CONTINUOUS

QUALITY IMPROVEMENT
Trisasi Lestari
 1
WHAT ARE QUALITY
AND QUALITY
IMPROVEMENT?
 IoM Definition of Quality

the degree to which health services for

individuals and populations increase the
likelihood of desired health outcomes and are
consistent with current professional knowledge
 What is Quality?
• Based on customer’s perceptions of a
product/service’s design and how well the design
matches the original specifications.
• The ability of a product/service to satisfy stated or
implied needs.
• Achieved by conforming to established requirements
within an organization.
Dimensions of Quality
quality improvement does not
guarantee better quality
 Quality Improvement

“ better patient experience and outcomes

achieved through changing provider behaviour
and organisation through using a systematic
change method and strategies” John Øvretveit
How good is good enough?
Apple Evolution
How can we improve Quality?

a combination of extrinsic and

intrinsic approaches is
needed to ensure sustained
improvement
 What would improve Quality?
• A sustained focus on the continuous
improvement in the quality of health services is
needed.
• Internal motivators
– professionalism,
– skills development,
– organisational development
– leadership),
• external motivators
– regulation,
– economic incentives
– performance management
 What would improve Quality?
• Align quality at every level to make sure that all
levels of the system relate to each other in
supporting quality.
• Redefine the nature of the relationship between
people who use services and those who provide
them.
• Build knowledge, skills and new practices,
including learning from other sectors that have
improved their performance and reliability in
highly complex areas.
 Principles of QI Methodologies
• understanding the problem with a particular
emphasis on what the data tell you
• understanding the processes and systems within
the organisation – particularly the patient
pathway and whether these can be simplified
• analysing the demand, capacity and flows of the
service
• choosing the tools to bring about change,
including leadership and clinical engagement,
plus staff and patient participation
• evaluating and measuring the impact of a change
Other Core Principles
Process improvement projects
are not always successful
Even the projects that were successful did
not always have sustained gains.
 Vital for QI
• How the change is implemented
• Leadership
• Clinical involvement
• Focus
• Resources to facilitate the change
 SOAP

Goals and objectives

Optimization that are not aligned
reduces waste in within and between
Long-term project materials, time, functions promote
sustainability only and talent. anarchy in
occurs when Improvements operations.
process built on processes
improvement is that are not
built on a optimized add to
stable process. the waste.
 Role of Commissioners
• putting the emphasis on assuring quality and safety in
evaluating current and potential providers
• looking at governance and leadership on these issues,
rather than merely policies and procedures
• building measures of quality and safety into commissioning
specifications and, where appropriate, penalties for
significant breaches
• putting in place performance management regimes that
assess quality and patient safety processes
• assessing for themselves how care is provided on the
ground, and how the culture and values of the organisation
are expressed in behaviour
• reward providers for quality improvement.
 Commissioners Questions
• what is being done to improve quality?
• What is providers’ focus on improvement?
• What progress they are making?
 2
COMMON
APPROACHES TO
QUALITY
IMPROVEMENT
 Some Common Principles
1. Data and measurement for improvement
2. Understanding the process
– Process mapping
3. Improving reliability
– mitigates against waste and defects in the system,
– reduces error and harm.
– Clinical pathway, care bundles
 Some Common Principles (contd)
4. Demand, capacity and flow
– backlogs, waiting lists and delays
– capacity problem
– insufficient staff, machines or equipment
– variation in the capacity available
5. Enthusing, involving and engaging staff
4. leadership,
5. staff engagement
6. patient participation.
Building Commitment to Improvement
• involving the clinical team early on, when setting
aspirations and goals
• ensuring senior clinical involvement and peer
influence
• obtaining credible endorsement
• involving clinical networks across organisational
boundaries
• providing evidence that the change has been
successful elsewhere.
 Some Common Principles (contd)
6. Involving patients and co-design
– Patients, carers and the wider public are the only
people who really experience the patient pathway
from start to finish.
– Board members must constantly ask the question
‘how do we know what constitutes good care?’
– What they view as the ‘problem’ or value within a
system may be surprising.
THE ROLE OF
THE BOARD
3
 Governance
seeking assurance that:
•the necessary actions (standards) are being
taken throughout the organisation,
•that reporting and monitoring are carried out
•and performance targets reached.
– Examples: safety issues such as minimising
healthcare acquired infections like MRSA, time
limits for access to care, achieve a minimum level
of performance.
 Leadership
• driving the organisational strategy for
transformation and continuous improvement.
• there needs to be an appropriate balance
between a focus on governance and on
quality improvement.
• It is a marathon, rather than a sprint
 Role of Leader
• being clear about the organisation’s goals in terms of
improving the quality of services
• agreeing and resourcing the approach that the
organisation will take to achieve its goals
• measuring for improvement
• focusing on implementing and monitoring progress
• regularly and consistently giving quality improvement
a high priority within the board of at least equal status
to financial matters
• recognising, rewarding and celebrating improvement
when ambitious goals are met.
 Model for Improvement
• Model ini dikembangkan oleh Associates in
Process Improvement
• Tujuannya untuk mempercepat terjadinya
perubahan
• Telah berhasil digunakan di ratusan institusi
pelayanan kesehatan
• Telah banyak dipublikasi dalam jurnal-jurnal
ilmiah
Model for Improvement
 Pertanyaan 1:
Apa yang ingin kita capai?
 Proses menetapkan tujuan
1. Bentuk tim dengan melibatkan semua orang
yang punya peranan penting dalam proses
perbaikan.
2. Tulis tujuan perbaikan mutu dengan jelas dan
menyebutkan target angka yang spesifik
– Pernyataannya tidak ambigu
– Targetnya bisa dicapai
– Batasannya jelas sehingga perbaikan bisa terfokus
(lokasi, strategi yang digunakan, populasi pasien,
– Flexible dan siap menyesuaikan fokus tujuan.
2. Libatkan top management rumah sakit.
- Budget kegiatan
- Laporan rutin (resmi/tdk resmi)
3. Fokus pada isu-isu yang sedang menjadi
perhatian rumah sakit
- Strategic plan RS
- Meniru inisiatif RS lain
 Contoh penyusunan tim
Tujuan: Peningkatan mutu pelayanan kesehatan untuk
memenuhi 6 dimensi mutu yang ditetapkan WHO, kepada
semua pasien dengan penyakit kronik di rawat jalan.

