Quality Improvement
The term quality means different things to different people. As defined by(1988), quality is fitness for use. In addition, quality is conformance to specifications as promoted in the manufacturing industry.
It is also defined as the judgment by customer or users of a product or service; it is the extent to which the customers or users believe the product or service surpasses their needs and expectations (1989).
Moreover, it is also means delivering products and services that meet customer standards, meet and fulfill customer needs, meet customer expectations, and will meet unanticipated future needs and aspirations (1990).
Definition of quality varies to different people. As summarized by (1992), in customer-based quality is defined as fitness for use and meeting customer expectations. In manufacturing-based, it is conforming to design, specifications or requirements and having no defects. The product has something that other similar products do not have that adds value, as defined based on the product. If defined based on the value, the product is the best combination of price and features.
Total Quality Management is a management strategy aimed at embedding awareness of quality in all organizational processes. It is a management philosophy that seeks to integrate all organizational functions like marketing, finance, design, engineering, and production, customer service and others, to focus on meeting customer needs and organizational objectives. TQM has been widely used in manufacturing, education, government, and service industries, as well as NASA space and science programs (2006).
Total Quality Management (TQM) is a method by which management and employees can become involved in the continuous improvement of the production of goods and services it is a combination of quality and management tools aimed at increasing business and reducing losses due to wasteful practices.
The key principles of TQM are management commitment, employee empowerment, fact based decision making, continuous improvement, and customer focus.
Quality Improvement for Emergency Medical Services (EMS) Systems
Emergency Medical Services has served the communities into the Twenty First Century having the goal to reduce unnecessary death and disability and protecting the communities’ health.
Quality for them is anything that enhances the product or services from the viewpoint of the customer or the patients. In EMS, their customer is not only the individual patient they serve but the entire community. They need to align their values with the community needs.
With the rapid change in health care environment, EMS must determine how it can best serve community health while still being the public’s emergency medical safety net. They need to provide more improved health, quality and efficiency.
To do this, EMS must establish and maintain a program for continuously monitoring and improving the quality of patient care and support services in all parts of EMS system that would encourage the leaders to integrate continuous quality improvement practices as essential parts of normal EMS routines.
In the United States, there is an increasing focus on quality which has the common thread of meeting the needs of those who pay for and use the services and products provided by an organization. All types of industries, including health care, have lowered costs and improved the quality of their operations and products by working to meet the needs of the people they serve.
Quality Improvement Methods includes qualitative and quantitative techniques, reduction of waste, benchmarking, training, customer focus and empowerment.
Quality Improvement will impact the EMS work processes, for example, changes in work site management and evaluation of work, use of self-directed teams, and re-alignment of work processes to achieve new quality targets on critical indicators.
The QI principles and methods provide a basic foundation for EMS Quality improvement efforts. QI principles and methods are applied to EMS organizations and system.
Qualitative and Quantitative Techniques
Tally Chart
EMS organization teams and work groups use brainstorming to generate list of process-related problems, potential solutions, approaches or options to address an issue. EMS organization has generated large unmanageable ideas so the organization uses another tool to identify the most important items on the list. Multivoting is used by EMS suited for use in large group that are reviewing long lists.
Multivoting is used to help EMS organization teams focus on problem-solving and identifying high priority items in an efficient manner. It is particularly valuable in deciding issues because each member of the organization has a clear understanding of how the team will reduce the number of items to manageable proportions and how it will identify them in priority order. Multivoting allows for each member to participate equally in the decision making process.Below is the result tally sheet of the multivoting in EMS organization.
