditing program has been well received and supported by PCI employees that requires employee contribution in both maintaining and improving the quality management system 4.5 Cost savings
In the areas of days in accounts receivable, payment on contracted rates, and workers’ reward insurance rates, specific cost savings have been acknowledged. PCI administration lately assessed our purchasing process by considering an inclined value stream mapping analysis and expects to categorize bonus cost savings for paper shredding, snow removal and cleaning. Outcome of these cost savings proposal will be appraised and accounted at a shortly date. Accomplishment of an ISO 9001 quality management system has been a clear-cut advantage to our organization. Time and effort on the part of both employees and management are required for experiencing it. We firstly supposed that the process would be fulfilled within a year, and even though our efforts requisite 2.5 years of work, we felt that there was sufficient time to carry out the tasks and we also considered that we had an improved buy-in from our employees by captivating
a slower approach and relating them in the effort. 4.6 The key learning points that we identified include:
Management must be dedicated
Exploit local resources
Benefits are both substantial and insubstantial
Changes the customs
ISO is a skeleton to be built upon
The key is process management
ISO systems in healthcare have immense potential
Future plans include formal expansion of a risk management program at PCI that will be included into the ISO quality management system. Recently, we accomplished a 20-page risk evaluation form at the request of our misconduct carrier. This form was somewhat broad but the work needed to fulfill the form was condensed considerably because the ISO quality management system agenda was previously in position within our organization. Our ISO quality management system stays us to pay attention on the requirements of our patients and consumers. We needed to evaluate our patient’s requirements in advance and assess patient approval on a structural basis afterwards. Our processes are all recognized and have to be enhanced incessantly to constantly meet patient’s requirements. We are certain that we are doing the accurate things and move in the accurate direction of quality development due to these ISO requirements. 4.7 Process oriented healthcare
The IOM has shown that quality of care is not frequently ample because healthcare processes are inadequately intended and characterized by redundant replication of services and long waiting times and setbacks. All processes have been recognized, optimized and explained in our quality management system. Performance indicators on process level are improved and supervised although we still needed to proceed further. The responsibility of department heads as “process owner” have to assure best possible process performance. 4.8 Constant improvement
The systems approach in relation to process management is a significant characteristic of ISO 9001:2000. We assemble information from numerous sources such as; complaints, patient satisfaction surveys, quality measurements, Faults Accidents and Near Accidents, internal and external audits. These measurements have to direct the perfection of the quality system, improvement of the quality of healthcare and upgrading the purpose and presentation of the healthcare processes. On every day process, the performance of risk analysis and design improvements produced a considerable amount of knowledge and dedication to quality of care and patient safety as required after the 2000 revision of ISO 9000. As stated in the first report of the IOM, in eliminating the fault in patient safety, these risk analysis and succeeding improvements can be considered an significant step (IOM 1999). 4.9 Performance measurements
As required by ISO 9001:2000, we have designed a set of performance indicators that is an crucial part of our quality management system. These set of indicators are published annually in our Annual Quality Report. Patient satisfaction is the most important indicator. One for each department, we use roughly 50 different types of questionnaires. The framework of all these evaluation forms and the ranking systems are indistinguishable, so all the consequences can be supplementary to give our hospital a total accomplishment on patient satisfaction. We allocate more than 2000 forms annually with the response rate of almost 50 percent, patients can rate four categories; “good”, “rational”, “can be enhanced” and “must be improved”. We have been able to attain reliable rates of above 80 percent “good” every year on every item.
CHAPTER 5: APPLYING EFQM EXCELLECNCE MODEL TECHNIQUES
It has been published in international scholarly literature in accordance to the vast skills of the implication of European Foundation for Quality Management (EFQM). Based on the conclusion it was strongly agreed that EFQM is an appropriate technique for the healthcare center. It not only increases the quality of the overall hospital but also benefits to the treatment for patients. Among the different techniques from the EFQM model, the most appropriate technique for the hospitals could be self-assessment technique. The reason behind it that it is considered as an encouraging technique for those professionals and managers who take part in it. It also supports advancement through a simple method by identifying the areas needed to be improved. The probability of doing benchmarking activities, its experience validity and its flexibility in agenda that grants an addition of already practicing processes that holds out as positive features. 5.1 EFQM excellence model:
An excellence model, which is the European foundation for quality management (EFQM), is working as a framework of self-assessment, which counts the strengths, and the areas that need to be improved of the certain organization. The “excellence” word is used specifically as a reason that it highlights those areas of the organization through that they could provide an excellent products or services to their customers that can provide them a competitive edge. Although, it was founded in public sector, than in private and now in voluntary sector and through this these organizations can have benefits of different kinds. This excellence model is basically non participative and nearly do not more engage in strictly following the rules, whereas it presents a consistent and broad bunch of assumptions that what exactly is beneficial for the organization and management as well. This flexibility of excellence model allows every organization to manage and have their improvements in their setup under the supervision of their own management rather than from external evaluator.
EFQM model possess nine criteria or big ideas, which are underline this basis and aim to wrap up all of the major activities of a particular organization. Farther these nine criteria are divided into results and enablers. The enablers criteria mainly focuses on different functions of the organizations including their performance, handling personnel’s and resources, proceeding its strategies and the monitoring process of the whole system. These criteria include Leadership
Policy and strategy
Partnership and resources
The results of an organization depend on what it achieve. These achievements
include the overall satisfaction level of the organizational customers and employees, their impact upon the whole community and the main performance indicators, which comprises Customer results
Results from society and
Main performance indicators
Among these nine criteria, every criterion is further divided in different divisions to explore more detailed excellence level in that particular area and additional how well an organization could be responsible regarding their performance. Now, it starts with the point that to gather the data for these nine criterion of model. Each of the criteria starts with point that ‘how good we are and how can we be at excellent level’. 5.2 EFQM Model in hospital system:
The management of the hospital wanted to apply a certain system that can enhance the overall quality care of the hospital. After the analysis of the data and experience, the management decide to implement EFQM model in their system. The project could be start with the technique of EFQM of self assessment through which management could find out that what exact areas of the hospital require improvements. Based on the results through self-assessment a quality management plan can be applied with the duration of 2 years. Afterwards, the second self assessment consist of double goals, one is to examine and compare the results obtained and the improvement plan and second and the important thing is to recognize the areas which need to be improved. According to (Moeller, 2001; Arcelay et.al, 1999; Mira et al. 1998; Holland et.al, 2000), the project techniques possessing two main phases; Identifying those areas that need to be improved through self assessment A team to implement those changes
Nabitz and his colleagues (2000) also suggested that to organize and apply the key self-assessment objectives and a team to implement it. Assuming according to the hospital data this assessment team possess five members in first year, and after the 2 year advancement it increased to the eight members from one ward of the hospital (Nabitz et.al, 1999). Most of the members from different area of field of that particular hospital were included in assessment team including the general manger and the quality improvement specialist. Afterwards, with the technological support that was provided by the quality improvement unit of the hospital the project was planned out and got approved from all of the hospital’s professionals (Moeller, 2001; Holland et.al, 2000; Jackson, 1999). The member of the unit was having less knowledge about EFQM model , for this sake the assessment team members helped them out who were well qualified in EFQM and quality enhancement (Jackson, 1999; Stewart, 2003; Pitt, 1999). 5.3 RADAR Logic:
