QAP Summary [R]

8/10/2019 QAP Summary [R]

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DR.HJ.MUHD KHAIRI BIN MOHD TAIBI, AMN.,AMP

PAKAR PERUNDING PERUBATAN KELUARGA


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What is QUALITY?

Means Different Things

To Different People


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What is Quality?

Invisiblewhen Good

Impossible to Ignorewhen Bad


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Quality assurance

KKM Definition

Securing optimum achievable result

for each patient,

avoidance of iatrogeniccomplications

and giving attention

to the patient

and family needs

in a manner

that is cost effective

and reasonably documented

Adapted from Thomson


5/77

ABNA concept

0

25

50

75

100

With unlimited resource ideal level of care

Optimal Achievable Level targetted level within

means

ABNA difference between OA &

present level QA aims at narrowing or

eliminating the gap

ABNA}Ideal

Optimum

Actual


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QUALITY ASSURANCEis equal to

ASSESS CORRECT&


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ProblemPrioritisation

Problem

Analysis

Quality

Assurance

Study

Identification

of Remedial

Actions

Implementation of

Remedial Actions

Re-evaluation

of the Problem

Problem

identification

Quality

AssuranceCycle

Evaluation


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Problem

Analysis

Quality

Assurance

Study

Identification

of Remedial

Actions

Implementation of

Remedial Actions

Re-evaluation

of the Problem

Problem

identification

Quality

AssuranceCycle

Evaluation

Verification of theproblem


9/779

28

December2014

Problem identification

1. It is problem or perception1. Verification of the problem check it out with

information /statistics/people involved/pilot study

2. Source of information to identify problem Suggestion from staff/Issues from

meeting/data/morbidity or mortalityreview/brainstorming

3. Criteria used to decide if problem is worth studying1. SMART


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Methodology of QA Study1. Problem / Opportunity Statement

A complete opportunity/ problem statement shoulddescribe :

* the problem or area of concern and itssignificance for the quality of care

* possible causes and contributory factors

* rationale of the study

* scope of the study

* intention to use the results to improve the

quality of care


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28

December2014

Quality Problem

Related to

Customer Satisfaction

Cost Savings

Increase Efficiency

Reduce Discomforts


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12

28

December2014

Non Quality Problems

Administrative Issues(Management problem)

Eg; Poor control of visitors outside visiting hours

High attendance of cold cases at A & E dept.

Not relatedclosely to the quality of care,

May not improved customer satisfaction

Problem of Scientific/Academicinterest

Eg; High mortality rate in diabetic ketoacidosis

High incidence of ADR from administering certain

antibiotics

Needs clinical research / study


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0

1000

2000

3000

4000

5000

6000

2006 2007 2008Kes DM Type II 3916 4912 5013

Diabetic foot Ulcer 108 127 145

3916

4912 5013

108(2.7%) 127(2.6%) 145(2.9%)

JUM

LAHPESAKIT

TAHUN

Verifikasi Masalah Mengurangkan kejadian Diabetic Foot UlcerDikalangan Pesakit Diabetes Type II


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Problem

Analysis

Quality

Assurance

Study

Identification

of Remedial

Actions

Implementation of

Remedial Actions

Re-evaluation

of the Problem

Problem

identification

Quality

AssuranceCycle

Evaluation

nominalGroup

Technique


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15

28

December2014

Nominal Group Technique( NGT)

THE GROUPCommon interest ----> quality improvement

NUMBER : 7 - 12

< 7 : Inadequate expertise>12 : Too many

Unsatisfactory group dynamicsFew loud-mouth, many nodders & sleepers


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16

28

December2014

NGT steps Silent generation phase: individual think about ideas

free from comment and interference

Round robin phase:

one-by-one responses

list exact phrases and displayed

no discussion except clarification


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18

28

December2014

Basis of Ranking - SMARTcriteria

SERIOUSNESS / SPECIFIC

Life at stake ( mortality)?Permanent disability ?Complication? Pain?

Costly? Causing distress to patient?

