DR.HJ.MUHD KHAIRI BIN MOHD TAIBI, AMN.,AMP PAKAR PERUNDING PERUBATAN KELUARGA What is QUALITY? Means Different Things To Different People What is Quality? Invisible when Good Impossible to Ignore when Bad Quality assurance KKM Definition Securing optimum achievable result for each patient. avoidance of iatrogenic complications and giving attention to the patient and family needs in a manner that is cost effective and reasonably documented Adapted from Thomson . ABNA concept Ideal 100 } Optimum 75 50 ABNA Actual With unlimited resource ideal level of care Optimal Achievable Level targetted level within means ABNA difference between OA & 25 0 present level QA aims at narrowing or eliminating the gap . QUALITY ASSURANCE is equal to ASSESS & CORRECT . Problem identification Problem Prioritisation Re-evaluation of the Problem Implementation of Remedial Actions Quality Assurance Cycle Problem Analysis Quality Assurance Study Identification of Remedial Actions Evaluation . Verification of the problem Problem identification Problem Prioritisation Re-evaluation of the Problem Implementation of Remedial Actions Quality Assurance Cycle Problem Analysis Quality Assurance Study Identification of Remedial Actions Evaluation . 1. Verification of the problem – check it out with information /statistics/people involved/pilot study Source of information to identify problem 2. Suggestion from staff/Issues from meeting/data/morbidity or mortality review/brainstorming Criteria used to decide if problem is worth studying 3.Problem identification It is problem or perception 1. 1. SMART 9 28 December 2014 . Problem / Opportunity Statement A complete opportunity/ problem statement should describe : * the problem or area of concern and its significance for the quality of care * possible causes and contributory factors * rationale of the study * scope of the study * intention to use the results to improve the quality of care .Methodology of QA Study 1. Quality Problem Related to Customer Satisfaction Cost Savings Increase Efficiency Reduce Discomforts 11 28 December 2014 . Non Quality Problems Administrative Issues (Management problem) Eg. May not improved customer satisfaction Problem of Scientific/Academic interest Eg.” Not related closely to the quality of care. “ High mortality rate in diabetic ketoacidosis ” “ High incidence of ADR from administering certain antibiotics” 28 Needs clinical research / study December 12 2014 . “Poor control of visitors outside visiting hours” “ High attendance of cold cases at A & E dept. 7%) 127(2.9%) 2006 3916 2007 4912 2008 5013 108 127 145 3916 JUMLAH PESAKIT 5000 4000 3000 2000 1000 0 Kes DM Type II Diabetic f oot Ulcer TAHUN .Verifikasi Masalah “Mengurangkan kejadian Diabetic Foot Ulcer Dikalangan Pesakit Diabetes Type II” 6000 4912 5013 108(2.6%) 145(2. Problem identification Problem Prioritisation Re-evaluation of the Problem Implementation of Remedial Actions Quality Assurance Cycle nominal Group Technique Problem Analysis Quality Assurance Study Identification of Remedial Actions Evaluation . Nominal Group Technique ( NGT) THE GROUP Common interest ----> quality improvement NUMBER : 7 .12 < 7 : Inadequate ‘expertise’ >12 : Too many Unsatisfactory group dynamics Few loud-mouth. many nodders & sleepers 15 28 December 2014 . NGT steps Silent generation phase: individual think about ideas free from comment and interference Round robin phase: one-by-one responses list exact phrases and displayed no discussion except clarification 16 28 December 2014 . defend. grouped. combined. dispute Problems maybe reworded.NGT steps ( cont…) Clarification phase : Serial discussion to clarify. deleted or modified Voting phase: select important items/problems voting process and ranking may revote and reprioritised 17 28 December 2014 . elaborate. community & hospital’s image Impact on cost & resources Frequent occurrence though not serious Big room for improvement Large ABNA 18 28 December 2014 .Basis of Ranking .SMART criteria SERIOUSNESS / SPECIFIC Life at stake ( mortality)? Permanent disability ? Complication? Pain? Costly? Causing distress to patient? Impact on patient. Basis of Ranking .SMART criteria Measurable Data available to quantify extent of problem Process clearly defined ( starting & ending points) Indicators identifiable with problems Appropriateness How much related to CORE BUSINESS? Objective consistent with organisational