According to (EFQM excellence model, 2001),in the center of EFQM and of self-assessment, the logic lies known as RARDAR logic. This logic includes four of the elements Results
Assessment & Review
This logic says that an organization need to
Establishment of the results that is aimed as an element of the strategy and policy making process. These results portray the operational and financial performance of the organization along with the perception of the stakeholders. Develop and plan an incorporated approach to get the desired results in present and in the future as well. To ensure the complete implication, organization of the approach according to the methodological system By reviewing and assessing the approachthrough analyzing and monitoring the outcomes that are achieved from ongoing learning actions
5.4 Self-assessment methods
VALLEJO and his colleagues (2007) suggested that the EFQM model recommended different methodologies and techniques to conduct the self-assessment. In this current study two of combined approaches to conduct the self-assessment could be performed. First, the submission document is draw up to be submitted in support of the “award simulation” methodto gather the data. Second, questionnaire method approach could be used for the particular case. The given document that is submitted for ‘award simulation’ approach is submitted with an assumption that with a recognized layout that illustrate the hospital’s attainments cross a series of areas that are linkedwith the sub criteria of EFQM model. To stimulate this award the first submitted draft of the document has to be submitted across all of the experts of the hospital, who would asked to analysis the document and present their comments and ideas. Afterwards, the staff members handed over their views and suggestions regarding the drafts, which encourage a approved final draft by the members of the hospital. This could be a very informative source of gathering the information on the basis of that self assessment could be conducted. To perform the self-assessment it includes the servel steps that are as follows; 5.5 How to perform a Self-Assessment? The standard 8-step process Step 1: Gain and maintain management commitment:
To conduct a self assessment program through EFQM model it is essential to have the involvement of senior and upper management of the hospital. The management need to have a brief concept and knowledge about the implementation of EFQM model and about the primary concept about the excellence. This means to initiate a high quality self assessment program the involvement of upper management of the hospital is necessary. Step2: To develop and organize the communication strategy:
To conduct a successful self-assessment program in the hospital it is essential and imperative that the team has a complete strategic plan to further conduct the process and should communicate clearly the message among the staff of hospital about the strategic plan of self assessment.
Step3: To plan the self assessment:
After developing the brief strategic plan for the hospital the next step is to plan for the adaptation of the technique to conduct the self-assessment while considering culture of the hospital. In order to adopt the technique of self-assessment there is no superior way is involved. The most important factor while planning for self-assessment is to consider the culture and to have clear image for the outcomes which hospital management want to achieve. After wards, to adopt the most suitable technique which is more appropriate to achieve the desired outcomes. To conduct the self-assessment in the hospital, keeping in view the culture of the hospital questionnaire and interview both techniques can be applied to conduct the self-assessment plan. The interview technique is more reliable for the upper management staff and the for the self-assessment of lower level staff questionnaire method is more appropriate. The self-assessment plan can be carried out at any level and al level. There is no specific rule to conduct the plan the important thing that matters is the context and the culture.
However, the most important practice which is consider in different organization is first to have a “Pilot test” to further learn and to more understand about the process. Step 4: To select and train the staff who are involved in the plan While conducting the self-assessment, a large amount of various roles that would be engaged during the practice that come into engage totally depend upon the particular technique employed. Some roles including project manager, sponsor and staff are featured regardless of other including Facilitator, Assessor, data gatherer, Assessor team leader and report writer are more dependent on the technique chosen. In hospital management, training plan should be arranged for the management staff and the doctors who are directly involved in the process and has their direct interaction with the patients as well. Step 5: To conduct self-assessment:
In this step the self assessment program will be implemented. This process needs to me mange more carefully. Without any exemption, self-assessment program should be practiced and managed as a project. As the purpose of the self assessment is to identify the strengths of the hospital and the areas that need more improvement which ultimately leads to the improvement of hospital management performance. Step 6: To consider the priorities and outcomes:
Hospital management are unlikely to contain the possessions to adopt all of opportunity alongside in addition to it would be unrealistic for the management to try all of them. in fact, some of opportunities might have restricted impact on the key results of the hospital. Therefore, the management needs to clear all processes in position for the prioritization of the results, Along with, the management of the following development action plan and the ongoing examining of progress during should review cycles.This means that the hospital management need to consider all of the strengths and then have to priorities acceding to the outcomes that are expected so that the desired results can be achieved. Step 7: Establish and Implement:
The results which the management receive after conducting the self assessment plan provide a timely moment picture for the current status of the hospital which are usually expressed in requisites of strengths, areas which need some more improvement. The above mentioned step 6 only provide with the list of prioritized improvement strengths. The next step involved is to provide a structured methodology to implement the action plan. To develop a structured action plan of the implementation in the hospital the following steps need to be consider Develop an outline of the problem or the gap which need to be fulfilled Define the requisite outcomes
Determine the success indicators
Embrace an suggestion of project resources and timescales
To have a specific and visible accountability of delivery
To make sure the actions are incorporated with the hospital planning cycle. Step 8: Monitoring of action plan development and evaluating the self-assessment practice. Concerning some other activity, the progress of implementing the improved actions for the hospital should be assessed regularly and process of connecting hospital planning with self-assessment should be examined and improved that would be prepared for the next self assessment. Along with, as discussed previously, while introducing the self assessment program into the hospital it should be varied that these program would be implemented for long term interference not a only a one time activity. Hence, this means that reviewing the process is an important and critical function for the maximization of learning process of hospital. 6.1 Perfil questionnaire technique:
Holland and his colleagues (2000) suggested that to perform the self-assessment questionnaire techniques that could be used is labeled as “Perfil”. It is an electronic questionnaire technique, which is granted by the EFQM including the 120 questions that are grouped with the sub criteria of EFQM having the rating scale of 1-100. To conduct the self-assessment using the eight criteria of the assessment process each member of the hospital that are included in the assessment would be rated first on the hospital development through the provided information as a reference from submitted document. This could be pursued by the agreement of the conference where each point would be discussed and can be agreed based on the outcomes of the self-assessment of the each individual along with, point out the strength areas and the area, which need improvement. The Perfil software automatically generate final scores based on the final results, keeping the weights of the EFQM criteria. 5.6 Benefits:
After the implication of self-assessment method, the fundamental result that could be obtained from this can be implementation of the structured quality management system that would be is based on EFQM model ideology in hospital. The EFQM model is a more suitable structure for to assess the performance of the hospital. After the assessing the program in hospital the nine sub criteria of EFQM model are analyzed and considered to implement in accordance to the hospital goal of business excellence. 5.6.1 Leadership:
Development of the vision, mission and values of the hospitals that are closely related to hospital objectives Development of the setup in which the hospital upper management is closely involved for the making of the hospital management system that is tan continuously improved. To ensure that how the staff and the doctors are involved with their patients. Along with, organization of a certain plan in which to ensure the involvement of upper management with the sub ordinates. 5.6.2 Policy and strategy:
Identification of the combine interest groups and aligning the strategy and policy in the interest of each group After the assessment to formalize such strategy that are based on performance management and research After the development of the policies to upgrade and review them To communicate and implement these strategy along side
Publication of the hospital portfolio.
