Quality management
The objective of a Quality Management, in any sector is to deliver a product or service, in this case a service, that satisfies the customer.
Heal without harm is the classic definition of the objective of the health sector. Maintaining a population with a high level of health would be a broader and more appropriate objective.
If you are a health insurer, then maintaining a high level of health is a factor that reduces expenses and brings benefits.
If you are a general hospital, without a health system, you are paid for services rendered. Maintaining a high level of health does not generate business for you. Worse, it reduces potential revenue. So you would not be motivated to improve health in general.
But the only strategy win-win is paying a health system for keeping the population in good health, avoiding or delaying chronic diseases: sedentary lifestyle, heart disease, diabetes, obesity, smoking, etc.
This is a win-win strategy for the government, the hospital and the patients.
Now, if a hospital commits an adverse event and the patient has to stay for 5 more days, it receives more money. Business generated from its error. Of course, the system in place does not help to resolve the issue of placing Quality at the top of the priorities.
Patient Safety is a discipline that forms part of quality assurance.
They use similar tools, but Quality is oriented towards improving performance, while Patient Safety is oriented towards reducing errors.
In healthcare, these methods are part of value-based care, a model whose values depend on effectiveness, not on the inputs used. Healthcare is now measured by the results achieved, and not by the quantity or volume of services provided.
Different techniques are available to help figure out what needs to be done. Some guiding methodologies such as PDCA, PDSA, Lean Six sigma, DMAIC and Lean Health are methods that prepare the use of quality tools in the different phases of analysis and problem-solving and indicate more effective improvement actions. The use of these methodologies is defined according to the complication of the problems and their impact on the organization's performance.
The PDCA cycle is one of the tools designed to improve processes. It is used as an action plan to solve problems or make modest improvements in organizations by improving previous indicators. It structures the actions that should be taken at all stages to diagnose and solve problems, and it is constantly evolving and has no mandatory end.
Another well-known cycle for improving processes is DMAIC, which is an alternative to PDCA in more complex projects. DMAIC is widely used in Six Sigma, and its project roadmap is best known.
PDSA is a roadmap that helps apply new knowledge about a given aspect of the process or correct and integrate pre-existing knowledge, thereby proposing changes that generate improvements. The PDSA cycle can be used at any stage of DMAIC, PDCA or Lean Health when the objective is to generate some knowledge.
Six Sigma is a methodology that seeks the most perfect results possible that will reduce costs and achieve the highest levels of customer satisfaction. These results are always consistent, as the data is collected in a structured manner and the performances are presented by graphs (indicators). It is necessary to understand which information will impact these results.
O Lean seeks to reduce waste and reduce variations and looks for better ways to improve the flow, understanding the routine and doing only what adds value to the processes.
The two methodologies together give rise to the Lean Six sigma.
The method Lean Health also based on Lean of the industries aims at actions for health care and due to the needs of hospitals for many process improvements it was suitable to reach hospital services.
It also aims to reduce waste, rework, bureaucracy, unnecessary steps and excessive expenses, in addition to increasing the value of its actions, such as more time with patients, risk and safety control, patient and employee satisfaction, and the agility and efficiency of organizations.
From 2000 to 2019, there was discussion in the USA about what perfect service is, about what generates value and from there they saw the need to include the methodology Lean to be able to deliver perfect care to patients.
Quality tools also used in industries were adapted for healthcare and this movement is new and will certainly facilitate, improve, speed up and reduce the cost of healthcare.
This new methodology will be the subject of a new text to present and explain these tools. All the methodologies mentioned above can be used both for quality control and for use in planning new actions.
In addition to these methodologies, Quality Tools are used to solve problems and adjust improvements in the procedures of any company. Many of them serve the same purposes, but have different levels of complexity.
They facilitate the collection, analysis and visualization of data, complementing and assisting decision-making methodologies and can be divided into two groups: basic or quality control tools, which will be discussed in this text, and management tools.
Basic tools are part of structured processes and are related to trivial problems regardless of the level of complexity.
Some examples include reducing customer complaints, handling deviations and routine activities, as well as optimizing the time of an Emergency Room.