goals 19 28 December 2014 . SMART criteria Remediable Resource & Expertise available Solution is possible Within capacity of group Timeliness / Timed no current operational. ethically acceptable Does not take very long to remedy 28 December 2014 20 .Basis of Ranking . political. financial or political issues which might affect the success of project Social. Problem identification Problem Prioritisation Implementation of Remedial Actions Quality Assurance Cycle Problem Analysis Quality Assurance Study Identification of Remedial Actions Evaluation Cause-effect Re-evaluation of the Problem Problem statement . PENYATA MASALAH/ PELUANG PENAMBAHAIKAN (PROBLEM /OPPORTUNITY STATEMENT) Purpose is to justify the study (to sell the project) Contents of problem statement 1) Background information of the problem 2) Explaining the problem – evidence if any 3) What are the effects (BAD) 4) What are the possible causes/contributing factors 5) Expected result 6) Why we want to do with the study . (INTRODUCTION) Those with compound fractures shouldn’t have to wait for a long time in the ward before they are operated upon.IMPROVING MANAGEMENT OF COMPOUND LONG BONE FRACTURES Management of compound fractures forms a major part of the workload of the Orthopaedic Dept. They should be treated promptly and effective rapid uncomplicated recovery (DESIRABLE OUTCOME/ EXPECTATION) There are ample opportunities to make this possible in our setting such as timely availability of OT. (INTENT TO IMPROVE) December 23 2014 .. blood or appropriate examinations and investigations (OPPORTUNITIES) We hope to identify areas that can be improved by carrying out a study using certain indicators to identify contributing factors 28 and propose remedial actions. consent. Problem Analysis To analyse the problem and the factors influencing it (a) 4W1H – What.Who are involved and How it happened (b) Analyse the possible causes of the problem and its effects using cause-effect diagrams (bubble charts / Fishbone charts (Ishikawa) 1) . When. Where. then put in as 1st generation bubble Then propose and arrange the inter-related causes in the 2nd generation and so forth… .Cause-Effect Analysis ( In QA we use the bubble chart ) List down all possible causes first Look at the main causes . Bubble chart Secondary causes Secondary causes Primary causes Primary causes Effect of the problem /complication Primary causes Secondary causes . CARTA SEBAB DAN AKIBAT DALAM MENINGKATKAN AMALAN PERANCANG KELUARGA DI KALANGAN IBU OA DI DAERAH PEKAN Meningkatkan promosi kepada masyarakat OA Memberi pendidikan kesihatan kepada ibu OA MENINGKATKAN PENGETAHUAN TENTANG KEPENTINGAN AMALAN PERANCANG KELUARGA Meningkatkan kefahaman mengenai kepentingan perancang keluarga Melibatkan orang berpengaruh seperti bomoh. suami dan keluarga terdekat tentang kepentingan perancang keluarga Tingkatkan perkhidmatan klinik bergerak Memberi latihan berterusan kepada anggota kesihatan MENINGKATKAN PERKHIDMATAN PERANCANG KELUARGA Pengesanan awal kes-kes cicir & lawatan ke rumah dijalankan Penyelianan dan pemantauan yang berterusan . Tok Batin dan JHEOA Menggunakan flip chart bergambar yang jelas dan menarik MENINGKATKAN AMALAN PERANCANG KELUARGA DI KALANGAN IBU OA DI DAERAH PEKAN MENINGKATKAN PENERIMAAN IBU TERHADAP AMALAN PERANCANG KELUARGA Penggunaan kaedah perancang keluarga yang sesuai 27 Memberi motivasi kepada ibu. waiting time . from registration and seeing doctor.standards Standard is the line that differentiates the good from the bad. .Acceptable lowest limit The standard is to : i) verify problem exist (First level) Ii) show factors identified are responsible for the problems (Second Level) Problem: Long waiting time in OPD 1st Level standard : within 60 mts. 2nd Level : 75%f the patient should <60 mts. standards setting Setting too high a standard may make the problem unsolvable and the target unreachable If its too low. it may not reflect quality level of care that’s acceptable Use literature and other studies to determine the appropriate standard in YOUR setup Or set standards after knowing current level of car When human factors are involved usually the standard should not be 100% . SOP. guidelines.Process of care ‘ Flowchart / pathway of care’ the steps of activities while delivering a particular care. circulars. CPG. etc Flow of care can be used to guide the development of ‘Model of Good Care’ . The flowchart should