Implication of a work climate review
Analysis security improvements in the hospital and the training of staff in subject to safety based on outcomes of the work climate review To give reward and reorganization to the staff members of hospital 5.6.4 Partnership and resources:
Assessment of hospital stability with out-patient healthcare centers Based on the results the assessment,
On the basis of the results of this assessment, a set of rules of communication procedures with the help of out-patient healthcare centers are formularized; Up gradation in patient discharge reports could be implemented, and also modification in referral procedures 5.6.5 Process:
The main process of the hospital could be identified systematically Assessment and illustration of enterance process
Using innovation to improve the process continuously that leads to identified increased patients value and their satisfaction. After the assessment at the organizational level, the need to get result from the people, customer, society and finally the to determine the key performance depend upon the perception and the performance of the organization. According to (Sánchez et.al, 2005; Nabitz, Klazinga, Walburg, 2000; and Vallejo et.al, 2007) after the implementing the EFQM model through self-assessment method, the results are quite different before the implication. According to study of (Vallejo et.al, 2007), customer results gradually improved from 50 to 70% from 2002 to 2005. Patients and their families satisfaction level increased about the treatment. Along with the people results include the ward training programs which also improved after the implication of self assessment method. In society the hospital got the social media coverage and good perception of people which ultimately leads to the increases overall performance of the hospital.
CHAPTER 6: CONCLUSION
Total quality management is considered to a systematic and participative approach to plan and execute an improved organizational process. This approach provides an opportunity to an organization to identify problems, fulfill customer expectations, building commitment and promotes an
interactive atmosphere among their workers to take part in decision-making. Therefore, to take advantage from this approach hospital started more focusing on their quality. With advancement in the technology and to fulfill the customer requirements now, the total quality management has its huge impact on hospital performance In order to develop and implement a total quality plan in hospital first a theoretical framework has been developed on the base of fourteen quality points of Edward Deming. Deming theses points are widely successfully implemented in different fields. Keeping in view, the hospital management draws a comprehensive framework based on some of the Deming points. To define an appropriate framework hospital management first needs to establish long-term goals and bringing the whole staff on a single point to work for the common welfare of the hospital. To establish the common goals the management of the hospital has to consider that quality comes first, patient are the focus, education of the staff and ethical standards should not be compromised. After the goal has been established, the second point in the framework is the training of the staff members and establishment of the new training techniques for the employees. The third most important thing to be considered while establishing a total quality plan according to the Deming points is the focused leadership. The leader of the hospital should help his subordinates to perform their better duties in the hospital and to take abrupt action against any unfavorable condition. Once the framework is established the next step is to identify the defects and to highlight the strengths of the hospital. To address this gap there are present many of the methodologies through which the management can identify their defects and to overcome them. Six sigma approach is the most popular and appropriate methodology to identify the weakness and the way to conquer those weakness. In hospital system,six-sigma approach could be used in reducing the cost and increase in the quality system. To implement a six sigma approach in the hospital there are five several steps including defining, measuring, analyzing, improving and to controlling. While implementing the six sigma streatgy a stepwise structure has been established to improve the decision making process of the hospital. First, the upper staff of the hospital who are named asgreen and black belts are educatedto implement the problem solving technique. Furthermore, after the defects has been identified and hospital management has implemented the six sigma technique afterwards the Healthcare organizations are likely to bring an abundant level of quality for their patients, Now a days the quality level of the hospital has been decreased to a deserter level. There is less care for the patients and the staff members do not deal them with an appropriate manner. To improve quality of care the IOM has introduced standards by ISO certification.
To achieve the ISO certification now the hospitals started improving their quality system that ultimately benefits them in the form of satisfaction of their customers. To meet these standards there are several steps including Design control, Quality system, improved management responsibilities, process control, inspection and checking of the hospital, control on the introduction of nonconforming products into the hospital. Once the hospital implement the quality system the hospital would be more likely to gain ISO certification and in long run it give benefits to the hospital in terms of cost saving, customer satisfaction and good reputation. According to Klazinga (2000) ISO 9001 and EFQM model are more similar to each other. Among different models the EFQM model is more likely to be seen best in accordance to management tool for supporting top management. As the EFQM model and ISO are more inter related to each other so to support in implementing ISO techniques the hospital management is more interested in implementing this model. The EFQM model is based on self-assessment technique that is used to develop the quality system of the hospital. To conduct the self assessment different steps need to follow. The implementation of EFQM model helps in improving leadership, policies and strategies, employees and processes. Hence, overall all these steps and techniques help a hospital to provide the best management practices and superior quality to their patients. Along with, the management can also train and retain their employees to provide their best in the interest of the hospital.
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Case study1: Implication of Edward Deming fourteen points
MING’S FOURTEEN POINTS ON QUALITY MANAGEMENT
Mary Levis , Markus Helfert, Malcolm Brady
Dublin City University,
Abstract. In the last couple of decades the search for quality has been spearheaded by the Total Quality Management (TQM) philosophy, not only for avoiding failure and reducing costs but also for gaining competitive advantage. TQM is based on the principle that customers are the most important factor in the organization. There has therefore, been widespread interest in the practical value, of achieving International Standards Organization (ISO) levels of quality. These standards have commercial and economic significance for organizations. Professionals rely on data to successfully carry out their work and the quality of their information source impacts their decisions. However, good quality is hard to achieve and sustain. Ensuring information quality (IQ) is challenging, particularly in the healthcare sector, where they deal with large quantities of vital life saving information. Patients expect the healthcare service to be supported by effective high quality information systems so as to offer adequate service. Practitioners in healthcare are facing increasing complexities and a high rate of negative media coverage by failing to deliver a high quality healthcare service.
Much of this can be traced back to IQ problems. However, Defining IQ has proved to be a difficult task and research in the field has not yet developed adequate theories, models and frameworks to address the issues involved. This study will primarily focus on Deming’s 14 points to quality management as a means of identifying IQ problems in a healthcare delivery scenario. We will look at it from the perspective of those who use the data to carry out their tasks. Our study shows that while a variety of relevant attributes in a healthcare context can be assigned to many of Deming’s 14 points on quality management we conclude that despite the fact that the basic tenets of quality are explained by leaders of quality such as Deming, Juran and Crosby, they are still not being forcefully followed. Keywords: Information Systems, Information Quality, Resistance to Change, EPR Systems, Quality Management, Total Quality Management. 1 Introduction
In recent decades the search for quality has been spearheaded by the Total Quality Management (TQM) philosophy, not only for avoiding failure and reducing costs but also for gaining competitive advantage. TQM
is based on the principle that customers are the most important factor in the organization. Nowadays, there is widespread interest in achieving International Standards Organization (ISO) levels of quality. Over the last decade as healthcare has become more complex the diversity of services has become fragmented thus increasing the cost to the HSE without improving the quality of the healthcare system . There is increasing evidence that problems encountered in the health service are not due to lack of funding, as expenditure in healthcare has increased considerably in the past ten years. According to a report in the ‘Irish Medical Council’, November, 2006, there was a €1.1 billion increase in health spending. Gross current spending increased to €13.9 billion. Total expenditure on healthcare in the US in 2004 estimated at $1.6 trillion . In the UK, expenditure on its public funded National Health Service (NHS) is budgeted to rise to over £90 billion by 2007/08 . Both of the Institute of Medicine (IOM) reports ‘To Err Is Human’ and the final report ‘Crossing the Quality Chasm: A New Health System for the 21st Century’ addressed a broad variety of quality issues when they alerted health care professionals to system defects and provided direction for significantly redesigning the health care system with IT playing a key role.
