Performance management and

Process improvement
Quality Approaches
Prepared by : Dr.Sara Abdallh( Quality consultant)
MBCHB, TQM, CPHQ, MBA. STMG, OSHA, TOT
Lecture content
1. introduction.

2. Process improvements approaches.

3. Evidence based practice, clinical guidelines, pathway and algorithms.

4. Managed care.

5. Case and disease management.

6. Quality tools
Performance Management and process
improvement
1) Performance improvement program structure.
2) Performance improvement program plan.
3) Implementation of improvement program.
4) Dissemination of improvement information.
5) Teams
6) Practitioners evaluation.
7) Training, Education and orientation.
1- Performance improvement program
structure
1. Definition of the term quality for the organization
2. Clarify leadership roles
3. Create an accountability structure
4. Determine what the name of your program will be (i.e., quality or
performance improvement)
5. Identify the important functions of the organization
6. Identify approaches to process improvement framework
7. Develop an information flow chart
8. Establish reporting routines
9. Integrate quality principles into organization's policies and procedures
10. Identify educational needs
 1- Performance improvement program
structure
1. Definition of the term quality for the organization
Every healthcare organization must define how they view quality for their
organization.
This definition will be impacted by: the type of organization, whether it is for profit
or not for profit, the mission, vision, and values of the organization, patient
population, type of services offered, type of practitioners utilized, geographic and
environmental factors, in addition to many other components.
 1- Performance improvement program
structure
2. Clarify leadership roles
it is important that all the leaders of the organization know and meet
the expectations regarding their role in the quality strategy of the
organization.
There must be evidence of cohesiveness and integration among the
leaders. If the leaders are not all working together toward a common
quality strategy, the organization will not have an effective quality
program.
The most knowledgeable senior leader should lead the Quality Council.
1- Performance improvement program
structure
1. Definition of the term quality for theClarify
organization
leadership roles:
2. Clarify leadership roles
Quality council and committees.
3. Create an accountability structure
4. Determine what the name of your program will be (i.e., quality or
performance improvement)
5. Identify the important functions of the organization
6. Identify approaches to process improvement framework
7. Develop an information flow chart
8. Establish reporting routines
9. Integrate quality principles into organization's policies and procedures
10. Identify educational needs
 2)Performance improvement program plan.

Written plan descries and include the following:

1. Patient safety.

2. Risk management.

3. Utilization management.

4. Quality management.
 2)Performance improvement program plan.

Quality/Performance Improvement Plan

1. Purpose

2. Organizational mission, vision and scope of service

3. Goals and Objectives for this year's plan

a. . Clinical goals b. Operational goals c. Strategic Initiatives

 2)Performance improvement program plan.

Quality/Performance Improvement Plan

4) Overview and Planning

a. Identify customers b. Organizational important functions c. Prioritization of

performance opportunities

5) Structure and Design-Program infrastructure a. Quality Council b. Roles and

Responsibilities c. Pl Teams
 2)Performance improvement program plan.

Quality/Performance Improvement Plan

6. Approach and Methodology

7. Documentation and Communication

8.Confidentiality and Conflict of Interest

9. Program Evaluation and .Approval Signatures

3)Implementation of improvement program.

1) Measurement/ performance improvement

2) Monitoring/ performance improvement

3)Implementation of improvement program.

Measurement/ performance improvement:

1. Definitions terms.( measurement, standard, guidelines and
indicators)
2. Types of measures
3. Indicators
Structure Process outcome
4. Balanced score card/ dashboard
5. Clinical guidelines.
6. Clinical pathways
3)Implementation of improvement program.

2)Monitoring/ performance improvement

 3)Implementation of improvement program.
Monitoring/ performance improvement
1. Organization monitors and review
2. Clinical process review
3. Operative process review
4. Medication management review
5. Blood and blood products review
6. Mortality review
7. Specific department review.
8. Patient satisfaction review.
9. Medical record review.
10. Utilization management review.
11. Risk management review.
12. Physician monitoring.
13. Nursing monitoring.
14. National performance review.
Process improvements approaches.
 Process improvements approaches
• For process improvement.
• Used by interdisciplinary team.
• Leadership and planning is needed for integration and gain
consensus.
• Used according to organization needs and acceptance.
• Documented in plan.
• Approaches should be continues, planned ,
• systemic, organization wide and collaborate.
Process improvements approaches common
characteristics.
• Identify /Focusing on organization priorities.
• Measuring and collection needed data.
• Assess current performance.
• Select approach and action plan implementation.
• Assess improvement.
• Use statistics and analytical tools.
 Quality Approaches and tools

PDCA PDSA Rapid cycle

Quality Approaches and tools

lean SIX SIGMA

Walter A. Shewhart developed the
Plan-Do-Check-Act (PDCA) cycle for
planning and improvement.

