What is QI?
Quality Improvement is a formal approach to the analysis of performance and systematic efforts to improve it. There are numerous models used. Some commonly discussed include:

* FADE
* PDSA
* Six Sigma (DMAIC)
* CQI: Continuous Quality Improvement - http://deming.eng.clemson.edu/pub/tutorials/
* TQM: Total Quality Management - http://www.mapnp.org/library/quality/tqm/tqm.htm

These models are all means to get at the same thing: Improvement. They are forms of ongoing effort to make performance better.

* In industry, quality efforts focus on topics like product failures or work-related injuries.
* In administration, one can think of increasing efficiency or reducing re-work.
* In medical practice, the focus is on reducing medical errors and needless morbidity and mortality.

Many people are familiar with the term Quality Assurance (QA), as it was a common term for many years.

Quality Assurance – QA was reactive, retrospective, policing, and in many ways punitive. It often involved determining who was at fault after something went wrong. This term is older and not as likely to be used today.

Quality Improvement – QI involves both prospective and retrospective reviews. It is aimed at improvement -- measuring where you are, and figuring out ways to make things better. It specifically attempts to avoid attributing blame, and to create systems to prevent errors from happening.

QI activities can be very helpful in improving how things work. Trying to find where the “defect” in the system is, and figuring out new ways to do things can be challenging and fun. It’s a great opportunity to “think outside the box.”

An effective QI program can really help make your life better.

Short Example of QI vs. QA
From the following statements, which do you think have a QA focus and which have a QI focus?
QI focus?

QA

QI
Which staff member failed to transfer the call to the correct extension?

Are we creating an environment encouraging clinicians to report errors?

How do we reduce production errors on the widget line?

Patient had a bad outcome; were the doctors or nurses at fault?

What could we do to increase the efficiency of chart filing?

If you think you have a good comprehension of the difference between QA and QI try to look at the QA statements and see if you could reword them to have a QI focus. Alternately you can also change the QI statements to QA. The main difference between QI and QA is that QI’s focus is on Improvement. The focus makes all the difference in how people respond to a quality project.

How Do You Define Quality?

The definition of quality often depends on the stakeholders. Stakeholders are, as the name implies, people with some stake or concern in the process.

In manufacturing, the definition of quality can be fairly straightforward. Products should work as intended with a minimum number of faults or failures. Stakeholders might be:

* Management, who wants to see improved production numbers with acceptable quality.
* Union officials, who want the best conditions and highest pay for employees
* Employees, who want consistent work in a safe environment.
* Customers/purchasers, who want value for their money.

In service industries, customer satisfaction is often the primary measure.
Example

John is the manager of a local Sleep-E Motel. He has just received the second quarter report from his national headquarters which shows his cost per room has been rising over the last year. John and his staff are given bonuses based on maintaining or lowering costs. Who/what are the stakeholders he should consider in assessing ways to lower his costs?

Who are the Stakeholders in Healthcare?

In Healthcare, the definition of quality can be complex and controversial because of the different views of people with a stake in good Healthcare. Let’s look at a few different stakeholders. What does each of these stakeholders want?
1-Providers:
Tend to view quality in a technical sense – accuracy of diagnosis, appropriateness of therapy, resulting health outcome.
2-Payers:
Focus on cost-effectiveness.
3-Employers:
Want both to keep their costs down, and to get their employees back to work quickly.
4-Patients:
Want compassion as well as skill with clear communication.

Can you see any conflicts between what these stakeholders want? The decisions around the conflicts often determine if a QI project will be a success.

Potential Areas of Conflict
1.Patient and Employer
* Patients expect an employer to offer a wide variety of options for health coverage that can be customized to their specific needs. They also look for the employer to fund the majority of the cost of health insurance. Basic premise is to provide the most options, and the least out-of-pocket cost to the employee.

