Project Guideline – Quality Management System - SMU

PART 1 – INTRODUCTION about the selected issue for study

PART 2 – LITERATURE on selected issue/topic
PART 3 – Case Organization/section/issue
1. Study the existing situation of selected section/issue in selected organization
After you have selected the organization or section or issue that you have interested, it is
necessary to study the existing or the current situations so that you can develop your
information and knowledge on the section/issue. Ask yourself, “What do I know about the
organization or section or the issue?”

2. Identify and select the quality problems

At this step you become aware of a quality problem that may be large, vague, or
complicated. You have some information, but do not have detailed facts. Clarify the
quality problem and breakdown it into smaller and individual ones. Quality problems may
be obvious.
Please consider those questions only in the context of your study project topic.
 What are the strong and weak side of the organization relating to its quality?
 What would customers want to improve? What are they complaining about?
 What quality problems do you observe in the organization? And where could quality
problems arise in the business process?
 What are the root causes of identified quality problems in the organization? What
does organization often fail to achieve? Where does organization have bottlenecks?
 What solution do you propose to improve quality in the organization?

3. Collect relevant information and data

4. Analyze the data and interpret the results/findings
5. Generate potential (alternative) solutions
PART 4 CONCLUSION AND RECOMMENDATIONS
Quality management system practice and their effect in a
healthcare institution.
BY: Bekalu Mulusew
Girum Tesfa
Mahlet
Eniyew

A Project Submitted to Amare Matebu(Ph.D.)

June 2023
 Quality management system project #1
Quality management system practice and their effect
in a healthcare institution.
Introduction to the quality management system in a Healthcare Center
Healthcare organizations are composed of a diverse group of professionals who provide
indispensable services. To ensure that every group within the organization is content,
implementing a quality management system program is crucial. While quality has always been a
crucial aspect of healthcare, it can't be measured physically. Instead, the term "healthcare
service" should be utilized to evaluate, monitor, and enhance the field. A top-quality healthcare
system should be accessible, appropriate, available, affordable, effective, efficient, integrated,
safe, and patient-centered. Practitioners in allied health services, dentistry, midwifery, obstetrics,
medicine, nursing, optometry, pharmacy, psychology, and other care providers all contribute to
the delivery of healthcare.

The concept of quality management in healthcare has evolved over time, from simply directing
healthcare personnel to a more comprehensive approach to managing the care process. This
involves observing the various organizational functions as a collective interaction of procedures
and processes, which can be addressed on individual and collective levels. While there have been
several models proposed, the triad of structure, process, and outcome introduced by Donabedian
remains the cornerstone of quality assessment in healthcare today.

Ensuring top-quality healthcare has become more crucial than ever, with patient satisfaction as
the ultimate goal. Rather than simply detecting defects, the new approach to quality control
focuses on prevention, continuous improvement, and patient-centered outcomes. It is therefore
essential to shift the paradigm of healthcare delivery towards this outcome-driven model.
Government officials must play a role in promoting and ensuring high-quality healthcare across
all fields, including dentistry and nursing, particularly in developing countries.
In the field of healthcare, professionals are responsible for maintaining high standards of quality.
Emphasis is placed on preventative maintenance rather than overall service maintenance.
Donabedian suggested using a triad of structure, process, and outcome to assess healthcare
quality. The structure component includes the necessary infrastructure, skills, and qualifications
of healthcare professionals and administrative systems for delivering healthcare. The process
involves the various components of care and their interactions. The outcome is measured by
factors such as recovery, functional restoration, and survival. To understand quality the key
features are reliability, assurance, and responsiveness. The seven pillars of quality as presented
by Donabedian are efficacy, efficiency, optimality, acceptability, legitimacy, equity, and cost.
According to the Institute of Medicine, services are of quality, when they are safe, effective,
patient-centered, timely, efficient, and equitable.

Quality management system in health care has observed a paradigm shift from expecting errors
and defects to considering that perfect patient experience is achievable. Philip Crosby supports
the same principle that the system for causing quality is prevention and not an appraisal.
Literature indicates that the cause of death for a large number of patients in hospitals is medical
negligence and nosocomial infections. These deaths can be easily avoided by incorporating
quality assurance programs.