They concluded that between 48,000 and 98,000 Americans die annually in hospitals as the result of medical errors, and this has necessitated radical changes in practice in order to eliminate errors and unnecessary deaths [3, 4, 5]. Many of these problems result from outdated, inadequate health care delivery systems that are not capable of providing consistent, high-quality care. Until the IOM report, however, medical errors did not receive the attention and awareness of the hefty financial burden to the health care system. Nevertheless, it is apparent that computerised information systems have not as yet achieved the same level of penetration in healthcare as in manufacturing and retail industries. In Ireland many serious errors and adverse incidences occur in our healthcare system as a result of poor quality information (IQ). On a daily basis the media reports on the impact of poor quality in the healthcare sector [6,7,8,9,10,11,12,13,14]. Unquestionable evidence shows that the current systems in the Irish healthcare service are error prone and not delivering safe, high quality, efficient and cost effective healthcare , and for that reason is currently undergoing major reforms. A crucial factor of an effective and efficient healthcare service is information of high quality. Information is often not provided in the required quality .
Conversely, quality in a healthcare setting is a complex issue and can be accessed on two levels; the care provided by the information system and the care provided by the nurse. Juran states in his book ‘the history of quality’ ‘what makes a difference to our modern world is ourperspective of quality’ . Yet, a universal definition of quality is difficult to achieve because nurses and patients define quality from different perspectives. To nurses, quality care could refer to how well they treat the patient. In contrast patients might place greater emphasis on bedside manner and at the end of the day patient satisfaction hinges on whether their hospital experience meets with their expectations. Consequently, assessing patient satisfaction and quality care depends on the perspective in which quality care is defined. For change to occur, healthcare professionals need to take the perspective of the patient into account. It is of critical importance to foster high-quality healthcare information to support high quality patient care atall levels of the healthcare system. This can be achieved by ensuring that good healthcare information becomes readily accessible and appropriately used in a quality rich professional manner. The measurements of performance should be tracked by employee, and by task, on a regular basis so that improvement of each employee can be plotted, and areas that hinder quality pinpointed and corrected. Following the policies of the hospital is critical for knowledge reuse in order to maintain the standard of care and to ensure high IQ in the knowledge base .
Quality assessment activities determine the extent to which actual practices are consistent with a particular indicator of quality, such as adherence to a practice guideline. We believe that many problems within the healthcare delivery service could be reduced if greater attention is paid to the quality of information communication, seeing that clear and precise communication is essential to providing high quality care. Successful implementation of the Electronic Patient Record (EPR) is shaped by perceptions of changes it will bring to the performance of everyday jobs in the hospital. Many doctors dislike working with the EPR, and nurses frequently complain about having to be competent in their own profession and also having to have the skills to manage the turbulence caused by other professionals’ resistance to using the EPR’s which increases their workloads. More specifically, for an order-entry system, success in short, has many dimensions: effectiveness, efficiency, organizational attitudes and commitment, worker satisfaction, patient satisfaction—not all departments in the hospital may agree about which dimension is most relevant. There is a crucial need to shift the focus of research towards improving the capture; use; maintenance and transfer of high quality data to facilitate professionals in providing the highest quality healthcare possible.
Everyone involved in the capture, use, transfer and documentation of healthcare data is responsiblefor its quality and ensuring the data is usable, accurate, comprehensive, consistent, relevant, and on time. Paperbased patient records have been in existence for centuries and their replacement by computer-based records has been slowly in progress in the last number of years. A recurring theme in literature is the effect of organization culture, which should have a strong positive effect on the process-driven / people-driven side of the business. The shift from traditional methods needs significant changes in skills, procedures, and culture that may require years to adjust. The traditional approach to quality however, predominantly focuses on technical aspects of quality and paying little attention to the soft systems (human side) of quality . This paper argues that control of information quality is the responsibility of all stakeholders in the health service delivery chain. We will examine the impact of resistance to using the EPR system in a blood ordering scenario in a major Irish hospital. The rest of this paper is organized as follows: Section 2 traces the evolutionof quality and its many definitions. Section 3: defines TQM; Section 4 briefly outlines IQM; Section 5 analyses of a case study mapped to Deming’s 14 points on quality management; Section 6 gives a brief summary and conclusions. 2 Evolution of Quality
The roots of quality can be traced to the pre Industrial
Revolution era, when inspection committees enforced rules for marking goods with a special quality mark to represent a craftsman’s good reputation. 19th century manufacturing followed this approach until the Industrial Revolution. Late in the 19th century the United States adopted a new management approach developed by Frederick W. Taylor. Taylor’s goal was to increase productivity by assigning inspectors, which led to a remarkable rises in productivity but, had a negative effect on quality. To remedy the quality decline, factory managers created inspection departments to keep defective products from reaching customers and quality was understood as conformance to standards [17, 20]. By the 1970’s, the U.S. embraced approaches that involved the entire organization known as TQM , and since the turn of the century new management systems such as Information Quality Management (IQM) have evolved underpinned by the teachings of Deming and Juran .