Impact on patient, community &hospitals image

Impact on cost & resources Frequent occurrence though not serious

Big room for improvement

Large ABNA


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19

28

December2014

Basis of Ranking - SMART criteria

Measurable

Data available to quantify extent of problem

Process clearly defined

( starting & ending points) Indicators identifiable with problems

Appropriateness

How much related to CORE BUSINESS? Objective consistent with organisational

goals


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Remediable Resource & Expertise available Solution is possible

Within capacity of group Timeliness / Timed

no current operational, financial or politicalissues which might affect the success ofproject

Social, political, ethically acceptable Does not take very long to remedy

28 December 2014 20

Basis of Ranking - SMART criteria


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Problem

Analysis

Quality

Assurance

Study

Identification

of Remedial

Actions

Implementation of

Remedial Actions

Re-evaluation

of the Problem

Problem

identification

Quality

AssuranceCycle

Evaluation

Problemstatement

Cause-effect


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PENYATA MASALAH/ PELUANGPENAMBAHAIKAN(PROBLEM /OPPORTUNITY STATEMENT)

Purpose is to justify the study (to sell the project)

Contents of problem statement

1) Background information of the problem2) Explaining the problem evidence if any

3) What are the effects (BAD)

4)What are the possible causes/contributing factors

5) Expected result

6) Why we want to do with the study


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23

28

December2014

Management of compound fractures forms a major part of theworkload of the Orthopaedic Dept.. (INTRODUCTION)

Those with compound fractures shouldnt have to wait for a longtime in the ward before they are operated upon. They should betreated promptly and effective rapid uncomplicated recovery(DESIRABLE OUTCOME/ EXPECTATION)

There are ample opportunities to make this possible in oursetting such as timely availability of OT, consent, blood or

appropriate examinations and investigations(OPPORTUNITIES)

We hope to identify areas that can be improved by carrying out astudy using certain indicators to identify contributing factorsand propose remedial actions. (INTENT TO IMPROVE)

IMPROVING MANAGEMENT OF COMPOUND LONG BONE

FRACTURES


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Problem Analysis

To analyse the problem and the factors inf luencing

it

(a) 4W1H What, Where, When,Who areinvolved and How it happened

(b) Analyse the possible causes of the problem

and its effects using cause-effect diagrams(bubble charts / Fishbone charts (Ishikawa)

1)


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Cause-Effect Analysis

( In QA we use the bubble chart )

List down all possible causes first

Look at the main causes , then put in as 1st

generation bubble Then propose and arrange the inter-related causes

in the 2ndgeneration and so forth


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Effect of the problem

/complication

Primary causes

Primary causes

Primary causes

Secondary causes

Secondary causes

Secondary causes

Bubble chart


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27

CARTA SEBAB DAN AKIBAT DALAM MENINGKATKAN AMALAN

PERANCANG KELUARGA DI KALANGAN IBU OA DI DAERAH PEKAN

MENINGKATKAN AMALAN

PERANCANG KELUARGA

DI KALANGAN IBU OA

DI DAERAH PEKAN

MENINGKATKAN

PERKHIDMATAN

PERANCANG KELUARGA

MENINGKATKAN

PENERIMAAN IBU

TERHADAP AMALAN

PERANCANG KELUARGA

MENINGKATKAN PENGETAHUAN

TENTANG KEPENTINGAN

AMALAN PERANCANG KELUARGA

Melibatkan

orang berpengaruhseperti bomoh,

Tok Batin

dan JHEOA

Penggunaan

kaedah perancang

keluarga yang

sesuai

Memberi motivasi

kepada ibu, suami dan

keluarga terdekat tentang

kepentingan perancangkeluarga

Pengesanan

awal kes-kes cicir &lawatan ke rumah

dijalankan

Tingkatkan

perkhidmatan

klinik bergerak

Memberi

latihan berterusan

kepada anggota

kesihatan

Penyelianan dan

pemantauanyang berterusan

Meningkatkan

kefahaman mengenai

kepentingan perancang

keluarga

Memberi

pendidikan kesihatan

kepada ibu OA

Meningkatkan

promosi kepada

masyarakat

OA

Menggunakan

flip chart bergambar yang

jelas dan menarik


28/77

standards Standard is the line that differentiates the good from the bad.

- Acceptable lowest limit

The standard is to :

i) verify problem exist (First level)

Ii) show factors identified are responsible for theproblems (Second Level)

Problem: Long waiting time in OPD

1stLevel standard : within 60 mts. from registration andseeing doctor,

2ndLevel : 75%f the patient should


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standards setting Setting too higha standard may make the problem

unsolvable and the target unreachable

If its too low, it may not reflect quality level of carethats acceptable

Use literature and other studies to determine theappropriate standard in YOUR setup

Or set standards after knowing current level of carWhen human factors are involved usually the

standard should not be 100%


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Process of care

Flowchart / pathway of care the steps ofactivities while delivering a particular care.