The Basic Tools of Quality Control
1. Brainstorming
2. 5 Whys
These are techniques to clearly define which problem will be addressed and through the stimulation of ideas in the team targeted by the problem, brainstorming and the 5 whys allow for many opinions and possible solutions in addition to concrete reasons capable of clarifying potential causes for deviations to occur and eliminating possible doubts.
No Brainstorming It is necessary to clearly define the theme and the team that will participate. Set the time and list the ideas mentioned in a visible place.
In the 5 Whys, the answers must be in-depth and complex in the search for information that gets to the root cause of the problem.
3. Checklist
It is a form for tabulating and monitoring data from a set of necessary tasks grouped by categories.
Through the occurrence of one or more phenomena, the frequency of events in a given period can be identified. For example, the number of falls by patients, medication errors, and tests released after the deadline.
The form must be clear, complete and simple. It must contain the purpose of data collection, fields for identifying the processes and professionals responsible for collecting the data, area codes and the person responsible for collecting the information.
The team must be made aware of the need to complete the list with information about the reason for it, where it will be carried out, for how long and where the information will be used.
Example:
4. Pareto Diagram or Chart
Using a bar graph with lines, it is possible to identify which of the analyzed items are most important based on the 80/20 rule, which determines that 80% of defects are concentrated in 20% of the processes and thus defines the degree of priority in resolving problems.
With the Pareto chart it is also possible to analyze different ways of grouping data such as by sector, by shift, by non-conformities or by frequency, measure the impacts of changes in processes and dissolve general causes into specific causes.
Example:
Prior data collection is required, which can be acquired through a checklist.
5. Stratification
It involves dividing information and data into different groups to find the causes or origins of a problem.
It is necessary to separate the different elements into sets, by stratification factors. And each stratum should be observed in turn, and then the results should be compared and conclusions drawn.
This tool must also use a checklist and the data collected must contain the event to be monitored and examined. When, where, what and who had the problem will be analyzed. Therefore, the data is exclusive.
To assist in the evaluation of this data, a stratification tree can be constructed to determine its suitability. Again, the objectives must be well defined, the purpose established, with reliable and correct measurements that can be recorded.
Example:
It is also possible to use historical data, but its quality must be correctly analyzed, knowing its origins, who collected it, how it was collected and the reliability of the measurements.
To have secure data, its collection must be planned and with well-defined goals.
6. ISHIKAWA DIAGRAM
Also called a Cause and Effect diagram, its function is to identify and classify into useful categories the potential causes of problems or aspects related to quality.
It facilitates the direction of efforts towards its solution by relating the effect and the causes that influence it. It will be possible to identify, explore, observe and map evaluated factors that affect the problem.
The steps for constructing the diagram are:
- Define which problem will be addressed, and it will be the vertex of the diagram (the Checklist and Pareto Chart tools will contribute to this step);
- Determine the primary spines and assign each one a branch from the main trunk that has the problem at its apex;
- Trace the secondary spines: secondary or indirect causes or those originating from a previous process according to pre-defined categories and included according to the problem already defined;
- Labor;
- Methods (Routines, procedures and conduct protocols);
- Materials (medicines, utensils);
- Machines;
- Environment (Temperature, ergonomics, conditions necessary for carrying out an activity and physical area);
- Measurements (quantities, dimensions, limits, data, calibrations and data collection);
- Guidelines;
- Procedures or Protocols;
- Facilities (Equipment and infrastructure);
- Guys;
At this stage it is possible to make a Brainstorming (brainstorming) that will help divide each category into the simplest elements to solve:
- Record general information on the diagram such as title, dates and people responsible.
It is normal for the causes of the problem to be related to day-to-day processes. Therefore, the analysis and interpretation of the factors will identify the most influential causes of the problem.
Additionally, it provides a very interesting and visual global perspective beyond the simple format.
Example:
7W5H
This tool helps in structuring the action plan, it will be used to conduct the planning and implementation of the solution in an organized manner, with identifying actions, methods, responsible parties, deadlines and associated resources all defined without leaving any doubt on the part of the managers of their team.
The characters 5W3H correspond to the initials, in English, of 8 guidelines aimed at eliminating doubts that may arise throughout the process or activity:
Example:
It is very important to make sure that the actions taken are about the causes of the problems and not their effects and that the actions will not have side effects.