Now quality has moved beyond manufacturing into service, healthcare, and other sectors . But before quality can be managed, it must be defined. Quality has been defined widely in the literature as conformance to specification or fitness for use measured against some standard. However, the most widely used definitions are based on customer satisfaction and meeting or exceeding the customer’s expectations. However, a universal definition of quality is difficult to achieve. Technically speaking, quality has two aspects 1 the characteristics of a product or service that satisfy customer’s needs that are free from deficiencies; 2 the perception of quality from the perspective of those that benefit from the process, product or service . Levis et al., outlines some commonly accepted definitions of the quality pioneers and their emphasis . 3 Total Quality Management
At the end of the eighties, quality became a crucial element in businesses all over America. To encourage international competitiveness, the Malcolm Baldrige National Quality Award was established in 1987. The birth of total quality came as a direct reaction to the quality revolution in Japan pioneered by the work of Deming, Juran, and Crosby [25, 26]. Rather than concentrating on inspection they focused on improving organizational processes [19, 27]. The focus in TQM is not on the technical aspect of service delivery, although technical skills are important. In essence, the three basic principles of TQM are: focus on customer satisfaction; seek continuous and long term improvement in all the organization’s processes and outputs, and ensure full involvement of the entire work force in improving quality. TQM is always people-driven and its results are high performance team work, employee morale enhancement and a harmonious organizational climate . However, the entire total quality effort must be planned and managed by the management team . Most management leaders agree that the biggest ingredient and most critical issue in quality is management commitment [19, 30]. Management needs to make commitment to quality clear to the entire organization and communicate the fact that total quality continuous improvement is essential for success [28, 29, 30, 31]: 4 Information Quality
After an extensive review of the literature, an agreed definition of information quality also seems to be an elusive concept and difficult to define in a way that is conceptually satisfying [32, 33, 34]. There are a number of theoretical frameworks for understanding data quality. Levis et al. summarized the main points of some important models . Redman, Orr and others present a cybernetic model of information quality that views organizations as made up of closely interacting feedback systems linking quality of information to its use, in a feedback cycle where the actions of each system are continuously modified by the actions, changes and outputs of other systems [19, 33, 35]. Data is of high quality ‘if it is fit for its intended use’ [36, 37, 38]. Wang and Strong propose a data quality framework that includes the categories of intrinsic data quality, accessibility data quality, contextual and representational data quality from the perspectivesof those who used the information . The goal of information quality management (IQM) introduced in the 1990’s is to increase the value of high quality information assets . Most researchers and practitioners agree, that the key to understanding information quality is to understand the processes that generate, use, and store data. However, quality cannot be measured in purely technical terms by some characteristics of the product or service. High quality Information is a critical enabler to TQM and, serves as a key to quality success. Better quality and productivity may not be the issue, but rather better information quality . Information is critical to all functions and all functions need to be integrated by information. Organizational knowledge is based on exchange of information between customers, employees, information suppliers, and the public. 5 Analysis of Hospital Case Study
We will now examine what happened when the EPR system came to work as a fundamental part of the daily work practices in one of Ireland’s major hospitals. A regular scenario was mapped from conversations and through in-person interviews with a staff nurse in one of Dublin’s major hospitals. To disguise the identity of this hospital we shall refer to it as hospital H in thispaper. Hospital H had just transferred from their outdated manual paper based blood ordering system to the new Electronic Patient Records (EPR) system. The EPR should become a valuable communication channel between doctors and other service departments. The implementation of this system should provide accurate and timely information and streamline work practices to increase information quality by reducing the inefficient manual paper based tasks. A description of TQM and how it maps to a hospital setting and the selected scenarios are tabled in appendix 1. Scenario1: Dr ‘A’ attends to patient P in his out-patients consultation room in hospital H and decides patient P needs blood tests.He enters the blood order into the EPR and sends patient P to the Phlebotomy department.
Patient P leaves the clinic and goes to the Phlebotomy department. The Phlebotomistchecks the EPR system for the blood order for patient P. The blood order for patient P is on the system and therefore s/he proceeds to take the blood sample. The phlebotomist is highly impressed with the new system because of the instant communication channel and having no problems interpreting Dr A’s handwriting. Fortunately, this new computer technology system has made it possible for Dr A to provide relevant information for the phlebotomist when they need it. This automated system improved overall efficiency and, thus, patient care quality. Scenario 2: Dr ‘B’ also working in hospital H attends to Patient Q in his outpatients consultation room and decides patient Q needs blood tests. However, he feels that the implementation of the EPR system interferes with his traditional long standing practice of using the paper based blood ordering form and is reluctant to use the system. To him handwriting is mechanical—he does not have to think about it, but using the EPR system is not. He has concerns about spending too much time on the computer and less time with his patients. Therefore he fills in the outdated manual blood order form. Patient Q leaves his clinic and goes to the Phlebotomy department. The Phlebotomist checks the EPR for a blood order for patient Q. The blood order is not on the system. The Phlebotomist is not impressed as s/he does not have the appropriate information to carry out the task in hand and refuses to accept the paper form from Patient Q.
The Phlebotomist insists that patient Q goes back to Dr ‘B’ to enter the blood order into the EPR. When patient Q arrives at Dr B’s clinic, s/he is told that Dr B is attending to patient R. In orderto pacify the irate patient the nurse on duty has to decipher Dr B’s handwriting and enter the blood order details into the system herself before sending unhappy patient Q back to the Phlebotomy department. On the patient’s arrival the Phlebotomist again checks the EPR for the blood order for patient Q and is happy to find it available on the system and proceeds to take the blood sample. Figure 1 show a typical high level process model to capture scenario 1 and scenario 2. Fig. 1. Shows a typical high level process model tocapture scenario 1 and 2 The ability to enter and store orders for blood tests, and other services in a computer-based system enhances legibility, reduces IQ problems, and improves the speed with which orders are executed.
The automated record is highly legible, generally more accurate, and instantly available to the phlebotomist who normally had to struggle with deciphering all kinds of handwriting on paper based forms. The use of the EPR was strongly opposed by Dr B, which unintentionally slowed down the patient flow and adversely affected the nurse’sworkload just because it altered his traditional workflow pattern. Until the implementation of the EPR, doctors used to work with the paper based ordering system, which was easy to handle and did not take much time, whereas the EPR takes more time – a very scarce resource for doctors. Nurses however, because of their proximityto the patient have a key role in co-coordinating patient care and protecting them from all organizational turbulence. Technology changes information flows and because of this, it also changes relationships between health care professionals. DrB’s resistance to change is stirring up pre-existing conflicts with nurses and results in new confrontations between them. We conclude that this could be due largely to computer illiteracy or low level of IT expertise preventing Dr B from using the EPR. Table 2 and table 3 shows the above scenarios mapped to Deming’s 14 points on Quality Management and figure 2 shows the processes mapped to some of Deming’s 14 points.
Dr writes manual blood order here we see barriers between departments; Dr enters blood order into EPR points out adequate training and education; Phlebotomist checks for blood order on EPR highlights adopting a new philosophy; Blood order not available on EPR indicates barriers between departments; Blood order available on EPR signifies job satisfaction; Blood test taken form patient signifies consistency of purpose for improvement of quality for patients; patient sent back to Dr clinic indicates barriers between departments; nurse enters blood order into EPR suggests lack of training and education for the doctor and barriers between departments; patient leaves phlebotomy department happy would suggest management transformation and consistency of purpose for improvement of quality. 6 Conclusion
A major re-engineering of the health care delivery system is needed for significant progress to be made, which will require changes in cultural, educational and training factors. The heightened pace of modern practice dictates the use of EPR’s, to improve quality of care and to build a safer quality healthcare environment. Yet, despite indication that clinical information systems can improve patient care, they have not been successfully implemented at least in Hospital X. Doctor B is still unwilling to change his long-established practice patterns of using the paper based blood ordering forms even though, automated records are highly legible, generally more accurate, instantly available and of higher quality for the phlebotomy department. Our research shows that in hospital X resistance tochange is an ongoing problem that hinders painstaking efforts to improve performance and quality and is seen as a major failure factor in implementing the EPR systemsuccessfully. Even though the benefits of the system are known, many individuals still need greater evidence to convince them to adapt it. One major obstacle is the time it takes physicians to learn how to use the system in their daily routine. Replacing paper based systems with EPRchanges the doctor’s traditional work practice; therelationships between doctors and nurses, and the work distribution.