Table 1. Multivoting Tally Sheet for Quality Improvement Project Selection
Topic
Vote Count
Total
1. Inaccurate run reports
******
6
2. Excessive response time
**********
10
3. Low scores on practical exam
***
3
4. Complaints about scheduling
***
3
5. Vehicle maintenance costs too high
**
2
6. Inability to get hospital feedback
*
1
7. Excess restocking time at hospital.
*****
5
8. Intubations success rates falling
************
12
9. Decline in fund raising revenues
**************
14
10. New member recruitment too low
**********
10
Run Chart
Run chart is a type of graph that is used to see if the organization performs the work in a consistent way, or if there are obvious changes as the work progresses over the course of time. A run chart can be prepared for any characteristic of a work process that we want to measure and evaluate.
In EMS organization, run charts is used to monitor characteristics or features in a number of work processes. Process characteristics that are typically measured include dimensions of quantity, quality, or time. When the data is plotted, the chart can be used to identify trends, shifts, patterns, and outliers that may exist in our work.
EMS has prepared a run chart to monitor ambulance response reliability during the month of January. In the run chart below the process characteristic Number of Late Arrivals on Priority 1 Calls is plotted for the month of January. The chart illustrates that the number of late arrivals fluctuates considerably, particularly around January 6th and 26th when major snow storms occurred. Also During this period the lowest number of late responses was 5 on January 11th and 12th while the highest number of late responses was 26 on January 7th.
Histogram
Histogram is one way to display the data collected to see how the organization doing at the present time. The foundation of the continuous improvement effort is data collection. Data are used to better understand variation in a work process and determine how well we are doing in meeting standards based on patient and other stakeholder expectations. A histogram is a useful tool to display these findings in order to identify our current performance and show how we are improving work processes over time It is also one way to describe and evaluate performance. In a histogram, data are grouped into defined intervals and displayed according to their frequency of occurrence in each interval. This method provides insights about performance and particularly the variation that normally occurs in work.
There are various situations where histograms can be used to show how much variation exists in work. For example, in EMS organization: how much time it takes an EMS organization to complete a routine job. If repeatedly measure the length of time it takes to complete a job, it is observe that the time varies in each instance. It is also seen that all of the measurements fall within a certain range.
In the example in Figure 2, the Histogram shows the response interval performance of an EMS agency to emergencies during one month. This chart shows how well the organization is meeting the needs of its patients.
Ishikawa Diagram (Cause and Effect)
A cause and effect diagram also known as the fishbone or Ishikawa diagram is used to show the causes of a problem. Since there is generally more than one cause to any problem, the diagram is used to further divide causes into groups or categories. This approach often uncovers the root causes of our problem. When the root causes are identified, we can evaluate how much each cause contributes to the problem.
A problem keeps us from completing a job. Cause and effect diagram may uncover the main problem and its causes. Cause-and-effect diagrams can help clearly illustrate possible relationships between causes. They can be used to uncover the root causes of problems or specific problem steps or bottlenecks in a work process. By arranging possible causes into categories in a diagram, we can develop a better understanding of problems and the contributing factors.
The main problem identified by EMS organization team was inaccurate ambulance run report. To identify the causes for why ambulance run reports are inaccurate, this cause-and-effect diagram below was developed. A quality improvement team brainstorms a list of category specific causes and marks them on the diagram. The central arrow points to the problem statement. Main branches lead to four categories of causes: People, Methods, Machines and Materials. For each major causal category, there are a number of specific causes that are shown as smaller branches. In this figure, under the major category of methods, the QI team believes that the education programs used to teach personnel how to use the run forms properly may be ineffective in changing the behaviors of existing personnel or may not be adequate to fully inform new personnel. After listing and developing this list of suspected causes, the team would decide which causes are most influential and worth pursuing.
Shown below is the EMS organization Cause and Effect diagram developed by the Quality Improvement team.
Fig. 3 EMS organization Ishikawa Diagram
Flow Charts
A flow chart illustrates the activities performed and the flow of resources and information in a process. There are two types of Flow charts. These are the high level and the detailed flow chart.