The flowchart should contain specificactivity in the area of concern for

improvement `

The steps is adopted from the professionallyaccepted standard or norm , SOP, guidelines,

circulars, CPG, etc Flow of care can be used to guide the

development of Model of Good Care


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Flow chart of Mx of Hypertensive patients

Pt with HPT

Uncontrolled Out patient Tx

Admit to ward

Pt seen by HO

Pt seen by MO/Pakar

No

Yes

Education Ix Rx

BP optimallycontrolled

No YesDisc. F/U


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What is MOGC MOGC is the process involves for specific health care

delivery to be implemented so as to produce the best /expected outcome.

good process will produce good outcome

The protocol and sequence of essential elements of the

process of care preferablywith the preset criteria andstandard of the critical processesso that the care is good.


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Criteria ( of the process of care )

It is an essential element for good care, Thing that make care good for the particular step

of care Example of essential element

i) things should do - perform ECG and serum enzyme on those

suspected MI- X-match blood before transfusion

- take consent from those for operation- drug counselling before dispensing

poly-medication


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Standards of MOGC For each criteria, a standard s set

Setting of standards is a percentage of fulfillment ofcriteria

If the criterion is related to a vital indicator, thestandard is 100%

i) Blood transfused must be GXM , standard 100%

Ii) Staffs must pass the test , standard 85%

MOGC


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Step Process of care Criteria Standard

1 HPT pt seen in OPD/A&E/

MOPD

Admit :BP>160/100

mm Hg(CPG 1998)

90%

2 Registration & adm for pt w

uncontrolled HPT

Diagnosis of HPT(Uncontrolled/For

stabilization)

100%

3 Pt reviewed by HO

Seen within 15 min onadm

Daily ward rounds

Prn if BP > 160/100or any complaints

100%

4

Pt reviewed by MO

Specialist

Daily ward rounds

Prn if 180/100

At least 1 X/week

100%

MOGC


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No. Process Criteria Standard

1. Registration

Address

Time of registration

Educational status

< 12 / 5290 %

*2. History Taking

LMP

Age

Parity

Family History Past Obstetric History

History

Conduct / TBA

PE

IUGR

LSCS Past gynae history

Past medical history

1 x /pregnancy

(During

booking)

100 %

Symptoms ofeclampsia

Every ANCvisit

Every Homevisit


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Problem

Prioritisation

Problem

Analysis

Quality

Assurance

Study

Identification

of Remedial

Actions

Implementation of

Remedial Actions

Re-evaluation

of the Problem

Problem

identification

QualityAssurance

Cycle

EvaluationTo knowmagnitude ofproblem & toprove thecause-effect


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QUALITY ASSURANCE STUDY


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QA STUDY A planned and systematic collection of data using

various methods for the purpose of

i. Verifying existence of Q problem

ii. Assessing the magnitude of the problem

iii. Identifying the factors contributing the problem The method must be sound, it need not very complicated

as in research (which follows strict statistical criteria)

The components of the QA study

-Literature Review

-Objectives of the study

-Study methodology


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Methodology of QA Study

1 Objectives: General & Specific2 Type of study3 Terms ( key words ) definition4 Inclusion & Exclusion criteria

5 Proposed Indicator and Standard6 Plan for data collection ( +proposedformats)7 Plan for data analysis ( +proposed

dummy tables)8 Gantts chart9 References


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2. Literature reviewwill help us in;clarify our problem

state the study objectivesknow what has happen elsewherecheck the implicit standardsset explicit criteria and standards

suggest suitable study methodsfind appropriate remedial actionsavoid duplication of works


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Objectives of the study

Thegeneral objectivewill mention the overall final aim tobe achieved in the study

The specific objectivesshould be stated using action

verbs that specific enough to measures: To determine - To compare To verify - To establish

To calculate - To describe

Avoid the use of vague non-action verbs such as;

To appreciate

To understand


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Specific objectives for QA study

1. To measure the magnitudeof the problem

2. To identify/describe the actual causesorcontributory factors involved

3. To formulate the remedialor improvementmeasures

4. To evaluate the effectivenessof the measurestaken.


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Variables

A characteristic of a person, object or

phenomenon that is measureable and cantake on different values

variable valueHeight tall , short

Sex male , female

Knowledge Good, poorSocioeconomic status High, middle, low

income group


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Type of Study

PASTRETROSPECTIVE

Looks for pastexposure to a factor or

describe the past event

NOWCROSS-SECTIONAL

Looks at the presentsituation

FUTUREPROSPECTIVE

Looks at development ofa condition over time

Descriptive study; can be retrospective, prospective orcross-sectional

Analytical study; can be either retrospective or prospective

Experimental study is always prospective


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Key Word DefinitionTo describe the definition of certain/

selective key words and terminology

used in this studyThe terminology probably applied only

for this study including application of

certain variables, situation, standard.Must be sound valid, acceptable,

reliable, clear and not ambiguous.