In our case study in hospital X there is a delay inaccessing patient B’s blood order and therefore theproductivity of the nurse on duty was reduced and her work load increased. It also led to dissatisfaction among system users i.e. the phlebotomist, and patient Q as the end user of the healthcare system. Further research is needed to identify and assess other barriers to its use. Management and human factors such as the information customer (the phlebotomist) and supplier (Dr ‘A’) played a critical role in implementing and maintaining a good quality healthcare system. Automating the manual tasks of blood ordering freed up paperwork time and increased the time spent with patient care. Inscenario 2, Dr ‘B’ fell victim of some of the barriers to EPR, which can be identified as his a lack of IT skills, training and motivation. For Dr B, handwriting is second nature and he does not have to think about it, but using a computer is not. There is a need to change Dr ‘B’s’ perception of the system, from seeing it as an additional burden to seeing it as a more effective use of timeand as a way to improve patient satisfaction as the end user of the healthcare service. For change to occur a major reengineering of the health care delivery system is needed.
An effective total quality effort will require the participation of everybody in the hospital  and good communication with other departments is important to get richer information . In a TQM effort, all members of an organization participate in improving the processes, services and culture in which they work. As shown in scenario 2, attempts to computerize processes were met with strong user resistance. There are many different reasons for resistance for example psychological factors such as fear of change. Untilthe moment of the implementation of the EPR, doctors were used to working with the paper ordering system, which iseasy to handle and does not take much time. With the EPR it takes much more time for doctors to order and time is a scarce resource for healthcare workers. The only cultural change necessary is accuracy and time needed to enter the order into the EPR once adequate training in using the system is put in place References
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Case study 2: Implication of 6 Sigma
Addressing the Issues at Doctors Hospital of Augusta
Sondra Smith February 26, 2010
About the Hospital
Doctors Hospital of Augusta is a 354-bed full-service medical/surgical facility located in Augusta, Georgia, USA. It employs more than 1,450 nursing and medical professionals. Among its special features are centers for cardiopulmonary health, digestive diseases, sleep disorders (polysomnogram), stroke care, diabetes care and wound management. It also is home to the nationally acclaimed Joseph M. Still Burn Center. Like most healthcare providers, Doctors Hospital in Augusta, Georgia, USA, has struggled with familiar issues related to quality, resource constraints and ensuring optimal, accessible services for the community. Implementing Six Sigma has allowed the hospital to begin winning the battles with these issues. In 2004, the hospital’s leadership team decided to launch a new initiative aimed at improving performance throughout the organization. This effort included project-based education in Six Sigma and change management.
The first wave of Green Belt training began in May 2004, with 16 people selected from the hospital’s staff. Initial projects targeted outpatient CT scan cycle time, wound center turnaround time, emergency department cycle time from the patient’s experience, wound center accounts receivable billing, operating room turnaround time and MRI cycle time. To a certain degree, the improvement initiative at Doctors Hospital was a test case for Hospital Corporation of America, the hospital’s parent organization. So far, the hospital’s leadership team has been pleased with the progress and achievements. “Much of the excitement generated during our Six Sigma experience has actually come not only from the accomplishments of the teams, but also from the experience of getting together and attacking opportunities together,” Shayne George, president and CEO at Doctors Hospital, said. “We have been able to gain a great deal of value during the journey, as well as the destination.” Linking Six Sigma with Strategic Plans
Doctors Hospital creates a strategic plan every year, and for 2004, driving Six Sigma and achieving culture change were major themes within the plan. The hospital concentrated on establishing a clear communication plan to keep everyone informed, making sure people received training and instilling the process as the way they would work going forward. Six Sigma has been viewed as supporting the organization’s strategic plan in several ways: Human resources – The project-based training helped to drive a specific strategy listed under human resources retention and productivity. Efficiency and growth – At the division level, the hospital has an outpatient imaging and surgery taskforce focused on driving efficiency and strategic growth. One objective is to effectively compete against freestanding imaging centers by improving the customer’s experience.
Projects in CT and MRI specifically addressed cycle time, aimed at reducing lengthy waits, which are a major source of dissatisfaction for patients. Another objective was to increase capacity in the operating room by striving for turnaround times found in ambulatory surgery centers. Emergency department performance – Another strategy targeted the improvement of emergency room performance metrics, including throughput time. Patient satisfaction – The hospital measures customer satisfaction each quarter using an independent survey company. In the outpatient test and treatment areas, one of the strongest drivers of satisfaction is wait time. The team knew that reducing cycle time with the CT, MRI and wound center projects would help improve satisfaction by shortening the wait time.
Teamwork and Solutions
Beyond specific projects and measurable results in key areas, an important byproduct of this effort has been greater proficiency, collaboration and communication among the team. Challenges that face the staff on a daily basis are being addressed through a common set of tools, and the approach is resonating well within the organization. Employees who went through Green Belt training said they felt as if they had received a “master’s” level education. They appreciated the investment leadership had made in promoting the initiative, providing the training and recognizing their achievements. All project teams, especially within perioperative services, received additional support as they went through each phase of their projects. Team members from various departments provided input and participated in Work-out sessions. They contributed suggestions in areas that might be considered outside their usual scope of work.
Work-out sessions, with their clear structure and focus on grassroots problem-solving, have changed the employee reactions to meetings at Doctors Hospital. A common employee complaint had been the seemingly endless meetings that did not create consensus or resolve the issues under discussion. People are beginning to use Work-out tools in other meetings to make the meetings more focused and productive. In one session, a team was able to scope the vision, develop a toolkit and create a who-what-when plan with specific assignments – all accomplished within one hour. As more employees go through the training and gain experience applying the tools, this approach is becoming ingrained as a common framework for problem-solving. People now feel they are better equipped to solve problems and manage change. Making the program work also depends on determining the right level of involvement for clinicians, and making the exchange of information as efficient as possible. One of the physicians participating in the process commented that this was the first time he had been really excited about an improvement project because he could actually see data-driven progress. Six Sigma is an objective and scientific process with a natural appeal for physicians. Tangible and Intangible Results
Improving processes and operating as efficiently as possible in every facet of patient care is crucial for ensuring quality, managing the bottom line and raising patient and staff satisfaction. The data-driven approach also is helping the hospital to meet its compliance obligations. With the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) survey process, healthcare providers have to be able to demonstrate that they are actually improving their performance and helping the patient. This type of rigorous, evidence-based approach is giving the organization the confidence to know it is doing the right things. All projects from the first wave are now in the Control phase. The leadership team is continuing to fine-tune processes and monitor progress, but its efforts have already paid off and delivered measurable benefits to the organization. Potential Increase in Departmental Earnings by Project
in Dept. Earnings
Reducing Turnaround Time
Capacity increased by 80 cases/month by reducing TAT from 39 minutes to 25 minutes. 8%
Reducing Time from Patient to Patient
Capacity increased by 22 cases/month by reducing time from 52 minutes to 45 minutes. No show reduction from 17% to 10%. 3%
Reducing Unscanned Supplies
Increase in number of items scanned; improved charge capture, and decreased losses for materials used. .5%
Reducing Cycle Time
Capacity increased by 100 cases/month by reducing cycle time from 59 minutes to 38 minutes. 8%
Reducing Cycle Time
Capacity increased by 254 cases/month by reducing cycle time from 135 minutes to 120 minutes. Increase in downstream ICU and med/surg patients for increase in number of ED patients (6 cases/month in ICU and 16 cases/month med/surg). 10%
Reducing Time from Patient to Coding
Reduced time to code records from 13 days to 5 days. Total out-patient
unbilled amount is lowest since 2003.