8. SCATTER GRAPHS
Through a graph, it is possible to identify and study a given process due to quantitative variations such as task execution time, number of employees, waiting time for service, service time versus patient satisfaction index, among others.
It will be possible to analyze whether the variation is positive or negative and allows finding a relationship between the transformations that the process presents.
The position of the points indicates the correlation between the variations, the validation for a theory, if the points are close they indicate correlation, very dispersed they indicate absence of correlation, if they are close to a non-linear fit they have correlation, but the straight line is not the best model.
There are different types of dispersion and through graphical tools it will be possible to format it in the way you prefer to interpret it.
Example:
9. CONTROL DIAGRAM
A statistical tool that allows you to track and study how a specific process changes over time through graphs. It is suitable for reporting process performance and exposes problems that also directly affect process performance for treatment.
It is possible to check whether the process is stable or not, allowing the impact of a certain element of a system in total, simplifying the understanding of process development, perceiving the difference between changes caused by common causes or due to specific and less routine factors and facilitating the evaluation of changes.
From there, it will also be possible to understand the statistical controls of the processes, how the causes of routine or sporadic variations alter the behavior of the process.
The interpretation of a control chart is associated with the behavior of the sources of variation. In the case of a chart such as a patient's blood pressure measurements, variations may occur due to medication times, type of food or even emotional conditions such as stress levels.
This tool is therefore used to assess the stability of a given process, signaling variations and special causes. In these cases, peaks that appear outside the specification parameters require greater attention in terms of analysis and actions to return to control according to each process.
Example:
10. HISTOGRAM
It is presented by a bar graph and is typically used to represent the distribution of variation in quantitative data and to show the frequency at which each different value appears in a data set.
It faithfully represents the variability and dispersion of values, so understanding its meaning is a valuable tool, and seeing its results presented allows us to analyze the state of variability of a process. It makes it possible to establish standards, verify the distribution of the process and create a basis for predictability.
It is especially useful for large samples and their repetition over time for stable processes, allowing Statistical Process Control (SPC), and thus increasing the tendency of the normal distribution, representing a curve with a shape similar to that of a bell, Gauss curve, being characteristic of quality.
There are different types of Histograms: the symmetrical ones, mentioned above, and the asymmetric ones, where the frequency peak can be shifted to one side.
To the left when the median is higher than the mean or to the right when the median is lower than the mean, but all graphs must answer questions about:
- What form of distribution?
- Is the center point well defined?
- How big is the variation?
- How broad is the data?
- Is there only one peak?
- Is the distribution asymmetric?
- Are there isolated barriers?
- What is the performance of the process in relation to its studied characteristic?
- Was the Histogram conclusive or was there a need for stratification to find the reasons for the anomalies found?
Example:
Quality Methodologies
1. PDCA
Also called the Deming Cycle, it was created in the 20th century by Walter A. Shewart, however it was Edwards Deming who spread its use throughout the world.
At the height of industry in the 19th century, organizations were already familiar with the steps involved in mass production, which consisted of product specifications, production itself, and inspiration for the final result. The introduction of additional steps into the processes created a cycle, and these new steps allowed the application of PDCA, and after the processes were resumed, it was possible to identify and correct flaws, continually improving them.
A successful PDCA cycle is in detailing all aspects of a problem or situation to be addressed. It can be applied to any problem in the organization.
Example:
P (plan)
– Define a map:
- Clearly determine the problem to be focused on and the objective to be achieved. It is necessary to gather appropriate and compelling evidence of the true reason for the problem. To do this, it is possible to apply tools such as: Brainstorming, 5 Whys Rule to generate and clarify a series of problems or questions. Thus, it will be necessary to delegate the actions to those responsible, with their delivery deadlines, in addition to the strategic identification of the problem's customers.
- Determine what to measure and how to measure it. It will be necessary to collect data for a reliable analysis of the process, and for this it is necessary to apply statistical tools such as: Checklist, Pareto chart and stratification, and thus establish a work plan designating desirable/required criteria. Through the data obtained and its structuring, the responses achieved led to the real cause of the problem.