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Inclusion & exclusion criteriaInclusion criteria

Criteria of study subjects (from a defined studypopulation) that is to be included in data (sample to

collected) List should not be too long

Exclusion criteria

Subjects (from a defined study population) to beexcluded from study

Limits sample size to relevant subjects


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Proposed Indicator and Standard

Describe the indicator proposed to beapplied in the study.

If rate based, what numerator anddenominator will you use.

Proposed the most acceptablestandard.


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Sampling

Better to get intended information from acertain population ( all ), but limited withproblems of logistics, costs, time & otherresources.

Thus, we have to do sampling; arepresentative sample with all importantcharacteristics of the drawn population

Sampling involves the selection of anumber of the study unit from a definedstudy population


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Sampling method1. Non-probablility

- -Convenience : study unit that happen to beavailable at the time of data collection areselected in the sample

- - Purposive sampling :targeting a certaingroup

2. Probability sampling- Simple random sampling

- Systematic sampling (using regular interval)- Stratified sampling (by geographic boundaries)- Cluster sampling (by Group/ characteristic)- Multi-stage sampling (


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Data Collection Techniques

Review of recorded sources

Observation

Interview Written questionnaires


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Plan for Data Collection

WHAT data to collectWHERE to get the dataHOW to collect themWHO will collect

WHEN will the data be collectedHOW LONG will it takesQUALITY CONTROL of the data


53/77

Plan for Data Analysis

The plan includes;

Data handling andstoring

Data processingData analysis


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Mapping the ProposalConstruct the Gantts Chart

List down the the plan of processes to

be undertaken in conducting the study

Chart the appropriate time frame for

each processTo mark the plan and actual task

carried out


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GANTTs CHART

Tugas T/jawab Jul

03

Ogos

03

Sept

03

Okt

03

Nov

03

Dis

03

Jan

04

Feb

04

Taklimat Ahli kumpulan

Surat arahan Ketua Jabatan

Sediakan format

pengumpulan

data

Ahli kumpulan

Pengumpulan

data

Ahli kumpulan

Analisa data Ahli kumpulan

Perlaksanaan Ahli kumpulan

Penilaian Ahli kumpulan

Sediakan laporan Ketua kumpulan

1

1

1

1

1

1

1

1plan actual


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9. References

List down all references quoted orreferred in the study


57/77

References1. Clinical Practice Guidelines on The Management ofHPT ( Academy of Medicine; 2002 )

2. Standard Operating Procedure for MA ( Ministry of

Health; 2000 )

3. King H. Revers M. Diabetes in adults is now a third

world problem. Bulletin of WHO 1991. 69 (b):643

648.14


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choosing indicator Reflects the QUALITYof service that is measured ( proxy )

Can be assessed objectively using certainCRITERIA

Can differentiate between the ones with quality from those

without

Should directly address the problem

Usually expressed in the form of rates (%) (rate based)

or nil occurrence (zero defect)


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variables IN SIMPLE TERMS ARE ME SUR BLE D T AVARIABLEis a characteristic of a person, object or

phenomenon that can take on different values. It ismeasurable

Is basically datacollected

It can take various values

All factors must be put in a variable form


60/77


61/77

Each step will contribute to the final serviceoutcome.

Essential elementsis the critical steps of carethat should be accomplished within the setcriteria and standard.

If violated, it might cause a multiplying effect offailure in the series of care. Finally end-up withan undesired product or sequalae of care.

( ie: NOT the good care )

MODEL OF GOOD CARE


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MODEL OF GOOD CARE

STEP NO PROCESS OF CARE CRITERIA STANDARD

A

B

C

C1

C2C3

D

(*)

(*) refers to Standard of EACH Process of Care

Standard setting in the MOGC


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Standard setting in the MOGC

isthe minimum level of acceptable performance forthe respective step in the process of care ( referred to asOptimum Achievable Standard (OAS )

thevalue of a Criteriathat marks the line between good

and poor

widely / professionally accepted value

( evidence-based / best practice )

preferably for thecritical steps only

consensusly agreed


64/77

SIQ: Investigation process

Evaluate every steps in the process of care & todetermine whether the step wasappropriate, timely& adequate

Where is the shortfall ?check your MOGC !

