6. 4. Continuous Quality Improvement 

6.4.1. Continuous Quality Improvement is an equivalent in the healthcare for Total Quality Management in the industry. 

Continuous quality improvement is an ongoing, organization wide framework in which health service organizations and their employees are committed to and involved in monitoring and evaluating all aspects of the health service organizations‘ activities and outputs in order to continuously improve them. (American Hospital Association) 

It is a continuous process with a goal of doing the right things right the first time, every time. 

• Doing the right things: investing resources on activities proven to achieve desired benefits 
• Doing things right: implementing designed interventions in a way that is acceptable to beneficiaries, at the lowest cost possible and in line with current professional knowledge. 
• Doing things right the first time, every time: achieving these as an institutional culture. 

6.4.2. Principles of Continuous Quality Improvement 

There are two important principles in continuous quality improvement. These are client focus and team work. 

• Client Focus: Focus first and foremost on meeting the needs and expectations of clients/patients. 
• Teamwork: Work is accomplished through processes in which different people are responsible for different activities. 

6.4.3. Components of Continuous Quality Improvement 

Continuous quality improvement includes two important components and a supporting infrastructure 

• Quality Measurement 
• Quality Improvement 
• Infrastructure for Quality Management 

6.4.3.1. Quality Measurement 

Quality Measurement is the initial step required to initiate quality improvement processes in any kind of institution. The primary advantage of quality measurement is it helps in identifying opportunities for improvement. In addition quality management encourages improved documentation system, builds skills for analysis and interpretation of data and facilitates informed decision making in other areas. 

Donabedian‘s framework for measurement of healthcare quality consist of three components measures. These are; structure, process and outcome. These quality measures are frequently confused as components of quality. Structure, process and output (S-P-O) are areas of measures on which information can be gathered and potentially inferred about the quality of healthcare. 

a. Structure is the setup in which care is being provided. Structure includes: 

• People 
• Resource 
• Knowledge and technology 

Using structural measures as quality measures takes the assumption: If appropriate resources are available, the" likelihood of their appropriate use and then achieving attainable outcomes is high." 

Eg. To measure the quality of HIV care, one can use "Percentage of hospitals with medical doctors trained on HIV care" as an indicator. 

b. Process is the set of interrelated activities that constitute what healthcare is. The Assumption in process measure is "if healthcare is provided in compliance with scientific recommendations, potentially attainable outcomes will be achieved."

c. Outcome is the change observed on beneficiaries of healthcare (individuals or population) that is attributable to healthcare. It may include intermediate or longer term outcomes. Outcome measure includes: change in physical, mental and social health status, knowledge and attitude of beneficiaries and behavior/practice of beneficiaries. 

How to use Structure Process and Outcome 

Selection of measures depends on who will use the information. The three categories of measures are not alternatives from which someone needs to choose one. It is usually recommended to mix measures in measuring quality. While selecting measures of quality, we should consider: 

• Evidences of importance 
• The degree of control at the specific level of care 
• Data integrity and other attributes of a good quality indicator (sensitivity, specificity, validity, reliability, measurability, understandability, comparability, …) 

Steps to measure quality 

• Identify priority areas for improvement 
• Select quality of care indicators related to priority areas of improvement 
• Collect data 
• Analyze data 
• Expected results 
• Opportunities for quality improvement identified 

6.4.3.2. Quality Improvement 

Quality Improvement is the step during which series of actions will be taken to: 

• Plan and implement potential solutions to address underlying root causes of problems 
• Study if changes bring improvement 
• Expand those changes that are found effective and modify those found ineffective 

The quality improvement steps are explained by the Deming‘s Cycle; which consists of four steps: Plan, Do, Study and Act

Plan 

Plan -based on findings of Quality Measurement 

• Investigate the root causes of performance gap 
• Come up with a prioritized list of feasible solutions 
• Set objectives for improvement 
• Plan implementation (who, what, where, when) 

Do 

• Carry out the plan – small scale 
• Document problems and unexpected observations 
• Begin analysis of the data 

Study 

• Why: 
  

– All improvements need changes but not all changes result in improvement 

• Analyze data completely 
• Compare findings with expectations and previous findings 
• Draw conclusions on what to expand and what to further improve 

Act 

• Expand changes that brought improvements 
• Modify changes that need modifications to bring more improvements 
• Find out other solutions for areas with no improvement 
• Start the next cycle 
• Work for small incremental changes with: 
• More frequent short cycles 
• Acceptable level of accuracy 
• Consistent methods of measurement to allow comparison "The perfect is the enemy of the good!! (anonymous)" 

Commonly used quality improvement actions 

Quality improvement actions should be developed by considering: 

• Nature of the problem to be addressed 
• Previous documentation of effectiveness 
• Feasibility of the intervention designed 
• Potential sustainability of improvements 
• Conformity with national and international efforts 

Examples of actions to improve quality of healthcare: 

• Training on specific topics 
• Development of standards, guidelines and job aids 
• Electronic diagnostic support 
• Physician reminders 
• Process redesign 
• Change in technology 
• Reallocation of resources (human, financial, material) 
• Patient education programs 

6.4.3.3. Infrastructure for Quality Management 

Infrastructure is important because quality management needs to be institutionalized if improvements have to be made continually. Quality Management is not a onetime activity; always, there are rooms for improvement. It should include the human and material resources that are required to: 

• Plan for continuous quality improvement processes 
• Measure quality of care 
• Test and implement quality improvement actions 
• Monitor and evaluate if the quality management program is working