- Through the analysis of the measured results it will be necessary to discover the fundamental causes to improve the quality of a given product or service, and here the tool used should be that of cause and effect (Ishikawa or “Fishbone” Diagram). This will make it possible to make adjustments to problems, minimize or eliminate the causes of process variation.
- Now you will need to draw up an action plan to block the root causes of the problems. It should contain, in detail, all the actions that must be taken to achieve the goal. You need to know the methods and resources available to achieve the improvements implemented in the processes. At this point you can work with the tool 5W3H which will help in structuring the action plan. And will ensure that the operation is carried out without any doubt on the part of the managers and their team. In addition, these results must be measured.
Action plans set management in motion and brilliant execution of them also defines the success of achieving the goal.
D (Do)
- To execute the tasks according to the plan:
At this stage, the entire structured plan is communicated to the people who need to be trained.
- In addition to the action plan presented, it should be discussed with the process owner, who will conduct its execution, always respecting the stipulated deadlines. It is important to note that some processes show faster improvements while others take longer to improve. It is also necessary to have contingency plans.
The control of the measures proposed in the action plan will be through the measurement of processes, for example, complaints, billing and late deliveries.
Displaying measured processes using graphs or tables will increase everyone's awareness and participation.
C (Read our BuurtBankjes Factsheet XNUMX)
- Check if it is as planned.
- Once the execution is complete, the results obtained must be compared with the planned results and the differences analyzed to demonstrate whether the objectives were actually achieved and to investigate the causes of these differences that occurred. At this stage, the checklist tool can also be used.
It is unlikely that any improvement will be noticed, but it is at this point that if the result is worse than planned it will be necessary to return to the P phase to re-plan the actions. If the result is better than planned the actions may become a standard, but if there was no effect there may have been a failure to identify or address the problem, so it will also be necessary to return to the P phase.
To compare results, you can also use the Pareto chart quality tool to compare the “before” and “after”.
THE (Action)
– The results are consolidated and systematized so that the problems do not happen again, actions are taken.
- It is important to review step by step what was accomplished and identify possible weaknesses or failures and restart from that point, rotating the PDCA cycle again until the planning is resumed. If necessary, corrective action should be taken to fix what is needed.
- When new practices are developed, it will be necessary to document them to standardize the new process and train employees in the new way of executing it.
At this stage, quality tools can be used: Flowcharts and POP (permanent plan for a repetitive process).
2. PDSA
Edwards Deming and Walter A. Shewart also developed it. Its purpose is to learn and establish knowledge through experiences.
Like PDCA, it also has four cyclical stages to adjust changes in search of improvements. Its main change occurs in the third stage of the cycle. It does not only aim to check and verify whether everything is as planned. It will be necessary to study and analyze the actions.
P (Plan) and it is the same as PDCA
D (Do) At this stage, the goal is to ensure that all inputs and outputs of the process are understood in order to understand the real importance and need for change in the process, which will be implemented as a pilot. Here, it is also necessary to monitor progress and assess whether the data collected guarantees the success of the action.
S (Study) At this stage, it is necessary to confirm whether the test was successful. To do this, after the pilot is implemented, it will be necessary to analyze the results to ensure that the goal was achieved, in addition to evaluating the lessons learned that will make it possible to identify any unforeseen circumstances and how they can be resolved. Here, it will also be necessary to analyze the opinion of the professional who performed the test.
To (Act) The actions should also be consolidated as in PDCA.
In this methodology, IHI recommends that care be taken when implementing:
- It should be quick;
- The practice will involve one or two professionals;
- It will be possible for the step to be unique for every implementation of this tool.
Although both tools, PDCA and PDSA, are for continuous improvement of processes, PDSA has the action of studying the results in addition to measuring them, so it can be understood as a natural evolution of PDCA, due to the need to adapt it for continuous improvement.
3. LEAN SIX SIGMA – LSS
Its main focus is on improving work routine processes. Identifying and eliminating waste, reducing costs and increasing quality based on structured information. It can also be used in any area, including services.