Why is the shortfall ?check bubble chart !

Guidance in providing the remedial measures andplanning to prevent or overcome similar shortfalls infuture

To reduce magnitude of ABNA by: eliminating or minimising Error of ommision Error of commission

improving the quality of care

Perbandingan peratus pencapaian


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Perbandingan peratus pencapaianpengendalian kes anemia

BIL FAKTOR / KRITERIA 2001 2002 (*)

1. Kedatangan pertama < 12/52 36.7% 71.4%

2. Penggunaan senarai semak yang betul 60.0% 92.2%

3. Pemberian Ferrous fumarate pada POG 18-20/52 78.3% 92.2%

4. Ujian Hb 2/52 sekali dibuat. 48.3% 93.5%

(*) selepas tindakan penambahbaikan

LANGKAH-LANGKAH PENAMBAHBAIKAN


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Bil Isu/ masalah Aktiviti Staf b/jawab

1. Pendaftaranantenatal


67/77

3.95

21.7

0

1

2

3

4

5

2001 2002 std

ABNAsebelum

ABNAselepas

Peratus anemia

pada 36/52 POA

Formulating DSA the proposal


68/77

1. TAJUK2. Group

3. Problem Identification/ Opportunity for Improvement4. Prioritisation & chosen/refined topic5. (Situational analysis / Literature review)6. Opportunity statement7. Quality factor analysis / cause-effect analysis8. Process of care

9. Model of Good Care10. QA study: Methodology10.1 Objectives: General & Specific10.2 Type of study10.3 Terms ( key words ) definition10.4 Inclusion & Exclusion criteria

10.5 Proposed Indicator and Standard10.6 Plan for data collection ( +proposed formats)10.7 Plan for data analysis ( +proposed dummy tables)10.8 Gantts chart10.9 References

Formulating DSA: the proposal

St d C it i


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Study Criteria

Inclusion criteria:Specific conditions or characteristics that are appliedand included in the study

Exclusion criteria:

The certain characteristic of the samples that to beexcluded in the data collection for specific reason.The excluded data shouldnt has any effect

( little or almost negligible ) on the result of the study


70/77

8. Mapping the ProposalConstruct the Gantts Chart

List down the the plan of processes to

be undertaken in conducting the studyChart the appropriate time frame for

each process

To mark the plan and actual taskcarried out


71/77

GANTTs CHART

Tugas T/jawab Jul

03

Ogos

03

Sept

03

Okt

03

Nov

03

Dis

03

Jan

04

Feb

04

Taklimat Ahli kumpulan

Surat arahan Ketua Jabatan

Sediakan formatpengumpulan

data

Ahli kumpulan

Pengumpulan

data

Ahli kumpulan

Analisa data Ahli kumpulan

Perlaksanaan Ahli kumpulan

Penilaian Ahli kumpulan

Sediakan laporan Ketua kumpulan

1

1

1

1

1

1

1

1plan actual

9 R f


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9. References

List down all references quoted orreferred in the study

1. Clinical Practice Guidelines on The Management of HPT( Academy of Medicine; 2002 )

2. Standard Operating Procedure for MA ( Ministry of Health; 2000 )


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Problem

Prioritisation

Problem

Analysis

Quality

Assurance

Study

Identification

of Remedial

Actions

Implementation of

Remedial Actions

Re-evaluation

of the Problem

Problem

identification

QualityAssurance

Cycle

Evaluation


74/77

74

rinciples for remedial action

- based on actual findings ( periodic

assessment / QA study )

- not construed as fault finding

not to imply to any party as negligent not to be punitive

- be practical:

* specific * manageable

* realistic * cost effective

* flexible * timeliness

Th k t di l


75/77

75

The key to remedial

actions is

CHANGE

R l ti Wh SIQ /


76/77

76

Reevaluation: Why SIQ /problem recurs ?

1. SMART concept not properly applied2. Impose wrong strategies3. Improper implementation4. Weak leadership, poor commitment

5. Change resistance6. Poor problem identification /selection7. Lack of resources8. Beyond control interference


77/77

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