1  Introduction

In the first part of the text, presented with the title: “Quality Tools – Part 1″ It was talked about the relationship and the constant search for patient satisfaction, through healing without harm and the use of tools and methodologies to improve health in general.

Public or private hospitals must optimize costs, encourage general health improvements through disease prevention and ensure quality.

2  The importance of history in continuous improvement

In 1930, Shewhart, a physicist, engineer and statistician, the “father of statistical quality control” initiated the use of statistical tools in process improvements. It was he who found predictable processes, which through control charts (figure 2.1) became the basis of statistical process control.

This made it possible to act on the processes through the PDCA and PSDA cycles in addition to the search for predictability of the process responses. However, it was only in 1980 after the reconstruction of Japan that Edwards Deming, also a statistician, recognized for improving production processes in the United States, took these techniques to rebuild the country, and through the Toyota System applied the culture of quality and process improvement and emerged as a great economic power.

After the development of the Toyota Production System, process improvement became popular as a strategic advantage, of lean production that involves employees, standardized and Just in time. In figure 2.2 more characteristics of the processes.

During the same period, the Lean Six Sigma also in the search for process improvements in work routines. In order to identify and eliminate waste, reducing costs and increasing quality based on structured information.

Toyota Systems and Lean state that front-line employees must be in charge of improving processes and therefore are partners in improvements.

Still talking about the importance of improvement in the history of health, it is necessary to understand the four pillars of in-depth knowledge, shown in figure 2.3 These four pillars enable changes to generate improvements.

2.1 Systemic view

The organization is a set of processes that aim to satisfy a customer's need, which in healthcare is the treatment of some pathology, or a consultation, or emergency care, among others. And often the lack of alignment of processes is responsible for losses, such as adverse events, unnecessary costs, rework, long waiting times and that is why it is extremely important to see the correlation between all processes with a single purpose.

2.2 Knowledge of Process Quality

It is necessary to know how to generate specific knowledge within the organization, for example, in the case of hospital pharmacies, pharmacy processes directly influence the administration of medicines to patients, and therefore the entire pharmacy team must be aware and very well trained on the importance of unitizing medicines, as an error could be responsible for Adverse Events, even the death of patients. In view of this, ongoing education in the pharmacy sector and in all hospitals related to unitarization is essential.

2.3 Study of variation

Variation is inherent and natural in processes, several factors lead to changes in results. Therefore, it is necessary to study and learn from these variations.

2.4     Culture

All organizations are made up of people and it is necessary to understand the characteristics and distinctions so that teamwork can achieve the organization's purpose. That's why happy, satisfied and engaged employees are essential to the company's purpose.

Culture is values, attitudes, habits, typical behaviors, shared beliefs. Culture determines how an organization functions.

Quality methodologies and tools teach how to understand and apply the concepts of the pillars of in-depth knowledge in order to generate improvements that will promote changes and strategic advantages.

To do this, it is necessary to define a focus for improvement, feedback, measurement, an indicator to show the changes and what actions will be taken.

An example of a process improvement could be in the purchasing process. In the search to reduce costs, time to make purchases and the lack of products, it is possible to define specific standards for the ideal suppliers.

They must meet particular quality requirements for all necessary products, in addition to acceptable average values ​​and the ideal product delivery time.

To achieve this, a well-structured supplier qualification process will make it easier to define the companies where purchases will be made.

3   Quality methodologies and tools

In health, the search for value-based care makes it possible to use different methodologies to increase the quality of care, to promote analysis of problems and improvements in services, in order to reduce errors.

The methodologies have already been covered: PDCA, PSDA, Basic Quality Control Tools and Lean Six Sigma na part 1 of the text and now in part 2 In the text on quality and safety tools we will talk about methodologies DMAIC, Lean Health and Quality Control Management Tools.

3.1 DMAIC

It is a structured way of improving processes and tackling more complex problems through continuous improvement.

It is possible, with innovations, to execute projects for new processes or services, and improvement projects for existing processes in order to improve them.