* Employers want to maintain or lower their cost contribution. They want the patient/employee to seek only needed care, follow providers’ instructions, and recover quickly to full utility. Patients should also seek to reduce their health risk behaviors, i.e. diet, exercise and smoking cessation.

2. Providers and Payers
* Providers want to provide the best service using the most accurate and newest tests and treatments (also likely most expensive). They also want to provide preventative care which the insurance company (payer) may not cover.

* Payers want providers to follow a clear, evidence based, diagnostic plan and reach an accurate diagnosis and treatment plan with the fewest visits and least number of tests.

Quality in Healthcare

If you wanted to get a sense of the quality of healthcare delivery, how would you go about it?

* You could ask each of the providers if they were following the guidelines for a specific disease
* You could ask providers to keep track of their errors or “near misses”

Can you imagine any reason these methods may not work?
Earnest Interviewer: Have any of your patients gotten worse because of treatment you provided?
Reluctant Provider: Er, um… No, never, of course not.
EI: Do you use the approved guidelines for this condition?
RP: Of course—every time!
EI: What about the time . . . ?
RP: (interrupting) Well, that was a special case.

These methods would be fraught with problems of validity and reliability. Self-report of errors is shown to be low and, particularly if there is a potential punitive response, reporting would be infrequent and inaccurate.

This leaves us with a deficit in how we can assess quality.

One means of getting around the problems with self-report is to use more objective data.

* You start with a small problem. Perhaps you want to see how well your group is doing with patients with a chronic disease, such as diabetes, asthma, or hypertension. From that point you can narrow your focus even further.
* Decide what aspect of care you think might be a problem.
o How about assessment of how well the condition is being controlled?
o Within an office visit what measurements would be useful?

Examples:
Asthma example :
Asthma staging may be helpful, but is more a measure of disease severity than control.
Diabetes example :
Hemoglobin A1C would give you an assessment of diabetic control. Does it tell you if the patient is controlling what they eat?
Hypertension example :
Blood pressure is certainly a measure for hypertension, but how reliable is a single reading?

Each of these measures is valid for a specific purpose. Understanding that value and its limitations determine if that is the correct measure to use for what you want to evaluate. These challenges are at the heart of healthcare QI.

The ultimate objective of quality improvement is not just to provide good quality service to customers; it is also to improve productivity while improving customers’ satisfaction. In fact, improving productivity and enhancing customer satisfactionmust go together because productivity improvement enables Hospitals to lower the cost of quality improvement.
One way of improving productivity is through the reduction of defects and rework. The reduction of rework and defects is not achieved through inspection at the end of production lines; it is done by instill-
ing quality in the processes themselves and by inspecting and monitoring the processes in progress before defective services are generated.

The prerequisites for improving customer satisfaction while improving productivity address two aspects of operations: the definition of the optimal level of the quality of the products delivered to customers and the stability and predictability of the processes that generate the products. Once those optimal levels (that will be referred to as targets) are defined, tolerances are set around them to address the inevitable variations in the quality of the product and in the production processes.

Variations are nothing but deviations from the preset targets, and no matter how well controlled a process is, variations will always be present.

For instance, if a manufacturer of gaskets sets the length of the products to 15 inches, chances are that when a sample of 10 gaskets is randomly taken from the end of the production line under normal production conditions, there would still be differences in length between them.
The causes of the variations are divided into two categories:

They are said to be common (E. Deming) or random (W. Shewhart) when they are inherent to the production process. Machine tune-ups are an example of common causes of variation.

They are said to be special (E. Deming) or assignable (W. Shewhart) when they can be traced to a source that is not part of the production process. A sleepy machine operator would be an example of an
assignable cause of variation.

To be able to predict the quality level of the products or services, the processes used to generate them must be stable. The stability refers to the absence of special causes of variation.
Statistical Process Control (SPC) is a technique that enables the quality controller to monitor, analyze, predict, control, and improve a production process through control charts. Control charts were developed as a monitoring tool for SPC by Shewhart; they are among the most important tools in the analysis of production process variations.