Reducing Cycle Time
Finishing implementation of improvements and remeasuring.
Yet to Be Determined
In the wound center, the hospital was able to reduce turnaround time for patient visit to coding of the medical record from 13 days to just five. The improvements in cycle time for outpatient CT scans provided the capacity for an additional 100 scans each month. A Black Belt team working in MRI reduced cycle time from 52 to 45 minutes, freeing capacity for 22 additional patients per month. With reduced cycle time in the emergency department, capacity was increased by approximately 250 more patients per month. Although the project team met its goal in this area, the hospital would like to see the numbers improve even more. A problem in the hospital’s operating room that had lingered for a long time was room turnaround time. By applying the right tools and getting the right people into a one-day Work-Out session, the team was able to create consensus and develop a viable solution. Room turnaround time was reduced from 39 to 25 minutes, adding capacity to perform 80 additional surgeries each month. Keeping the Momentum Growing
With the results that have been achieved so far, momentum has begun to build. Ideas for new projects are constantly rolling in. Four of the initial Green Belt liaisons are coordinating all projects during the second phase of the initiative. The hospital has integrated the entire process into the performance improvement committee. All projects – including Work-out sessions and larger Green Belt projects – now report to this committee. The group’s members comprise a major portion of the organization’s JCAHO survey process. The level of information the hospital is tracking and the results it is able to demonstrate assist in reporting progress to the board of trustees and medical committees.As requests increase, the improvement committee will continually prioritize projects, with a particular focus on increasing patient safety, clinical quality and patient satisfaction. The leadership team is putting a process in place to streamline how people make improvement suggestions.
To familiarize new employees with the purpose and basics of Six Sigma, a short elevator speech on the methodology has been created. “During orientation, new employees learn that Six Sigma is a highly structured process that we began using in 2004 to evaluate and improve the way we work,” said John Doriot, a Green Belt who also teaches customer service training at the hospital. “An important part of our service excellence culture is to make decisions based on data rather than opinions. We need help from all employees to identify changes that need to be made, and to support and sustain change,” Being able to clearly explain the purpose of the process helps to build acceptance and encourage participation. For 2005, Doctor’s Hospital focused on maintaining the momentum and using the training to impact other key areas in the organization. With a large influx of new physicians, the hospital is streamlining existing processes to accommodate extra procedures and volume. It also is continuing to use Six Sigma as a way to create greater efficiencies in perioperative services. Hard work and dedication from the entire team, along with ongoing leadership commitment, have been key factors in making this initiative a success. Beyond specific process improvements, one of the most important benefits of this initiative has been the ability to furnish people with proven new tools and techniques to solve everyday problems.The approach is creating a common foundation for leading change within the organization. Instead of simply making assumptions about underlying issues, teams are gathering, analyzing and verifying data to make an educated decision. Then they put in place solutions that can be sustained.
CASE STUDYSELFREGIONAL HEALTHCARE’SSUCCESSSTORY
Case study: implication of ISO9001
SelfRegionalHealthcareinGreenwood,SouthCarolina, USAhasfoundthe answerthatthehealthcareindustryis searchingfortobegintosolveissues withongoinginefficiencies,waste,patienterrors,increasingrisk,etc.,through theimplementationofandregistrationtotheISO9001:2000 standard. Self RegionalHealthcaresoughttheconsultingservicesofMAIanduponcom- pletion oftheimplementationoftheirQualityManagement System,theysuccessfully obtained registrationtotheISO9001:2000 standard inselecteddepartments through QMI.Asyouwillread, thebenefitsandimprovementstheyareenjoying havedramaticallyimprovedtheiroperationsandhaveresultedinmill- ionsof
SelfRegionalHealthcarebeganasSelfMemorialHospitalin1951andwasbuilttobeoneofthemostadvancedhospitalsintheUnitedState- s.The commitmenttoprovideadvancedcarewithleading-edgetechnologycontinues today.SelfRegionalHealthcareisanindependent,not-for-profithospital governedbya boardoftrusteescomprisedofcommunitymembers.They havegrownintoa majorreferralandmedicalcenterthatprovidesadvanced healthcareservicestoa populationofmorethana quarterofa millionpeople. Atonetimeoranother,everyoneinthesurroundingsevencountieshasbeen touchedbySelfRegionalHealthcare.
SelfRegionalHealthcarehasavisionaryCEOandboard inthattheyhave realizedthattheanswerstotheirqualityissuescouldbefoundthroug- h the implementationofandregistrationtotheISO9001:2000 standard. Withthe helpofdedicatedMAIconsultants,SelfRegionalHealthcarehasbeenable
toinvestinimplementingaworld-classQualityManagement Systemandhas become registeredtotheISO9001:2000 standard. Theleadershipteamat SelfRegionalHealthcareknewthatthisprojectwasnotacostexpendit- ure, butratheraninvestmentthatwouldresultinongoingcostsavingsthro- ughout theorganization.
MAIis ariskmanagement consultingcompanyspecializing inpre-eventriskmanagement. ForHealthcare, MAIhas developedMAPSS,atargetedriskmanagement tool, utilizingmanyoftheimprovementmethodologiesfoundinotherdiscip- lines specificallyforthehealthcareindustry.MAIspecializesinassistingcustomers develop, implement,andmaintainmanagementsystemsincompliancewiththe ISOfamilyofinternationalstandards. MAIworkswithSelfRegionalHealthcare onanongoingbasisastheycontinuetolookfornewwaysintheirISOjour- neyto improvetheperformanceoftheirorganization.
9001:2000 QualityManagement Systemareastonishingtosaytheleast.Below,anextensivelistis offered,however,each and everydaySelfRegionalHealthcareexperiencesfurtherbenefitsthat- continuetoleadtosignificantcostsavingsbenefits.
•SelfRegionalHealthcareimplementeda 340Bplan(an acceleratedrebateplanforvolumepurchasebuyingof medications)yielding$2.5Minannualized savings.They evaluatedtheireligibilityfora 340Bplanduringthe developmentoftheirqualityplaninaccordancewiththe ISO9001 standard,
andhavingadisproportionateshareof Medicare andMedicaid clientsinthepopulationtheyserve (morethan10%),realizedtheycouldapplyfortheirrebates quarterly;itappearstheywillbecloserto$3.0Minsavings forthe2007 year. •Improvedthepercentageofpharmacistscapableof performingaminoglycosideandvancomycintherapeutic drugmonitoringfrom43%to100%. Thismeansthatall 15 pharmacistshavebeenfullyqualifiedandthisadds significantvaluetothepharmacistutilizationfactor.Thetotal numberofpharmacistscapableofperformingthistaskis 100%duetotheISOstandard’scompetencyawareness andtraining requirementsforallstaff. •OrderingmethodologieshavebeenrevisedtoensurePitocin is onlyorderedwhenneeded.Thishasdramaticallyreduced thechancesofthePitocinpremixexpiringbeforeitis used andhasresultedincostsavingsfromtheeliminationof requireddisposalofexpiredPitocin. •Improvedphysicianordersreconciliationofmedication administrationrecordfrom70%toover95%.