To do this you need:

• Know the processes (What do they produce? What resources do they use? How do they produce?)
• Know how to measure processes (What data do we have about the process? What is a problem or defect?)
• Know how to improve processes (How to attack the problem or defect? ​​What to attack first? What to focus on?)
• How to standardize the process so that the problem does not return?

With the answers to these questions it will be possible to define which improvement projects should be carried out.

In each phase of DMAIC, several quality tools will be used to help resolve problems.

3.2 Lean Health

He came from Lean industries, but with a vision for healthcare and improving hospital processes.

It aims to facilitate, improve, speed up and make processes cheaper.

According to Vital Directions for Health & Health Care: In the initiative of the National Academy of Medicine (2017), in the USA medical care costs are approximately US$3 trillion per year, 30% of which is waste.

The classic question on this topic related to healthcare spending is:

What can be done to reduce healthcare costs?

Given these high numbers, the Lean Health searches for opportunities to improve hospital processes, capable of reducing waste due to errors, rework, failures, bureaucracy, unnecessary steps and excessive expenses, in addition to increasing the value of its actions, such as more time with patients, risk control and safety, patient and employee satisfaction, agility and efficiency of organizations.

waste are considered actions that consume energy and resources without adding value to the customer. Therefore, the entire hospital must think about adding value to its actions so that the patient, who is the end user, receives actions with safety, quality and satisfaction.

With this, the practice of Lean can identify and quantify waste where assistance takes place, in the industry called the factory floor.

Below, in table 3.1, some examples that cause waste:

Tabela 3.1

	EXAMPLES	CAUSES	CHANGES
SUPER PRODUCTION	Repeat and perform unnecessary exams.	Incorrect forecasts, errors in processes, culture of excesses.	Actions such as reducing inventory, producing what is necessary, reviewing processes and changing culture are necessary.
WAIT	Waiting for surgeries, appointments or some material.	Due to lack of communication, standardization, priority, pushed system, unbalanced work.	Workflow synchronization, Cell deployment, balancing in stages.
MATERIAL TRANSPORTATION	Transport of kits to the operating room with missing material.	Lack of standardization, pushed processes.	Kanban, inventory control.
PERSONNEL MOVEMENT	Lack of materials to make bandages.	Lack of standardization, organization, security, inadequate stock.	5S, workflow.
INVENTORY – STOCK	Expired medications.	Processing order, supplier lead-times, long setups.	KANBAN, supplier development, continuous flow.
DEFECTS	Machines down, medication errors, rework.	Process failure, lack of barriers, lack of work instructions, lack of standardization.	Procedure improvements, project improvement, creation of Poka-Yoke.
SUPER PROCESSING	Repetition of activities due to poorly designed processes.	Delays between processes, pushed system, bad layout.	Continuous flow and lean design.
WASTE OF HUMAN TALENT	Disregarding opinions of employees who are directly part of processes that need changes.	Lack of culture, superiority, high hierarchy.	Organization Culture.

For each waste, actions are taken using quality tools to reduce or eliminate it.

In health the Lean It has 6 principles, they are:

• Attitude of continuous improvement, the system's need to improve, the entire institution is involved with the improvements and the PDSA cycle is fully linked to the processes;
• Always create value for patients, reduce waiting times, create safer environments, be more efficient, listen to patients, offer fairer care for patients;
• Unity of company purpose. The true north where she wants to go and the employees in the same direction;
• Respect for people, believe in employees, open and socialized communication, create a safe environment, direct employees on what to do;
• Visual, culture of transparency, clear processes, goals, satisfaction levels and exposed costs;
• Standardization with flexibility, facilitating processes, avoiding and eliminating errors. Establish standards to stabilize processes.

Many tools are used to apply the system Lean in continuous improvement.

According to the objectives, which methodologies should be used for each problem are defined.

Another example widely used in healthcare is the A3, which is responsible for identifying the problem. It is a communication tool and can be used in any process within the institution. This improvement model is recommended by the IHI. It is based on the PDSA and summarizes the problem and the solution on an A3 sheet.

3.3 Quality Control Management Tools

As 7 tools are focused on the search and identification of problems (“Problem Finding”) and situations not covered by the basic Quality Tools.

Through them, managers are able to visualize and enable the mapping of quality problems and the planning of efforts, and thus will be better able to draw up action plans to improve the quality of projects, compliance and performance.

