Quality Management in Health Care
Lecture 1 – introduction (13/11)
Defining quality in healthcare:
Patients, safety, satisfaction, equipment, time, effectiveness, efficiency, protocols, goods
supply, …
Approaches to define quality
Approach Definition variables Underlying discipline
Transcendent Innate excellence, based on Philosophy
experiences
Product-based Quantity of desired attributes, Economics
based on differences in
products/ingredients/attribute
s
User-based Satisfaction of individual Economics, Marketing and
consumer preferences, based Operations Management
on user views/needs
Production-based Conformance to requirements, Operations Management
concerned with manufacturing
and engineering
Value-based Affordable excellence, based Operations Management
on performance and costs
Quality = balance of health benefits and harm
Dimensions of healthcare quality
1. Safe – avoiding harm to patients
2. Effective – evidence-based healthcare, providing services based on scientific knowledge to
who could benefit
3. Patient centered – responsive to preferences, needs, capabilities, patient values guide clinical
decisions
4. Timely – reducing wait or delays
5. Efficient - avoid waste in resource use
6. Equitable – equal treatment (no variation in quality based on e.g., gender, geographic
location, socioeconomic status)
Why increased attention for quality in HC?
Aging population / chronic diseases / staff shortages pressure on care and costs
Professional differentiation knowledge explosion
Complexity of organizations organize care across organizations
Innovations and technology
Consumerism / transparency / reputation
Acceptance of society / individuals reduced
Effectiveness (usefulness) vs. efficiency (performance)
You want to do the right things and you want to do the things right.
Scarcity of resources can result in bad quality of care.
1
,Dutch healthcare system is one of the best in Europe. Also, there is a lot of spending in outpatient
care and in long-term care.
There is a shortage of healthcare professionals
Growth in healthcare personnel slows down (high workload, increased stress levels,
bureaucracy, irregular working hours, insufficient wages)
Shortage of 56.000 healthcare professionals by end of 2023
Estimated shortage of healthcare professionals increases to >150.000 in next 10 years
o These together with aging population increased chronic disease burden and rising
healthcare costs
Sustainability healthcare delivery
People-centred approach: having the right number of healthcare professionals with the right skills,
in the right place, at the right time, to provide healthcare services to the right people
Example: virtual care
Care provided over a distance using information and communication technology to enable interaction
between patients and healthcare professionals
Telemonitoring, video consultations
Pre-visit planning, advanced care at home
Evidence on quality of care and (economic) benefits limited
Reduction of hospitalizations
Virtual care costs (e.g., video consultations, data interpretation)
Implemented in various ways
Changing roles and trust from healthcare professionals (and patients)
In-person care vs. remote care
Specific care pathway vs. different care pathways
Quality deficiencies in healthcare
Patients not receiving care according to latest standards (30-50%) Crossing the Quality Chasm
(IOM 2000)
Good and best practices not implemented
Too much adverse events and unnecessary deaths (~1800 in NL) To Err is Human (IOM 1998)
Large variations between providers
Various stakeholders with different levels of importance
o Internal: staff, supervisory board
o External: insurance, patient representatives, inspectorate, press
Call for action: define gaps opportunities to improve quality
From quality to operations management
Professionally-initiated (1975-1990):
Audit / ‘intercollegiale toetsing’, specialty certifications
GRADUAL SHIFT TO:
Organisational quality (1990-current)
Q-Assurance (accreditation, programmes)
Continuous improvement
Value based healthcare
Positive approach of safety and resilience (SAFETY-II)
Networking and coordination
Total quality management (NIAZ, EFQM)
2
,Levels of quality management
Macro – Government: legislation (e.g., BIG)
Inspectorate (IGJ)
National Quality Institute (e.g. NICE-UK)
Meso – Institutional (quality management systems, transparency, consumers
Branche (e.g. hospitals, physicians)
Institutional (e.g. safety management systems, improvement projects)
Micro – Professional: professional quality assurance / improvement
Clinical pathway (e.g. improvement projects)
Individual treatment (e.g. professional quality & integrity)
Quality management systems
Formalised system that documents processes, procedures and responsibilities for achieving
policies and objectives
Coordinate and direct organisational activities to meet requirements and improve on a
continuous basis
Assurance: ISO guidelines / norms
o ISO 9001: international standard specifying requirements for quality management
systems
Total Quality Management
o NIAZ – Netherlands institute for accreditation in the care
o EFQM – European foundation for quality management
European foundation for quality management – EFQM model
3
, Evaluation of Healthcare Quality
Structure: focus on healthcare providers and healthcare setting
o Education, training, certification, equipment
Process: focus on appropriateness and skills
o Right actions? How well? Timely?