The high level flow chart illustrates how major groups of related activities, the sub processes, interact in a process. High level flowcharts can readily show an entire process and its key sub processes. Meanwhile, a detailed flowchart provides a wealth of information about activities at each step in a sub process. It shows the sequence of the work and includes most or all of the steps, including rework steps that may be needed to overcome problems in the process.
Hundreds of tasks are completed in order to meet specific objectives in EMS systems. It would be easier to see if how specific task contribute to their mission if they can picture the whole process. EMS organization pursuing quality improvement is constantly looking for ways to improve the effectiveness and efficiency of its work. Flowcharts are useful to generate ideas on how to be more efficient and effective. It is helpful to define and document how activities are actually performed. It can be useful to identify activities in a process that reduce our effectiveness and efficiency. It also can be used to identify conditions that cause delays and bottlenecks. This can bring focus to problems at various points within the process that need further evaluation and improvement.
Figure 4 is an example of a high level flow chart of EMS organization with its sub processes that includes EMS system access, information gathering on triage, prearrival instructions and dispatch.
Figure 5 is an example of detailed flow chart for two of the access and dispatch sub processes. It shows the sequence of the work and includes most or all of the steps, including rework steps that may be needed to overcome problems in the process. A quality improvement team can increase the detail to show the individuals performing each activity or the time required to complete each activity.
Fig. 4 EMS High Level Flow Chart Fig. 5 EMS Detailed Flow Chart
Pareto Diagram
A Pareto Diagram is a type of bar chart in which the bars representing each problem cause are arranged, or ranked, by their frequency in descending order. A Pareto diagram is useful in interpreting data and confirming the relationships that are suggested in cause-and-effect studies. This approach is based on the idea that 80% of the problem comes from 20% of the causes; the diagram is used to separate the “vital few” problem causes from the “trivial many”. This aids in focusing on correcting or improving the vital few causes that contribute most to the problem.
An example of a Pareto Chart is shown in the figure below. In this case an ambulance company wanted to identify the leading causes of incomplete data on run reports. Company managers found that about 35% (using the cumulative scale on the right) of the incomplete forms were missing the patient’s zip code. Moreover, 35% of the missing data sheets showed that the ID of other responding agencies was missing. These two data elements accounted for 70% of all run reports with missing data. With this information, managers can work with field personnel to identify potential solutions. In addition, examining the specific data elements that are most likely to be missing may point out specific solutions. In the case of the problem of EMS organization, zip code data is missing because map books in the ambulance do not show zip codes. Simply adding a zip code map book could solve the problem. The benefit of the Pareto Chart analysis was that it isolate the two major sources of missing data so that the most effective solutions can be pursued.
Fig. 6. EMS Pareto Analysis
The Emergency Medical Services (EMS) leader’s role in promoting and developing quality improvement is creating and sustaining a personal and organizational focus on the needs of internal and external customers and consumers. To promote quality emergency medical services and performance excellence, leaders should demonstrate a clear commitment to the organizational mission, values, goals and expectations.
The EMS organization’s chief officer or executive must spearhead leadership for QI program. All managers and leader’s must work together to set the direction for quality improvement by creating a strong patient focus, to create clear and unambiguous statements that define organization’s mission, and values and identify operational objectives and long term expectations and to demonstrate continuous commitment to achieving organization’s quality improvement goal.
All members of the EMS system must feel empowered to make an impact on the quality of their system. Training in topics like team dynamics and problem-solving may help provide personnel with the skills needed to make the new working relationships successful. In addition, other personnel, such as dispatchers, fleet maintenance, and data collection personnel can be added to create other teams that focus on ways by which the entire EMS response, patient care and transport process can be modified to better meet patient needs.
Patients and other stakeholders can also be thought of as customers of the EMS system, and, depending on how they relate to the EMS system, as either internal or external customers of the system. Focusing on patients and other stakeholders means first identifying who those individuals and entities are and then working to understand their needs and expectations.
Credit:ivythesis.typepad.com
0 comments:
Post a Comment