contain specific activity in the ‘ area of concern for improvement ` The steps is adopted from the professionally accepted standard or norm . Flow chart of Mx of Hypertensive patients Pt with HPT No Uncontrolled Out patient Tx Yes Admit to ward Pt seen by HO Pt seen by MO/Pakar Education No Ix BP optimally controlled Rx Yes Disc. F/U . “ good process will produce good outcome “ The protocol and sequence of essential elements of the process of care preferably with the preset criteria and standard of the critical processes so that the care is good. .What is MOGC MOGC is the process involves for specific health care delivery to be implemented so as to produce the best / expected outcome. take consent from those for operation .X-match blood before transfusion .Criteria ( of the process of care ) It is an essential element for good care.perform ECG and serum enzyme on those suspected MI .drug counselling before dispensing poly-medication . Thing that make care good for the particular step of care Example of essential element i) ‘ things should do ‘ . standard 85% . a standard s set Setting of standards is a percentage of fulfillment of criteria If the criterion is related to a vital indicator. the standard is 100% i) Blood transfused must be GXM .Standards of MOGC For each criteria. standard 100% Ii) Staffs must pass the test . MOGC Step 1 2 3 Process of care Criteria Standard HPT pt seen in OPD/A&E/ MOPD Admit :BP>160/100 mm Hg (CPG 1998) 90% Diagnosis of HPT (Uncontrolled/For stabilization) 100% Registration & adm for pt w uncontrolled HPT Pt reviewed by HO Pt reviewed by MO 4 Specialist Seen within 15 min on adm Daily ward rounds Prn if BP > 160/100 or any complaints Daily ward rounds Prn if 180/100 At least 1 X/week 100% 100% . 1. Address Time of registration Educational status History Taking LMP Age Parity Family History Past Obstetric History History Conduct / TBA PE IUGR LSCS Past gynae history Past medical history Symptoms of eclampsia Criteria < 12 / 52 Standard 90 % 1x/ pregnancy 100 % (During booking) Every ANC visit Every Home visit .No. Process Registration *2. Problem identification Problem Prioritisation Re-evaluation of the Problem Implementation of Remedial Actions Quality Assurance Cycle Problem Analysis Quality Assurance Study Identification of Remedial Actions Evaluation To know magnitude of problem & to prove the cause-effect . QUALITY ASSURANCE STUDY . Identifying the factors contributing the problem The method must be sound. Assessing the magnitude of the problem iii.QA STUDY A planned and systematic collection of data using various methods for the purpose of i. Verifying existence of Q problem ii. it need not very complicated as in research (which follows strict statistical criteria) The components of the QA study -Literature Review -Objectives of the study -Study methodology . Methodology of QA Study 1 Objectives: General & Specific 2 Type of study 3 Terms’ ( key words ) definition 4 Inclusion & Exclusion criteria 5 Proposed Indicator and Standard 6 Plan for data collection ( + proposed formats ) 7 Plan for data analysis ( + proposed dummy tables ) 8 Gantt’s chart 9 References . 2. Literature review will help us in; clarify our problem state the study objectives know what has happen elsewhere check the implicit standards set explicit criteria and standards suggest suitable study methods find appropriate remedial actions avoid duplication of works Objectives of the study The general objective will mention the overall final aim to be achieved in the study The specific objectives should be stated using “ action verbs” that specific enough to measures: To determine To verify To calculate - To compare - To establish - To describe Avoid the use of vague non-action verbs such as; To appreciate To understand Specific objectives for QA study 1. To measure the magnitude of the problem 2. To identify/describe the actual causes or contributory factors involved 3. To formulate the remedial or improvement measures 4. To evaluate the effectiveness of the measures taken. low income group .Variables A characteristic of a person. poor High. object or phenomenon that is measureable and can take on different values variable Height Sex Knowledge Socioeconomic status value tall . short male . middle. female Good. can be either retrospective or prospective Experimental study is always prospective .Type of Study PAST NOW FUTURE RETROSPECTIVE