In managing healthcare, system designs are essential, but they alone cannot ensure high-quality
clinical care. To achieve superior clinical quality, it is crucial to utilize resources efficiently. Six
Sigma design is known to yield almost zero defects, but there is no consensus on any single
model being superior for quality management. Ultimately, the success of any approach depends
on the commitment of top management and the team to achieving high quality.

Ensuring patient satisfaction is the ultimate goal of a quality assurance program that entails
delivering patient-centered care while adhering to efficient protocols and standards. According to
the Institute of Medicine, patient-centered care involves providing respectful and personalized
care that aligns with the unique preferences, needs, and values of each patient, while ensuring
that their values inform all clinical decisions. An alternative approach is shared decision-making,
whereby clinicians and patients collaborate to make informed decisions based on the best
available evidence. The concept of patient satisfaction is complex and not clearly defined, as it is
subjective and influenced by multiple factors. Most studies exploring the relationship between
service quality components have been conducted in developed countries, which may not be
applicable to developing countries due to cultural differences. In choosing a dentist, patients
generally prioritize the overall quality of service provided as a significant factor.

In order to enhance the effectiveness of healthcare quality management systems, a range of tools
can be utilized. These may include conducting internal quality audits, seeking input from
stakeholders, and implementing corrective/preventive measures to meet relevant standards. The
successful execution of these actions is aided by the integration of IT-based Health Management
Information Systems and strong leadership. The most commonly employed approach to achieve
continuous quality improvement in healthcare is the four-stage quality model, also known as the
Deming Cycle or Plan-Do-Check-Act (PDCA) (Fig. 1). Additional techniques such as Six
Sigma, Lean, and Total Quality Management (TQM) are also applied. To determine patient
requirements or enhance their satisfaction with healthcare services, the Kano model is employed.
To ensure quality control, well-defined protocols in line with standard operating procedures and
ongoing staff training are implemented internally, while accreditation serves as an external
evaluation of quality.

How we can see a Quality management system in healthcare institutions in Ethiopia?

Ethiopia has made significant progress in providing healthcare access to its entire population.
However, with this achievement comes the added responsibility of planning, improving, and
controlling the quality of care being delivered to ensure equity. The country defines quality care
as comprehensive, safe, effective, patient-centered, timely, affordable, and efficiently utilizing
resources and services. Over the past two decades, the Federal Ministry of Health (FMOH) in
Ethiopia has prioritized enhancing the quality of care, as seen in the Health Sector Development.

The Ethiopian Hospitals Management Initiative, established in 2006, is an innovative approach

to introducing standardized quality practices. In 2011, the hospital reform was supported by the
implementation of Key Performance Indicators for hospitals, as outlined in the hospital
performance monitoring and improvement guideline. The Ethiopian Hospitals Alliance for
Quality (EHAQ) and Clean and Safe Hospitals Initiative (CASH) are based on the experiences
gained from implementing the Ethiopian Hospital Reform Implementation Guidelines. Quality is
of utmost importance in the healthcare industry as it is responsible for maintaining and caring for
the community's health. Hospitals are an integral part of the healthcare system, and despite their
small number, they are considered the most significant element as a substantial portion of
healthcare spending is attributed to them.

LITERATURE

What does the literature say on quality management systems in healthcare institutions?

2.1 What is Quality Management?

Quality management (QM), as a new management model, changed the focus of the analysis of
product or service to a quality system conception, and it influences the organizational culture as
attitude and behavior changes are now required towards performance commitment, self-control,
and process enhancement. It is defined as the application of a quality management system in
managing a process to achieve maximum customer satisfaction at the lowest overall cost to the
organization while continuing to improve the process. Total quality management (TQM) can be
defined as a management approach to long-term success through customer satisfaction. It
emphasizes both process and outcome and requires a dramatic shift in many established
healthcare management values and concepts.

QM is based on the following concepts:

1. It is important that any changes made in a service or product are based on the needs of the
customer, rather than the values of the provider. If there is a lack of achievement, it is
likely due to a system failure, rather than individual performance. As a result, problem-
solving efforts should focus on the process and joint responsibility, rather than just
improving individual output. Decisions for improvement should come from those who
provide the service or product, rather than solely from top management. The focus should
be on continuous improvement, rather than simply meeting a specific standard.
 2. Starting with a basic concept and the belief that all things can be enhanced, Quality
Management (QM) comprises a philosophy and a collection of principles and practices
that serve as the basis for an ever-improving entity. QM combines essential management
approaches, ongoing improvement initiatives, forward-thinking quality strategies,
innovative ideas, and their effective execution.

