CQI PRINCIPLES FOR A SUCCESSFUL LABORATORY

OPERATION- in Lesotho

By Sejojo Phaaroe

HEAD –CYTOPATHOLOGY

What is the CQI process?• CQI stands for continuous quality improvement• The principle and techniques of quality improvement were

formulated in the 1950s by Edwards Deming(an American Management expert using Walter Shewart from the 1930s.)

• The principles and techniques have been applied in corporations all over the world Particularly Japan, in Business & manufacturing

• The recent concepts have been used in Managing health services including those offered by Family planning, Or laboratory site

• These include services any hospital programme

CQI• CQI can be implemented across an entire organization such as

business, hospital, social or health agency or school.• Managers can adapt and use CQI to improve services in

individual organizational units or in several combined units to suit their work setting

• CQI recognizes that many organizational problems results from systems and processes rather than from individuals.

• CQI encourages staff members at all levels to work as a team, to draw on their collective experience and skills to.analyze systems and processes

• to use information to identify the nature and size of each problem

CQI• design and implement activities to improve services• When staff begin to make improvements, they them

selves monitor the impact of their changes• If at first the desired outcomes of the process are not

achieved, then the staff can continue to make improvements until these results are achieved.

• In preparing to introduce CQI, managers must create an environment for quality improvement by obtaining the commitment of leadership

• This should focus on the client’s perspective• Analyzing the work process• Motivating all levels of staff to participate in a

continuous effort to improve cervical cancer screening services

The CQI and good leadership---what makes a good leadership?

• The essence of leadership is the ability of a manager to motivate groups to achieve certain goals, without the use of any force or coercion

• A good leader is someone who is followed, rather than someone who obviously leads. Some one with the driving force inside and people follow him because he inspires trust, he creates confidence that he knows what he is doing in that particular job.

• F.W Taylor(1911) “ what workmen want from their employers beyond anything else is high wages”- Taylor argued that tasks even simple ones like shoveling could be broken down into smaller components and analyzed by performance management, and inefficient processes can be removed (

Motivating a team• E.MAYO(1933) postulated that managers should be encouraged

to recognize and realize the importance of praise, attention,and good communications in getting workers to identify and work toward company goals.

• F.Herzberg(1966) postulated that the real motivators at work are factors relating to the job itself, like the opportunity for achievement, recognition and career advancement, the chance to exercise creativity and to take on responsibility

• D.MCGREGOR(1960) ‘s theory Y is based on assumptions that people find work natural, that they exercise self-control in meeting objectives to which they are committed, that they will not only accept but actively seek responsibility and be part of decision making

Mcgregors’s Theory Y• Good managers are encouraged to create theory Y so that

workers can motivate themselves with managers performing a supportive role rather than a traditional controlling role

• Does participation in decision making motivate?---Research shows that where workers participate in decision making, motivation is enhanced through them becoming more involved and committed and feeling that their opinion matter.

• Workers participation can take place on different levels• Consultation committees/ and workshops• White collar unions• Support group associations

The role of a good CQI- Manager

CQI- Spokes man He describes the organization to the outside

CQI-Leader Creates climate,which bring together the needs of an organization and the individuals under his/her command

The CQI- managerCQI- Dissemination

Passes on data to others in the organization

CQI- Liaison Maintains a network of relationships with others outside the org

CQI -Figurehead Acts as a representative of the organization

CQI- Negotiation Negotiates with others making decisions about the commitment of the organization

The CQI-manager cont--

• CQI- Monitoring: takes note of what is going on both within and outside the organization about cytology

• CQI- Entrepreneur: he sets in motion changes which need to be made for the good of the organization

• CQI- Resource allocation ; deals with matters concerning the allocation of money, people, equipment and time etc

Implementation of CQI cycle• Once the preparation for CQI has been identified & completed,

CQI team must be formed and trained to initiate CQI• STEP 1: Identify an area where opportunities for improvement

exist in a cervical screening• STEP2: Define a problem, within that area, outline the sequence

of activities (process)that occurs in that area(smear taking, transport, screen…

• STEP 3: Establish the desired outcome of the process & the requirements needed to achieve them(e.g target 5% reduction of mistakes)

• STEP4:Select specific steps in the process to study and for each step, list the factors that prevent the achievement of the desired outcome

Cont---• STEP5: Collect and analyze data about the factors that are

preventing the achievement of the desired outcomes of the specific step being studied, and quantify the outcomes of that step

• STEP 6: Take corrective action to improve the process-(today's workshop excirse)

