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QA in Healthcare

Quality assurance (QA) can be defined as all activities that contribute to defining, designing, assessing, monitoring, and improving the quality of healthcare. These activities can be performed as part of the accreditation of facilities, supervision of health workers, or other efforts to improve the performance of health workers and the quality of health services.

Since 1990, the QA Project has developed tools and methods based on quality management principles used in industry and applied them in the context of developing country health systems. Four core principles have emerged out of this experience to guide quality assurance in healthcare:

  • Focus on the client: services should be designed so as to meet the needs and expectations of clients and communities
  • Focus on systems and processes: providers must understand the service delivery system and its key service processes in order to improve them
  • Focus on measurement: data are needed to analyze processes, identify problems, and measure performance
  • Focus on teamwork: quality is best achieved through a team approach to problem solving and quality improvement.

Focus on the Client

Health services exist to meet the health needs of clients, so the delivery of health services should be designed to meet those needs. A focus on the client examines how and whether each step in a process is relevant to meeting client needs and eliminates steps that do not ultimately lead to client satisfaction or desired client outcomes. This focus on the client can be achieved by gathering information about clients and then designing services to cater to the needs that are discovered. Client-focused organizations meet client needs and expectations, thereby providing higher quality care. This encourages clients to return when they need additional care and to recommend the services to others.

A focus on clients not only involves people that come to a facility to receive services (referred to as external customers), but also addresses the work-related needs of personnel (referred to as internal customers) involved in the delivery of care. External customers include the people receiving the end product, or output, of a system. For example, patients are external customers of healthcare in a hospital. Internal customers are organizational members involved in the processes necessary to produce the output: healthcare. Doctors, nurses, administrative personnel, and cleaning staff are all examples of internal customers in a hospital, and each is important in achieving the overall goal of quality care. Internal customers benefit from system efficiency by being able to perform their jobs better, thereby better meeting the needs of external customers.

Focus on Systems and Processes

Quality management views all work in the form of processes and systems. Systems are arrangements of organizations, people, materials, and procedures that together are associated with a particular function or outcome. As shown in the figure below, a system consists of inputs, processes, and outputs/outcomes. A process is defined as "a sequence of steps through which inputs from suppliers are converted into outputs for customers." All processes are directed at achieving one goal or output from the system that encompasses the processes.

Conceptual Model of a System

Inputs, Processes, Outcomes

There are different types of processes in healthcare. These include:

  • Clinical algorithms: The processes by which clinical decisions are made
  • Information flow processes: The processes by which information is shared across the different persons involved in the care
  • Material flow processes: The processes by which materials (e.g., drugs, supplies, food) are passed through the system
  • Patient flow processes: The processes by which patients move through the medical facility as they seek and receive care
  • Multiple flow processes: Most processes are actually multiple flow processes, whereby patients, materials, information, and others are involved simultaneously in the same process of care.

In routine healthcare delivery, many processes occur simultaneously and involve many professional functions in the organization. Processes can cause inefficiencies due to problems that occur in the execution or the transition of one step to the next. Inefficiency in a process often results from unnecessary steps that add complexity, waste, and extra work to a system, ultimately reducing the overall quality of care.

Tools such as a flowchart help people understand the steps in a process. Processes also may be unclear and/or missing steps, and therefore in need of clarification. By increasing understanding of the processes and systems of care, QA activities can identify weaknesses and change processes in ways that make them produce better results.

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Focus on Measurement

In quality assurance, data are used to analyze processes, identify problems, test solutions, and measure performance. Data are important because they ensure objectivity. For example, the collection and analysis of data allow us to develop and test hypotheses. Comparing data from before and after a change can allow us to verify that the changes have actually led to improvements.

Specifically, measurement and data are used in QA to:

  • Identify opportunities for improvement to initiate QA efforts
  • Detect and assess problems
  • Verify possible causes of problems
  • Inform decision making
  • Show if a quality intervention yielded improvement and by how much
  • Monitor processes over time to see if the change or improvement is maintained

The degree to which data are collected and analyzed varies with different quality assurance tasks. Data may be quantitative in nature, such as service statistics, or qualitative, such as customer feedback or comments of healthcare workers.

Focus on Teamwork

A team is "a high-performing task group whose members are interdependent and share a common performance objective" (Francis and Young 1992). QA Project experience has shown that teams are important to QA for several reasons. First, processes consist of interdependent steps that are executed by different people, so the group working within a process will understand it better than any one person. Including key people in the improvement of a process often involves clarifying and incorporating the insights and needs of clients into healthcare delivery. The participation of major stakeholders improves the ideas generated, builds consensus about changes, and reduces resistance to change. Moreover, mutual support and cooperation arise from working together on a project, leading to increased commitment to improvement. Such an atmosphere of support discourages blaming others for problems. Finally, the accomplishments of a team often increase the members’ self-confidence. This empowers staff to work towards the goal of quality by motivating them to contribute their knowledge and skills to improve organizational and individual performance.

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The Quality Assurance Project (QAP) is funded by the U.S. Agency for International Development (USAID) under Contract Number GPH-C-00-02-00004-00.