They help with qualitative factors. For example: classification of a service (good/bad), result of an inspection (compliant/non-compliant).

To achieve this, management tools constitute a three-phase process.

3.3.1 PHASE 1 – Identify Problems

• AFFINITY DIAGRAM:

Groups similar ideas related to the topic, can contemplate the Brainstorming (brainstorming), as it seeks to synthesize, classify and structure poorly defined ideas.

• RELATIONSHIP DIAGRAM:

Allows you to discover and analyze cause and effect interrelationships. It helps to identify the root cause of a problem. A Brainstorming. It serves as a complement or alternative to the fishbone diagram. It makes it possible to identify the main area for improvement.

With the relationship diagram it is possible to define measures to reduce patient complaints, improve and eliminate defects in processes and simplify problem solving.

3.3.2 PHASE 2 – Determine Actions and Resources

• TREE DIAGRAM:

It explains in detail the reasons for the problem. In health, it is derived as a Driving Diagram (DD): Tool created by IHI that helps in defining the improvement goal, directing primary and secondary actions in addition to the concepts of change necessary for improvement to be achieved. Always with a logical set of related objectives that can be transformed into executable subprojects or initiatives. Identifies characteristics that can be controlled immediately.

It can be used as support in phase D (Define) do Lean Six Sigma or in the P phase (Plan) in PDCA/PDSA.

This diagram allows for a complete change program, in addition to structuring measurement to monitor the progress of improvements.

The tree diagram helps organize the concept of changes and ideas. It allows a team to see where they want to improve and what will really work.

To do this, you will need to assemble a team with people who can add to the topic; objective must be clear and defined; To do brainstorming; create drivers; identify the links between the drivers and what actions and interventions to carry out; define which driver and intervention to measure; validate work with the team.

The diagram should be updated and changed during the project, if necessary. Because it reflects a team's view on the topic, it is a “hypothesis” as in figure 3.1.3.

• MATRIX DIAGRAM:

Used to understand the interactions and behaviors between different changes around a problem.

• PRIORITIZATION DIAGRAM:

To define more relevant factors and solve it. GUT Matrix (Severity, Urgency and Trend), FEMEA (Analysis of the effect and type of failure) and QFD (Deployment of the quality function).

It is important to guide decision-making on what to prioritize, with the Pareto chart, for example.

3.3.3 PHASE 3 – Contingency Plans and Schedule

• DECISION-MAKING PROCESS DIAGRAM (Process Decision Program Chart – PDPC): Directs the best outcome of activities, and the choices to be adopted in the event of deviations, maps all possible paths to achieve the objective.
• ARROW OR ACTIVITY DIAGRAM:

To program and monitor the steps of a plan/work, explaining the critical paths. It is concerned with describing the steps to be taken to achieve the goal.

The diagram has the initial state, final state and action state and uses arrows to show the path of the next action.

All the different techniques in quality management tools help analyze quantitative and qualitative data and are typically used to address more complex problems.

The set of management and basic quality tools allow planning, organization, implementation and continuous improvement in the search for quality and excellence.

4 CONCLUSION

By applying quality methodologies and tools, it will be possible to understand process variations and know where they are, as well as how to reduce them.

Each specific tool is indicated for a type and stage of improvement.

Regardless of which Improvement project will be used, three questions must be asked:

• Will employee and patient satisfaction increase?
• Will it eliminate waste by focusing on value for the patient?
• Will it simplify and standardize processes?
• Will it encourage awareness of processes and encourage continuous improvement and innovation in care?

These questions will be able to guide the quality of the improvement projects to be implemented in the organization, as if they do not meet any of these areas they must be reviewed.

Much of the difficulty organizations have in carrying out projects is directly linked to the lack of basic pillars for implementing improvements. This is essential for making improvements in a solid and effective way within organizations.

The greater the organization's investment in the training and development of employees, the better people's performance and the greater the clinical focus on risk prevention and process improvement, as they will be aware of the quest to achieve the organization's objective.

See also:

https://opuspac.com/br/artigos/ferramentas-da-qualidade-parte-1/