CROSS-SECTIONAL PROSPECTIVE Looks for past exposure to a factor or describe the past event Looks at the present situation Looks at development of a condition over time Descriptive study. can be retrospective. prospective or cross-sectional Analytical study. clear and not ambiguous. .Key Word Definition To describe the definition of certain/ selective key words and terminology used in this study The terminology probably applied only for this study including application of certain variables. standard. acceptable. Must be sound valid. situation. reliable. Inclusion & exclusion criteria Inclusion criteria Criteria of study subjects (from a defined study population) that is to be included in data (sample to collected) List should not be too long Exclusion criteria Subjects (from a defined study population) to be excluded from study Limits sample size to relevant subjects . what numerator and denominator will you use. Proposed the most acceptable standard.Proposed Indicator and Standard Describe the indicator proposed to be applied in the study. . If rate based. a representative sample with all important characteristics of the drawn population Sampling involves the selection of a number of the study unit from a defined study population . we have to do sampling. costs. time & other resources.Sampling Better to get intended information from a certain population ( all ). Thus. but limited with problems of logistics. Probability sampling .Stratified sampling (by geographic boundaries) .Simple random sampling .Purposive sampling :targeting a certain group 2.Multi-stage sampling ( .Systematic sampling (using regular interval) .Sampling method 1.Cluster sampling (by Group/ characteristic) . Non-probablility - - -Convenience : study unit that happen to be available at the time of data collection are selected in the sample . Data Collection Techniques Review of recorded sources Observation Interview Written questionnaires . Plan for Data Collection WHAT data to collect WHERE to get the data HOW to collect them WHO will collect WHEN will the data be collected HOW LONG will it takes QUALITY CONTROL of the data . Plan for Data Analysis The plan includes. Data handling and storing Data processing Data analysis . Mapping the Proposal Construct the Gantt’s Chart List down the the plan of processes to be undertaken in conducting the study Chart the appropriate time frame for each process To mark the plan and actual task carried out . GANTT’s CHART Tugas T/jawab Taklimat Ahli kumpulan Surat arahan Ketua Jabatan Sediakan format pengumpulan data Ahli kumpulan Pengumpulan data Ahli kumpulan Analisa data Ahli kumpulan Perlaksanaan Ahli kumpulan Penilaian Ahli kumpulan Sediakan laporan Ketua kumpulan Jul 03 Ogos 03 Sept 03 Okt 03 Nov 03 Dis 03 Jan 04 Feb 04 1 1 1 1 plan 1 1 1 1 actual . References List down all references quoted or referred in the study .9. Clinical Practice Guidelines on “ The Management of HPT” ( Academy of Medicine. King H.14 . Bulletin of WHO 1991.References 1. 69 (b):643 – 648. Standard Operating Procedure for MA ( Ministry of Health. 2000 ) 3. 2002 ) 2. Diabetes in adults is now a third world problem. Revers M. choosing indicator Reflects the QUALITY of service that is measured ( proxy ) Can be assessed objectively using certain CRITERIA Can differentiate between the ones with quality from those without Should directly address the problem Usually expressed in the form of rates (%) (rate based) or nil occurrence (zero defect) . variables IN SIMPLE TERMS ARE MEASURABLE DATA A VARIABLE is a characteristic of a person. object or phenomenon that can take on different values. It is measurable Is basically data collected It can take various values All factors must be put in a variable form . . ( ie: NOT “ the good care” ) . Essential elements is the critical steps of care that should be accomplished within the set criteria and standard. Each step will contribute to the final service outcome. If violated. it might cause a “multiplying effect of failure” in the series of care. Finally end-up with an undesired product or sequalae of care. MODEL OF GOOD CARE STEP NO PROCESS OF CARE CRITERIA A B C C1 C2 C3 D (*) refers to Standard of EACH Process of Care STANDARD (*) . Standard setting in the MOGC is ‘the minimum level of acceptable performance’ for the respective step in the process of care ( referred to as ‘ Optimum Achievable Standard ‘ (OAS ) the value of a Criteria that marks the line between good and poor widely / professionally accepted value ( evidence-based / best practice ) preferably for the critical steps only consensusly agreed . SIQ: Investigation process Evaluate every steps in the process of care & to determine whether the step was appropriate. timely & adequate Where is the shortfall ? check your MOGC ! Why is the shortfall ? check bubble chart ! Guidance in providing the remedial measures and planning to prevent or overcome similar shortfalls in future To reduce magnitude of ABNA by: eliminating or minimising Error of ommision Error of commission improving the quality of care . 