• STEP7: Monitor the results of the actions taken• It is essential to build CQI into routine organizational procedures

by continuously repeating the CQI cycle, and training • This will help to maintain improvements and to identify and

address new areas where services can be improved on a regular basis

Differences between traditional Mgt and CQI

Aspects Traditional CQIQuality STandards

pre-determined program objectives & is periodically monitored

Feed-back and needs. Monitored continuously & built into a process

Problem solving p.s & decision making done by senior MGT & SPECIALISTS

DONE in collaboration with staff based on hard data

Improvement Short-term and often at point of crisis(reactive)

Gradual, continuous & made in all functions(proactive)

Program clients Are not usually consulted for their opinion

Are partners and are regularly consulted

Aspects Traditional CQI

Work environment

Staff work individually

Staff work in teams

Performance recognition

Authority is rewarded

Capabilities are rewarded

Source of problems

Come from people

Come from complex processes & systems

Style of supervision

Control & direct staff

Encourage staff to take initiatives

Financial perspective

Quality costs money

Quality saves money

CQI’S Major principles• Secure full commitment and support of leadership , and

programme Directorate• Satisfy internal clients• Satisfy external clients• Focus on processes to solve problems• Respect the contributions of all staff in the health care.• Capitalize on available resources• INVOLVE A CONSULTANT WHEN ONLY

NECESSARY.• Collect and use data to improve processes• Monitor processes continuously

Leadership must provide firm commitment and support for CQI

• CQI; requires a new away of thinking• A willingness to change(bottom –up)• A mutual support amongst management and staff in a health

team• Whether The family health Director, a DMO or a manager of a

busy clinic you must be willing to initiate CQI and provide on going guidance to staff

• This should be done at every stage of the process• Head of programmes must prioritize the CQI• They must communicate the importance of quality to their staff• They must be prepared to implement changes proposed by their

staff( monna-tonki)

Satisfy your clients• In a (Family planning) or e.g cervical cancer screening programme

there are 2 kinds of clients• Internal clients[ programme staff, nurses, drivers,,

colposcopists,Gyaenacologists etc]• External clients[women who receive services and their families,

community]• Service providers become satisfied internal clients of commodity

supply system• When Managers, warehouse staff, delivery agents have ensured that

sufficient levels of stock are available• CQI wants managers to serve internal clients well• Every level of staff{internal client, managers,need to be involved in

quality improvement activities

External clients.• When Women (who should be screened) are satisfied a

clinic programme not only gains more new acceptors, and continuing users, but significantly contributes to the impact of the screening program on health and fertility. Hence quality of life, and reduced financial burden on health care

• CQI demands that managers should believe that meeting clients’ needs and expectations will improve services and will better satisfy those clients. This should be a continuous process, and commitment.( Get out of the Ivory Towers and the Laboratories and get into the Community.)

Focus on the process to solve the problem

• A set of activities= process= goal • These are performed repetitively to produce a

service( e.g. taking a patient clinical history and register, pre-counseling,smear taking etc)

• CQI assumes that the problems in a service delivery are as the result of inefficient, poorly designed or malfunctioning process

• If one improves the appropriate part of a process where a problem has been identified you fix the problem

• Focus CQI on defining and improving a problem

Respect your staff’s ability to improve processes

• Managers who respect the skills and abilities of their staff can empower them to work together to prevent or solve problems

• Improve quality of service• In a busy program or clinic it is difficult for the most

conscientious manager to be completely aware of every step involved in delivery services

• Staff who carry day-today activities of the clinic know which aspects of their work function well and which do not.

• They are in excellent position to use this knowledge so great an environment for them in CQI and in decision making.Increase job satisfaction

• Do not fear reprisals

The Division of Labor in a programme

• Henry Fayol: the father of the scientific management operation theory stipulates that for an effective CQI, an organizational manager should understand the fact that in a programme we should divide labor in accordance with our specialties.

• Every programme is a Banking system where there is an overall coordination , the Administration, technical services, Financial services, Public relations, security services for the effective running of a programme, and these processes should have a CQI composite

Collect and use data• Decisions about process improvement must be

based on facts• Managers must use data to determine the size of

the nature and problem• To justify any decisions made to improve the

problem• Problems should be real and not virtual Problems should be real and not virtual

“ a lot of complaints are not supported “ a lot of complaints are not supported by statistical or measurable evidence.by statistical or measurable evidence.