Outcomes: focus on achievement of healthcare goals
o Health status, costs, satisfaction
Quality management instruments
Benchmarking
Clinical pathways
Audit cycles
Lean management / Six Sigma
Quality management during COVID-19 pandemic
From regular hierarchical structure to:
Crisis Policy team: 1-3x per week
Outbreak management team: bi-weekly/daily
Capacity/Floor management team: daily
Regional Organization Acute Care (ROAZ): daily/weekly
Quality improvement in healthcare
Variation in care – distribution of medical resources (Dartmouth Atlas)
Use of Medicare data to provide info about national, regional, and local markets, as well as
hospitals and their affiliated physicians
Quality improvement (Mike Evans): video on slides
Quality improvmeent in practice – PDCA
Plan - analyse problem / pre-measurement
Do – improve / intervene
Check - analyse the effects
Act - implement definitive change
Safety management systems
Systematic procedures, practices and policies to
manage safety risk and assuring the effectiveness of safety risk controls
Incident reporting (safe system)
Prospective risk assessment
Continuous improvement
4
Lecture 1 – introduction (13/11)
Defining quality in healthcare:
Patients, safety, satisfaction, equipment, time, effectiveness, efficiency, protocols, goods
supply, …
Approaches to define quality
Approach Definition variables Underlying discipline
Transcendent Innate excellence, based on Philosophy
experiences
Product-based Quantity of desired attributes, Economics
based on differences in
products/ingredients/attribute
s
User-based Satisfaction of individual Economics, Marketing and
consumer preferences, based Operations Management
on user views/needs
Production-based Conformance to requirements, Operations Management
concerned with manufacturing
and engineering
Value-based Affordable excellence, based Operations Management
on performance and costs
Quality = balance of health benefits and harm
Dimensions of healthcare quality
1. Safe – avoiding harm to patients
2. Effective – evidence-based healthcare, providing services based on scientific knowledge to
who could benefit
3. Patient centered – responsive to preferences, needs, capabilities, patient values guide clinical
decisions
4. Timely – reducing wait or delays
5. Efficient - avoid waste in resource use
6. Equitable – equal treatment (no variation in quality based on e.g., gender, geographic
location, socioeconomic status)
Why increased attention for quality in HC?
Aging population / chronic diseases / staff shortages pressure on care and costs
Professional differentiation knowledge explosion
Complexity of organizations organize care across organizations
Innovations and technology
Consumerism / transparency / reputation
Acceptance of society / individuals reduced
Effectiveness (usefulness) vs. efficiency (performance)
You want to do the right things and you want to do the things right.
Scarcity of resources can result in bad quality of care.
1
,Dutch healthcare system is one of the best in Europe. Also, there is a lot of spending in outpatient
care and in long-term care.
There is a shortage of healthcare professionals
Growth in healthcare personnel slows down (high workload, increased stress levels,
bureaucracy, irregular working hours, insufficient wages)
Shortage of 56.000 healthcare professionals by end of 2023
Estimated shortage of healthcare professionals increases to >150.000 in next 10 years
o These together with aging population increased chronic disease burden and rising
healthcare costs
Sustainability healthcare delivery
People-centred approach: having the right number of healthcare professionals with the right skills,
in the right place, at the right time, to provide healthcare services to the right people
Example: virtual care
Care provided over a distance using information and communication technology to enable interaction
between patients and healthcare professionals
Telemonitoring, video consultations
Pre-visit planning, advanced care at home
Evidence on quality of care and (economic) benefits limited
Reduction of hospitalizations
Virtual care costs (e.g., video consultations, data interpretation)
Implemented in various ways
Changing roles and trust from healthcare professionals (and patients)
In-person care vs. remote care
Specific care pathway vs. different care pathways
Quality deficiencies in healthcare
Patients not receiving care according to latest standards (30-50%) Crossing the Quality Chasm
(IOM 2000)
Good and best practices not implemented
Too much adverse events and unnecessary deaths (~1800 in NL) To Err is Human (IOM 1998)
Large variations between providers
Various stakeholders with different levels of importance
o Internal: staff, supervisory board
o External: insurance, patient representatives, inspectorate, press
Call for action: define gaps opportunities to improve quality
From quality to operations management
Professionally-initiated (1975-1990):
Audit / ‘intercollegiale toetsing’, specialty certifications
GRADUAL SHIFT TO:
Organisational quality (1990-current)
Q-Assurance (accreditation, programmes)
Continuous improvement
Value based healthcare
Positive approach of safety and resilience (SAFETY-II)
Networking and coordination
Total quality management (NIAZ, EFQM)
2
,Levels of quality management
Macro – Government: legislation (e.g., BIG)
Inspectorate (IGJ)
National Quality Institute (e.g. NICE-UK)
Meso – Institutional (quality management systems, transparency, consumers
Branche (e.g. hospitals, physicians)
Institutional (e.g. safety management systems, improvement projects)
Micro – Professional: professional quality assurance / improvement
Clinical pathway (e.g. improvement projects)
Individual treatment (e.g. professional quality & integrity)
Quality management systems
Formalised system that documents processes, procedures and responsibilities for achieving
policies and objectives
Coordinate and direct organisational activities to meet requirements and improve on a
continuous basis
Assurance: ISO guidelines / norms
o ISO 9001: international standard specifying requirements for quality management
systems
Total Quality Management
o NIAZ – Netherlands institute for accreditation in the care
o EFQM – European foundation for quality management
European foundation for quality management – EFQM model
3
, Evaluation of Healthcare Quality
Structure: focus on healthcare providers and healthcare setting
o Education, training, certification, equipment
Process: focus on appropriateness and skills
o Right actions? How well? Timely?
Outcomes: focus on achievement of healthcare goals
o Health status, costs, satisfaction
Quality management instruments
Benchmarking
Clinical pathways
Audit cycles
Lean management / Six Sigma
Quality management during COVID-19 pandemic
From regular hierarchical structure to:
Crisis Policy team: 1-3x per week
Outbreak management team: bi-weekly/daily
Capacity/Floor management team: daily
Regional Organization Acute Care (ROAZ): daily/weekly
Quality improvement in healthcare
Variation in care – distribution of medical resources (Dartmouth Atlas)
Use of Medicare data to provide info about national, regional, and local markets, as well as
hospitals and their affiliated physicians
Quality improvement (Mike Evans): video on slides
Quality improvmeent in practice – PDCA
Plan - analyse problem / pre-measurement
Do – improve / intervene
Check - analyse the effects
Act - implement definitive change
Safety management systems
Systematic procedures, practices and policies to
manage safety risk and assuring the effectiveness of safety risk controls
Incident reporting (safe system)
Prospective risk assessment
Continuous improvement
4