•Pulmonaryevaluationsimprovedfrom58%to100%; this wasraisedasanarea forimprovementthrough theongoing monitoringofprocessesandpickedupthrough performance indicatordata. •Ventilatorweaning readinessscreeninghasbeenimprovedtoover98%.OneoftheJointCommissionsafetygoalswastoreduceventilatoracqui- red pneumoniaandpreparingpatientsforweaning fromventilatorsdecreasestheirchancesofventilatoracquired pneumonia. •SelfRegionalHealthcarehasdramaticallyimprovedheadofbedelevat- ioninordertoreduceventilatoracquired pneumoniasincethisincreasesdrainage.TheirQuality Management Systemfoundationhasenabled themtomake thesetypesofrecommended improvementsandhasallowed fororganization-widecommitmenttopatientsafety. •TheRiskPriorityNumber(RPN)through theFMEAprocessfor arterialbloodgashasbeenreducedbyover1000 points orroughly50%-
•IVsiteeventshavebeenreducedfrom 26 to 1.
•Averagenumberofdaystoreportaclaimtotheinsurance companywasreducedfromroughly6 daysto2.5days.Thisisattributabletotheimprovementsintheclaimsreporting processusingtheISO9001 qualityobjectivefoundation. •ThePressGaneyscoreonsafetyasansweredbyall discharged patientshasimproveddramaticallyfromamean of44%toameanof86%onthe“SafeandSecure”question.
•Decreased medicalequipmentwork orderturnaroundtimes by25%. •Reduced“couldnotlocate”medicalequipment.
•1000protocolshavebeenreducedto600 and900 formshavebeenreducedto400 bystreamliningprocessesand reducingredundancies throughouttheorganization. •Duetotheroughly50%reductionintotal numberofpolicies,procedures, protocols,
andforms,therehasbeenareductionof atleast125 employeehoursrequiredfor protocolreviewonanannualbasis. •Overall,thecultureis changinginthe hospitalanditis resultinginhugesavings.
SelfRegionalHealthcare’scommitmenttoimprovingquality,reducing waste,increasingoperationalefficiencies,andenhancingtheirpatient/ clientfocusthroughoutthe organizationhasledthemtoverysuccessful outcomes,nottomentionanextensive listofISO-relatedbenefits andimprovementsasoutlinedabove.Theynowunderstandthat“anorganizationwithinthe healthcareindustrycommittedtomaintaining aqualitymanagementsystemwithdisciplineandrigorshouldsee increasesinoveralleffectivenessandefficiencyequatingtoacost benefitofuptoa17:1ratio”(IWA1:2005 GuidanceDocument).Theyhavemadeaconsciousdecisiontoputaqualitymanagementsystem platforminplacethatwillprovideforcontinuousimprovementwhile maintainingfocusonensuringpatient/clientsatisfaction.
Oncethe basicfoundationoftheirqualitymanagementsystemhad beenimplemented,seekingregistrationfromathirdpartyindependent auditingfirm,suchasQMI,providedassurancetothe organizationthat the systemhadbeenimplementedproperlyandisinfactcontinuingto meetthe intentofthe ISO9001:2000 standarditself.
Allhealthcareserviceprovidersareconcernedwithimprovingpatien- t carewhileincreasingoperationalefficienciesandreducingrisk,anda commitmenttothe implementationofanISOqualitymanagementsystem thatparallelsSelfRegionalHealthcare’scommitment willcontinueto yieldresultsthe healthcareindustryisindesperateneedof.Itwill allow organizationstoworktowardachievinggoalsinasystematicwaythat clearlyhasproventobeextremelysuccessful.
ItisextremelyimportanttostressthattheISO9001:2000 standardisnotaframeworkthatwouldreplacerelevant healthcareaccreditationrequirements.Infact,theimplementation ofaqualitymanagementsystemallowshealthserviceproviders tobebetterpreparedfortheiraccreditationsurveyssincethe rigorsofacompliance-basedaudittothisinternationalstandard keepstheorganizationcontinuallythinkingaboutwaysto improvewithclient/patientsatisfactionastheendgoal.It shouldnottaketheplaceofaccreditationandactuallyworks incomplement toaccreditationallowingtheorganizationto furtherreapthebenefitsofbothprocesses.
9001:2000 standardisaproventoolthatthehealthcareindustry canadoptandbeginimplementinginordertohelpincrease operationalefficiencies,reduceerrorsandadverseoutcomes, experienceagreaterpatient/clientfocusedculture,produce amorepreventive/proactiveapproachinsteadofareactive environment,andreducewaste,amongmanyothers.Healthcare serviceproviders,suchasSelfRegionalHealthcare,shouldworktowardcreatingaculturewhereallemployeesunderstandt- hat theirjobsultimatelyaffectthehealthcaredeliveryreceivedbythe patient/client.
“Theinvestment in a
QualityManagement System will result in an ROI that any CEO and board will be proud to boast about!” TheimplementationandregistrationoftheISO9001:2000standard cancreateafoundationonwhichthehealthserviceorganization canachieveongoingimprovementthatcanbemonitoredandmeasuredthr- oughthesatisfactionlevelsofthepatients/clients,andworksincomplementtorelevanthealthcareaccreditationrequire- ments.Thisistheanswerthathealthservice providershavebeensearchingfor!Asahealthcareserviceprovider,don’tyouwanttowork
towardachievingthesameastonishingbenefitsthatS- elfRegionalHealthcareisalreadyenjoying?ClearlyasshownintheextensivelistofISO-relatedbenefits,theinvestmentinaQualityManagement Systemwillresult inanROIthatanyCEOandboard willbeproudtoboastabout!
Since registering their ISO
9001:2000 Quality Management System, Self Regional Healthcare experiences benefitsthat continue to lead to significant
ContactQMItolearnmoreabouthowyourhealthserviceorganizationca- nbenefitfromtheimplementationof,aswellasregistrationto,theISO 9001:2000standard. QMIhas registeredhospitalsandotherhealth serviceorganizationstothisstandardandhasa numberofqualified,full-timeauditorsonstaffreadytoassistanyorganizationinthisindustr- y.
Toronto,Ontario M9W 7K6
QMI,NorthAmerica’slargest managementsystemsregistrar,hasbeenaleaderinmanagementsystems registrationsincetheadventofthe standardsandregistrationmovement. Since1984,QMIhasledthewayin registeringorganizationsacrossabroad rangeofindustries,helpingbusinesses obtainnotonlytheirregistration certificate,butalsoachieverealandlastingimprovementsintheir
businessoperations.QMIhasextensiveexpertise inthehealthcareindustryinterms ofmanagementsystemsregistration andthatknowledgeandexpertise isavailabletohealthcareservice providersintheir pursuitofimproved operational efficienciesandpatient/ clientsatisfaction.
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