The importance of lean thinking methodology as a way of creating value through actions that generate value, puts into practice principles of thought LEAN. Presented through tools such as:
- Value stream mapping;
- KAIZEN (continuous improvement in Japanese);
- KANBAMS;
- Standardization;
- Setup reduction;
- Total productive maintenance;
- Visual management;
- Poka-Yoke (mistake proof in Japanese).
It was at Motorola in 1986 that Bill Smith and the company's engineers created the term Six Sigma that allowed the company to improve its quality 10 times through a comprehensive and flexible system that also understands the needs of customers.
The lessons learned from the quality control tools were compiled and a roadmap was created. All the techniques were used in a structured manner to define, measure, analyze, improve and control the processes that, in addition to greatly improving the company's quality, reduced costs and waste. Thus began a new cycle, DMAIC.
In the 90s, another company, GE, also embraced the benefits of Six Sigma and showed more groups its advantages, such as billions of dollars in improvements, reduced costs and gained new markets. It was from there that the Six Sigma methodology gained its space in the market and is still widely used today in several organizations in different sectors.
In 2000, the great evolution and dynamization of Six Sigma stood out in several segments, including healthcare in hospitals.
Its use within company management systems has become aligned with organizational strategy.
In healthcare, several organizations generate value in the market with knowledge and skills in healthcare project management through six sigma.
Articles with their applied improvements were presented, however factors such as the selection of projects relevant to the company's strategy, financial implications and available HR influenced the success of many projects.
Some problems solved by applying six sigma:
- Reduction in hospital stay for patients with chronic obstructive pulmonary disease (COPD).
- Reduction in the number of patients using intravenous antibiotics;
- Reduction in waiting times for hospital beds;
- Reduction in the delivery time for complementary exam results.
Authors cited 3 steps necessary to establish evidence on the best way to apply LSS.
- Improvement of information on the data obtained;
- Study the lessons learned from the actions taken for the quality sector;
- Publish project failures in an attempt to avoid mistakes in other institutions.
The method shows clear benefits for improving service in institutions by increasing or improving: flexibility, quality, safety, capacity for innovation and employee motivation and by reducing waste such as: costs, need for space and work demands.
Below are the DMAIC steps, which will also be covered with greater emphasis in another text with possible quality tools applied to assist in the analysis and solution of problems.
• DEFINE Define and condense the process that should be analyzed. At this point, the SIPOC tool can be used to help organize the objectives and workflows.
• MEASURE – It allows you to analyze the current scenario through the measurements taken to find out what was happening in the process and discuss the causes. Here, quality tools such as flowcharts, measurement systems, trend graphs, descriptive statistics and indicator analysis can be used.
• ANALYZE – The causes and effects of the main problems are analyzed to identify the root cause of the problem. To do this, it is necessary to analyze possible causes, discovering the correlation between variables, and from there prioritize where improvement efforts will be concentrated.
• IMPROVE – Here the improvement opportunities identified in the previous step are attacked through many tests.
• CONTROL – The last stage is control, which is monitoring so that the action plan built in the previous stages is not lost.
Changes are implemented and checklists monitor the results and goals are tracked through statistics.
At this point, new deviations, waste and opportunities for improvement may be identified, which is why this stage is continuous.
The methodology of Lean Six Sigma, when applied correctly, is capable of significantly improving a company's productivity and efficiency.
In another text, all its phases will also be detailed, link at the end.
CONCLUSION
In addition to the current modernization and automation of hospital processes to improve the quality of services provided to patients, it is essential to analyze and discuss the main problems in order to address them. To this end, quality methodologies and tools must be part of companies' planning as problem-solving and improvements.
In addition to technical knowledge, the more professionals are engaged in the philosophy of continuous improvement, the more efficient the institution will be and the more satisfied its customers will be.
This concern in knowing the problems is extremely important, as processes must always be reviewed and updated.
After all, even with the implementation of systems and machines in the search for mitigating errors, at least one qualified person is needed to guide them. It is necessary to be exaggerated in the quality of processes, systems, employee training, as well as a pleasant organizational climate, all in the search to avoid making mistakes, because where there are health services, for lives in general, requires redoubled security.
Continue reading Part 2 of this article: Click Here
REFERENCES – Novaes, Ana. Fundamentals for Improving Quality in Health Services. 2017.