W. Edwards Deming adapted PDCA and

called it the Plan-Do-Study-Act (PDSA) cycle
 PDSA/PDCA
• Plan ( design or redesign process)
1. Identify area for improvement( prioritization).
2. Collect data and prioritize.
3. Develop action plan and target.
4. Identify method to achieve plan, responsibility and time frame.

• Do:
1. implement Action plan on small scale( Pilot testing)
2. Education and training
• Check /Study :
• Collect data and determine goal achieved or not, if there is needed modification.
• Act: implement on wide scale
Sustain improvement/ gain continue improvement.
plan for other cycle is needed
Rapid/ Accelerated rapid cycle Approach
• To accelerate change in healthcare organizational culture used during
accusation and merges.
• Instead of changes occur within 3 – 6
months changes occur within to 4-6 weeks.
• Reengineering efforts change systems,
functions, and processes radically,
not incrementally, as continuous quality
improvement.

• Leadership support is very important.

Lean approach
• Waste is defined as "any activity or resource that destroys value or
consumes resources without creating value for the patient or the
healthcare enterprise"
• Value added e.g. care, safety.
• Non value added for patient but value added for the ognization.
Lean approach
• Lean management strives
towards elimination of
waste
and non-value added
activities
Eliminate poor application of
resources and the supply of
equipment/supplies.
Types of waste MUDA
Lean approach

To implement lean in organization:

• Culture of improvement and
• no blame culture.
• Manger act as facilitator.
• Involve frontliners.
• Good quality manger.
• Use scientific methods.
Lean approach
• Toyota JUST IN TIME.
Lean approach
visual management tools:
• In healthcare, bed boards, patient tracking systems, surgery flow
boards.
• These tools communicate important information, keep all involved
moving in the same direction, create transparency, increase trust, and
create common information sharing for decision making, and shares
and spreads improvements
 Lean approach
value stream map
Lean approach
Supplier Input Process Output customer

Patient Equipment Patient arrival Patient examination Patient

Cashier Assessment sheet and assessment Cashier
Physician Registration Physician
Nurses Nurse
Cashier

Waiting area

Assessment by
nurse and
physician
Exercise 1
Six Sigma

• focusing on continuous improvement:

understanding customer needs, analyzing
business processes, and utilizing appropriate
performance measures and statistical
methodology.
• Minimize the variability.
six 𝜎 Approche
• Is technique or approaches for process improvement.
• The term Six Sigma comes from statistics, specifically from the
field of statistical quality control, which evaluates process
capability. Originally, it referred to the ability of manufacturing
processes to produce a very high proportion of output within
specification. Processes that operate with "six sigma quality"
over the short term are assumed to produce long-term defect
levels below 3.4 defects per million opportunities
six 𝜎 Approche
• Process capability: Data fill within 3 sigma level around mean.

Extreme Extreme
six 𝜎 Approche

Voice of customer
specification.
six 𝜎 Approche
−3𝜎 −2𝜎 +1 𝜎 +2𝜎 +3𝜎
−1𝜎

Lower Mean Upper

specification 25 minutes specification
10 minutes 40 minutes
six 𝜎 Approche
D – Define
• Problem statement.

• Define Goal: SMART

• Define Process→ Map process.

• Define your customer and expectation.
six 𝜎 Approche
M– Measure
• Determine how the process currently performed.
• Causes of problems in the process.
• Create plan to collect data.
• Ensure data reliable.
• Create your project charter.
Project charter
Business Case: Opportunity Statement:
Lengthy waiting time more than 1 hour An opportunity to improve Patient satisfaction
for 60% of patients due to un-readiness score from 90% to 97% and increase hospital
of bed for admission revenue by 10%
That decrease patient satisfaction and
decrease revenue by 10%.

Goal Statement: Project Scope:

reducing the waiting time between The process starts by vacancy of bed until that bed
vacancy of bed and when that bed is ready for the next patient.
becomes ready again to 30 minutes.

Project Plan: Team Selection:

Activity Start End A.H. Admission office supervisor (Black belt)
Define 9/4 15/4 M.A nurse
Measure 15/4 22/5 H.M Infection control officer
Analyze 22/5 29/7 K.A Maintenance department
Improve 29/7 30/8 A.H housekeeping department
Control 30/8 27/9 L.M physician
six 𝜎 Approche
A– Analyze
• Identify cause of problem by brain storming

• Verify or prioritize problem causes ( Pareto )

• Update project charter.