Tools and techniques for CQI

• USING A MATRIX FOR SELECTING AREAS OF IMPROVEMENT

• Flowcharting• Brainstorming• Cause-and effect diagrams• Client flow analysis• Tally sheets• Bar charts & Histogram's• Pareto analysis• Bench marking

Form CQI TEAMSOnce you have formed and trained your core group, you are

ready to perform the support function for CQI initiative for a cervical screening program

1 st step form a CQI team, made up of different staff members who will look at management processes and activities

They should Identify areas of improvementCross-functional Team made up of staff from several

departments, such as nursing, laboratory services, administration.

These have the advantage of being able to look at the processes, system and problems from different perspectives

The roles and responsibilities of each should be defined.

CQI- Team---

• The team should include the members of the CQI core groups(legal & business community) to help guide the process

• At a minimum each team should have a leader, and /a facilitator, and a recorder. If the team is small the Leader & the facilitator may be the same person

• Adding people with expertise in a chosen area can strengthen the team’s ability to effectively address the selected problem

• CQI team may be permanent or formed for a specific quality improvement

Conduct CQI training• Members of the CQI team mut be trained in the Techniques

that they will use to implement CQI., These include• Team work• Process analyses• Measurement & interpretation of data• Problem solving• Monitoring activities• Staff may be Trained formally, through seminars or informally• Any material used in training should be gathered or prepared

ahead of time• CQI team is the best team to motivate staff and client

IMPLEMENTING CQI

• Flow charts

Flow chart

Succesful maintenance of quality standards and operating systems ;

BUDJETS

Program Flow mechanics-target areas of activities

Women, village, councilors, Chiefs,

CHWs, etc.

Health Centre/ANC clinic

Doctors / Nurses at District Hospital

Cytology lab

Central lab

Police posts, teachers, churches

Colposcopy& histopathology

Oncology/surgery/ Bloem

Palliative care

National Cancer associations

1997 tariffs for non-Residents I RSA• RANDS • Boarding (~42 days) 365/day• Profesional fees (~42 days) 98/day• Clinics 78/day• Radiotheratpy(30 day course) 156• MRI 2520 • CAT scan 598• EUA and investigations 3000• Palliative Radiotherapy 12 000/patient• Investigations include haematology, urology, cytoscopy, clinical

chemistry, general medical examinations [bp/pulse,etc]etc• Special investigations {biopsy & transport excluded

•

CQI- Process in clinics• Patient identification,• Clinical information recording• precounseling• request form filling,• smear taking & labeling tools• Quality assurance scheme• generating a data for recall follow system and Registry. • Consigning driver to Send slide to the Lab/hospital• Recording results back• Selecting important results• Suggesting a follow up record

CQI PROCESS CONSIGNMENT TO THE LAB

• Transportation of samples,

• Relationship between nurses & consignees/drivers.

• TRAINING OF DRIVERS OR CONSIGNEES

• Quality assurance steps (consignment book record) with a list of clinic NUMBER of slides

CQI-process in the Laboratory• Laboratory sample reception,• identification,• handling,• labelling, • recording,• processing for screening,• Quality smear assessment, • interpretation of results,• reporting, • correlation, further novel techniques, recommendations, data

processing, posting, recall follow up system, registry, communicating, coordination. Quality assurance scheme.

CQI –in Histology Lab• Laboratory sample reception,• identification,• handling,• labelling,• recording, • processing,• Quality assessment,• interpretation of results,• reporting,• correlation, further novel techniques, recommendations, data

processing, posting, recall follow up system, registry, communicating, coordination. Quality assurance scheme.

CQI-GYAEN CLINIC

• Client reception,• identification,• recording, • Client clinical examinations, • Quality assessment,• interpretation of results• Correlation of cyto, colp, histology, further novel

techniques, recommendations, Surgical intervention, follow up system, registry, communicating, coordination. Quality assurance scheme. etc

The best favorite Quotes I go for • “You make the rules”- Jay Abraham

• “There is no reason of a carrying, catching and rolling the ball when you do not know where the goal is” -Mitchell Tolle

• “if its going to be, its up to me , its up to us, what ever it takes, never, ever, never ever give up”-Rick Eriksen

• “You can not build a business bigger than your self- TONY KENT

• “The love you give is the love you get”- Sidi Shaik Mohammed

• “ Without a Dream there is no reason to practice, without practice , there is no reason to Dream”- Trevor Levine

• “everything changes when you change”- Jim Rohn• “you can get what you want if you help enough

others get what they want”-Zig Ziglar • The love we fail to share is the only pain we live

with:- Brian Bivo

Thank You for your Ears