2% 4.5% (*) selepas tindakan penambahbaikan .7% 71. Penggunaan senarai semak yang betul 60. Kedatangan pertama < 12/52 36.Perbandingan peratus pencapaian pengendalian kes anemia BIL FAKTOR / KRITERIA 2001 2002 (*) 1. Ujian Hb 2/52 sekali dibuat.2% 3.4% 2. 48.3% 92. Pemberian Ferrous fumarate pada POG 18-20/52 78.3% 93.0% 92. CME penggunaan senarai semak kepada JM/SN baru dan kursus 6/12 sekali kepada kakitangan. Pendaftaran antenatal <12/52 yang rendah a.S/Kesihatan. Penyeliaan secara berkala bagi JM yg dikenalpasti a. SN/JM c. P. a. Penasihat c. Penggunaan senarai semak yang tidak lengkap a. Menjalankan klinik dengan masa yg lebih fleksibel. b.LANGKAH-LANGKAH PENAMBAHBAIKAN Bil Isu/ masalah 1. JM & S/N b. Pengesanan kes secara aktif b. Pengendalian kes a. SN/JM 3. CME di setiap klinik b. Perawatan & pencegahan anaemia Aktiviti Staf b/jawab b. c. Memberi penerangan/ ceramah kepada komuniti. KJK/ SN . Penggunaan senarai semak pengendalian anaemia c. JM/SN 2. a. FMS/MHO/ KJK b. KJK/JKU a. Ceramah/nasihat mengikut format yg disediakan. 7 1 0 2001 2002 std .5 4 3.95 ABNA sebelum 3 2 Peratus anemia pada 36/52 POA 2 ABNA selepas 1. 6 Plan for data collection ( + proposed formats ) 10.5 Proposed Indicator and Standard 10. Model of Good Care 10. Opportunity statement 7. Problem Identification/ Opportunity for Improvement 4.7 Plan for data analysis ( + proposed dummy tables ) 10.4 Inclusion & Exclusion criteria 10.2 Type of study 10.8 Gantt’s chart 10.Formulating DSA: the proposal 1. Prioritisation & chosen/refined topic 5. QA study: Methodology 10. Group 3.9 References . Process of care 9.1 Objectives: General & Specific 10. TAJUK 2. (Situational analysis / Literature review ) 6. Quality factor analysis / cause-effect analysis 8.3 Terms’ ( key words ) definition 10. The excluded data shouldn’t has any effect ( little or almost negligible ) on the result of the study .Study Criteria Inclusion criteria: Specific conditions or characteristics that are applied and included in the study Exclusion criteria: The certain characteristic of the samples that to be excluded in the data collection for specific reason. Mapping the Proposal Construct the Gantt’s Chart List down the the plan of processes to be undertaken in conducting the study Chart the appropriate time frame for each process To mark the plan and actual task carried out .8. GANTT’s CHART Tugas T/jawab Taklimat Ahli kumpulan Surat arahan Ketua Jabatan Sediakan format pengumpulan data Ahli kumpulan Pengumpulan data Ahli kumpulan Analisa data Ahli kumpulan Perlaksanaan Ahli kumpulan Penilaian Ahli kumpulan Sediakan laporan Ketua kumpulan Jul 03 Ogos 03 Sept 03 Okt 03 Nov 03 Dis 03 Jan 04 Feb 04 1 1 1 1 plan 1 1 1 1 actual . .9. 2002 ) 2. References List down all references quoted or referred in the study Clinical Practice Guidelines on “ The Management of HPT” ( Academy of Medicine. Standard Operating Procedure for MA ( Ministry of Health. 2000 ) 1. Problem identification Problem Prioritisation Re-evaluation of the Problem Implementation of Remedial Actions Quality Assurance Cycle Problem Analysis Quality Assurance Study Identification of Remedial Actions Evaluation . based on actual findings ( periodic assessment / QA study ) .be practical: * specific * realistic * flexible * manageable * cost effective * timeliness 74 .not construed as fault finding not to imply to any party as negligent not to be punitive .Principles for remedial action . The key to remedial actions is CHANGE 75 . 7. 4. 6. SMART concept not properly applied Impose wrong strategies Improper implementation Weak leadership.Reevaluation: Why SIQ / problem recurs ? 1. 8. 5. 2. poor commitment Change resistance Poor problem identification /selection Lack of resources Beyond control interference 76 . 3.