six 𝜎 Approche
I– improve
• Brainstorm the solutions.
• Select the practical solutions.
• Develop map of best solutions.
• Implement the best solutions.
• Measure improvement.
six 𝜎 Approche
C– Control
Maintain the solutions ( sustain the gain)
• Continues improve the process by lean principle.
• Ensure process managed and monitored properly.
• Expand the improvement to the organization.
• Apply the knowledge to other process.
• Share and celebrate the success.
six 𝜎 Approche
Evidence based practice, clinical guidelines, pathway and algorithms.
 Evidence Based Practice
• Evidence base practice ( EBP): Integrate best current evidence with
clinical expertise and patient/family preferences and values for
delivery of optimal health care.
• Best evidence, best clinical experts and best outcomes.
• Standard of care: A predefined outcome of patient care that the
patient can expect that is accepted within the community of
professionals, based upon the best scientific knowledge, current
outcome data, and clinical expertise(broad and generalized).
Common sources for EBP guidelines and national measures
are
• AHRQ (e.g., National Clinical Guideline),
• Cochrane (e.g., clinical evidence comparisons),
(e.g American Cardiology Association),
• . Leapfrog Group (e.g., hospital-based measures).
 Clinical Guidelines, clinical pathway
• Clinical guidelines :
Are consensus statements developed to assist in clinical management decisions.
• The improvement of performance in clinical processes is more complex than improvements
in governance, management, or support processes.
• In healthcare, complexity is increased through the addition of the patient as
a variable
• clinical pathways : is a prospective patient management strategy and tool that
organizes, sequences, and specifies the timing of key patient care activities and interventions
in the process of care for a given diagnosis or condition that the healthcare team determines
are most likely to result in positive outcomes.
• For standardization of care and decrease variability
• Clinical pathways, also known as care pathways, critical pathways, integrated care pathways,
or care maps.
 Clinical pathway Clinical Guideline
Display goals for patients and provide the sequence and timing Clinical guidelines are consensus statements that are
of actions necessary to achieve systematically developed to assist
these goals with optimal efficiency. practitioners in making patient management
decisions related to specific clinical
circumstances
tool that details used in pathway development,
processes of care and highlights inefficiencies.

Based on guidelines Guidelines come from many sources.

Common sources for EBP guidelines and national measures are
AHRQ (e.g., National Clinical Guideline),
Cochrane (e.g., clinical evidence comparisons),
(e.g.,American Cardiology Association),
. Leapfrog Group (e.g., hospital-based measures), and
 Clinical guidelines
• The Joint Commission and National Committee for Quality Assurance
(NCQA), as well as other accreditation and regulatory agencies,
require the selection and implementation of clinical practice
guidelines, along with guideline.
• The guideline selection is based on the organization's mission,
priorities, and patient populations.
 The development of a clinical pathway includes the
following steps
• The development of a clinical pathway includes the following steps:
1. Select the topic. The topic should concentrate on high-volume, high-cost diagnoses
• and procedures; higher mortality; longer length of stay or variations.
• Surgical procedures are more suitable for pathways
2. Select a multidisciplinary team, including representatives from all groups that would be
• affected by the pathway.bundles
3.Evaluate and map the current process of care for the condition or procedure to identify
• current variation and create an idealized process.
4. Evaluate the current evidence with the best practices, comparison
with other organizations, or benchmarking, is the best method to use.
5. Determine the clinical pathway form.
6. Educate all users on how to use the tool and implement it. It is critical to define roles
7. Document and analyze variances that do not meet the expectation of the pathway.
 The development of a clinical pathway includes the
following steps
• unlike in manufacturing, not all variation in patient care is negative
as individual patient factors may contribute to variation

• Without physician support of the pathway, it is unlikely to achieve

any of the stated cost-saving or quality goals.
Standards of development of guidelines
1. Establish transparency
2. Management of conflict of interest
3. Guideline development group composition
4. Clinical Practice guideline-systematic review intersection
5. Establishing evidence foundations for and rating strength of
recommendations
6. Articulation of recommendations
7. External review
8. Updating
 Clinical Algorithm
• National practice guidelines offer solid baseline information for the
development of organization-specific clinical pathways (clinical management
plans). In addition, practice guidelines help in the development of clinical
algorithms to support clinical pathways.
• For example, physicians can support the effectiveness of a clinical
pathway for ventilator-dependent patients by developing an acceptable
weaning protocol or algorithm.
• Another example is physician development of algorithms for the prescription
of appropriate antibiotics for patients with pneumonia.
Managed care.

Case and disease management

Managed care
Used as base for
payment, medical care
and coverage
 Managed care

• In the U.S., healthcare organizations must be certified as complying

with the CMS Conditions of Participation.
• This is necessary in order to receive approval for payment for
Medicare and Medicaid patients.
• In addition, many insurance carriers and self-insured employers, as
well as many managed care
Case management Vs Disease management

• integration of cost, quality, and risk monitoring activities are happening within
the context of a care coordination model across the network.
Case management:
• in some "Integrated Delivery System" interdisciplinary team case management
activities that are centered on the patient care process and are based upon a
developed clinical path that includes preadmission and aftercare.
The disease management approach in managed care (for some chronic
conditions such as asthma, hypertension, and COPD), integrating primary care,
acute care, and aftercare using validated practice guidelines.
Process improvement tools
 Goal of using tools
1. Decision Making.