Tim:
Technical expert: dr….. Sp.PD
Pemimpin harian: Perawat…..
Anggota tim: Edukator pasien, Asisten dokter/perawat,
administrator, petugas laboratorium, cleaning service, rekam
medis, dll.
Sponsor/Pelindung: Salah satu/lebih, staf manajemen RS.
Contoh tujuan
Contoh-contoh indikator klinis yang
bisa digunakan untuk penyampaian
tujuan bisa ditemukan di website
berikut:
https://indicators.ic.nhs.uk/webview/
http://www.qualityindicators.ahrq.gov
www.cihi.ca
www.achs.org.au
www.nuh.com.sg
Nine dimensions of quality health care
Mengidentifikasi area perbaikan berdasarkan
dimensi mutu pelayanan kesehatan
Mengidentifikasi area perbaikan berdasarkan
dimensi mutu pelayanan kesehatan (lanjutan)
Mengidentifikasi area perbaikan berdasarkan
dimensi mutu pelayanan kesehatan (lanjutan)
Untuk memahami proses dan
menemukan celah perbaikan
 Latihan
• Perhatikan program perbaikan mutu yang
sedang berlangsung di RS Anda
• Review dan jelaskan tujuan program
perbaikan mutu tersebut
• Jika tujuan program belum jelas, gunakan
lembar bantu penetapan tujuan program
• Luangkan waktu untuk membaca indikator-
indikator klinis internasional
Check Indikator
Pertanyaan 3: Perubahan apa yang
bisa kita lakukan untuk perbaikan?
Change Concept
Eliminate Waste
Improve Workflow
Metode pemilihan ‘Change’
Model for Improvement

?
Mengapa harus diuji coba? Mengapa tidak
langsung saja diimplementasikan?
• Meningkatkan kepercayaan terhadap intervensi
yang dipilih
• Mendokumentasikan proses lebih mudah
• Pemahaman tim lebih baik
• Mencatat dan mengevaluasi biaya dan efek
samping dg lebih baik
• Menguji intervensi pada situasi yang berbeda-
beda
• Belajar dan beradaptasi terhadap perubahan
yang terjadi
The Quality Improvement Phase

Dilakukan
berulang kali,
dimulai dari
skala kecil ke
besar
 Menurunkan
Penggunaan PDSA Cycle angka pasien
jatuh 30%

IMPROVEMENT

SOP
Spread
di RS
TA
DA Implementation of SOP di
change bangsa
l
Wide scale Seluruh perawat di bangsal
tests dilatih dan implementasi

Follow up
Tests Pelatihan pencegahan pasien jatuh pada
sekelompok perawat dan ujicoba

Very small Intervensi pencegahan pasien jatuh oleh

scale test perawat koordinator bangsal
 Multiple PDSA Cycles

Respon Respon Ketepatan Manajemen

time di IGD time lab order Xray komplain
CITO
Change Concept
The Quality Improvement Phase
The Quality Improvement Phase

What is the
Questions or
Problems?
What is the problem
or question?
The Quality Improvement Phase

What can we
improve?
What can we improve?
How can we improve?
 The Quality Improvement Phase

Have we
achieved
improvement?
Have we achieved improvement?
 The Quality Improvement Phase

Have we
sustained
improvement?
Have we sustained improvement?