2.Process improvement.
 What we should know about each tools
1. How to construct.

2. When to use.

3. How to display if applicable.

 Brain storming
• structured group process used to create
as many ideas as possible in a short
time as possible.
• Lists generated in this process may
relate to problems or topics, components of
a process, indicators, criteria, elements for
data collection, and possible solutions.
• Brainstorming can be structured or
unstructured.
• In this process ideas are clarified, but not
criticized
 Nominal Group Technique

• Nominal Group Technique is a similar to brain storming technique used to

give everyone on the team/group an equal voice in brainstorming, problem
selection, or resolution.
• When the team/group is new, or some members are more vocal, or the
issue is controversial.
• ideas and/or the most important issues are brainstormed in silence,
written down.
• In this process ideas are clarified, but not criticized
• Each idea is then rated by each participant.
 Multi-voting
• The technique used to prioritize a long list of possibilities or alternatives
and to move a team toward consensus.
 Delphi technique
• The Delphi Technique is a tool used to reach team consensus concerning a
particular goal or task.
• The technique can be used whether or not the team is in session or if
members are in different locations.
• Steps:
1. Choose facilitator.
2. Choose experts.
3. Choose topic
4. A questionnaire or listing of possible options is drafted by the team
facilitator or the team leader to tap each individual's views or attitudes.
5. Collect result analyze them and act according to results.
Cause & Effect Diagram (Ishikawa)

• The Cause & Effect Diagram is a display of the relationship between

some "effect" and all the possible "causes" impacting it.
• It is also often called a "fishbone" or "Ishikawa" diagram.
• It is a tool generally used to gather all possible causes, the ultimate
goal being to uncover the root cause(es) of a problem.
• Industry utilizes the 5 M's: Manpower, Materials, Machines, Methods,
and Management. In healthcare, there are the 5 P's: People,
Provisions (supplies), Policies, Procedures, Patient and Place
{environment).
Fishbone Diagram
people procedure

Shortage of
staff

Delay of labs
from ER

Long distance
bet. Er and lab

patient
place provision
 Interrelationship diagram
• Is a tool that allows a team to :
1) Analyze all the interrelated cause-and-effect .
2) Relationships and factors involved in a complex problem.
• It can also be utilized to assist in identifying root causes
• In order to create an interrelationship diagram, a problem statement should be developed, and then issues
related to the problem.
• These issues may be identified through brainstorming or with the use of other tools
Interrelationship
Interrelationship diagram
diagram

Scheduled appointment

• Nursing availability • Doctor pay level

• Administrative workload • Emergency appointment

• Changes in appointment • Support function

Interrelationship diagram
 checklist
• A checklist or task list is a listing of things to do or obtain in order to
keep the team on schedule, to help team members remember
commitments (e.g., the Safety Surgical Checklist),
 Gannt chart
• A Gantt chart is a project-planning tool for developing schedules.
 Affinity diagram

• An affinity diagram is an organizational tool most often used at the

beginning of a team's work to organize large volumes of ideas or
issues into major categories.
• The ideas may have come from the group's initial brainstorming
session.
• "Affinity" means close relationship or connection, or similarity of
structure.
 Affinity diagram
delay of problems regarding anticoagulant management
 Flow chart/process map
• A flowchart is a pictorial representation displaying all the steps in a process and
their interrelationships.
• It displays the actual sequence of steps and their inter-relationships in a specific
process in order to identify handoffs inefficiencies, redundancies, inspections,
and waiting steps.
• It can also be utilized to display the ideal sequence of steps.
• Flowcharts can be used to identify and describe a current process; to proactively
look for potential process weaknesses or failures, e.g. Failure Mode and Effects
Analysis (FMEA) to analyze problems to determine causes, Root Cause Analysis
(RCA) ,to redesign the process as part of improvement action/
 Force field analysis
• In order to create a Force Field Analysis in a template list in two columns all the
driving (strengths) and restraining (weaknesses) forces affecting a desired change.
• Discuss the overall value of the proposed change and then the team comes to a
consensus about priorities for effecting change.
• Plan solution OR actions to diminish or eliminate the restraining forces while
strengthening the driving forces
 Force field analysis
example integrating quality and risk management
in one department
Driving factors / strengths Restraining factors/weakness
Shared vision/mission/resources Loss of autonomy
Cross training Staff turn over
Reduced duplication Work load