3. The concept of QMS was initially introduced in the manufacturing sector during the early
1980s and later adopted by the service sector, including healthcare. QM has gained wide
acceptance in healthcare institutions for various reasons. In recent years, several
healthcare institutions have implemented the principles and practices of QM to address
the issues they are currently encountering.

4. Quality management (QM) is an essential component of a well-functioning organization,

but it's not the only factor. Running a successful business requires a solid strategy and
effective decision-making skills. However, QM can help align the organization with its
strategy and mobilize resources to ensure its success.

2.2 Quality Management in Healthcare

During the 1860s, Florence Nightingale VI played a pivotal role in establishing quality assurance
programs by advocating for a consistent system for collecting and assessing hospital statistics. In
1910, Abraham Flexner's report unveiled the substandard quality of medical education in the
USA. Dr. E.A. Codman was a key figure in evaluating quality, particularly through his 1914
study on the outcome of care. His study highlighted current concerns regarding the quality of
care, such as the necessity of licensure or certification for providers, the accreditation of
institutions, the severity or stage of the disease, co-morbidity, the patient's health and illness
behavior, and economic barriers to access care.

Quality Management Systems (QMS) in healthcare were initially developed from industrial
experience. However, implementing the same concepts in the healthcare industry may not be
effective. While some believe that the healthcare industry is similar to any other organization or
industry, a closer look reveals five significant differences. These include a stronger connection to
politics, a more complicated organizational structure, and unique characteristics such as
intangibility, heterogeneity, inseparability, perishability, labor-intensive, and a credence product.
Additionally, the industry's objective is continually changing, and its environment is under
constant pressure from concurrent government changes. Finally, differences in the perceptions,
values, and work ethic of healthcare providers further contribute to the industry's uniqueness.

It is crucial to acknowledge the variations between industries in order to effectively establish and
advance a Total Quality Management (TQM) system in healthcare. Simply transplanting TQM
practices into healthcare would be unwise, given the unique challenges and distinctions that
exist. Therefore, it is the responsibility of quality professionals in the healthcare sector to
establish their own principles, philosophies, and techniques that align with the specific quality
standards of their industry.

In the context of healthcare, Total Quality Management (TQM) refers to achieving satisfaction
among patients, doctors, nurses, suppliers, and other stakeholders through effective planning,
programs, policies, and strategies, while efficiently utilizing all resources within a hospital
setting. The goal of TQM in the healthcare sector is to prioritize patient satisfaction, foster
continuous improvement, encourage teamwork, manage processes and systems, establish a
strong organizational culture and structure, and secure commitment from management and
supportive leadership.

Providing quality healthcare is a complex and challenging task for organizations and
governments alike. Total Quality Management (TQM) is a method used by healthcare providers
to improve the effectiveness, flexibility, and competitiveness of their facilities and services.
TQM also aims to reduce waste by involving everyone in the process of improving the way
things are done.

In recent decades, quality assurance has become a major concern for healthcare organizations. It
is not only a requirement for economic survival due to the increasing demands of consumers, but
also an ethical, legal, and social matter that revolves around customer satisfaction and
minimizing health-related risks to an acceptable level.
2.3 Factors affecting quality management system implementation

Numerous studies have identified managerial approach and behavior as significant factor in
Quality Management Systems (QMS). Inspiring managers can facilitate the adoption of a
quality-oriented culture and mindset among employees, leading to the ongoing implementation
of Total Quality Management (TQM). Conversely, a lack of support from top management can
hinder the implementation of quality approaches in organizations, ultimately impacting customer
satisfaction by establishing quality management system

Managers can utilize models to design an effective quality management system that can lead to
success in the current situation. Additionally, hospital officials can prioritize corrective actions
and create improvement strategies with the help of these models.

A study was conducted in a Saudi healthcare setting to examine the positive impact of
organizational culture on Quality Management (QM) in hospitals. The findings revealed that
organizational culture plays a critical role in the implementation of QM by promoting
recognition and acknowledgment of quality practices, initiatives, and experiences among
employees. It also helps to reduce resistance to change, resulting in a more seamless application
of QM. Additionally, empowering employees with quality care responsibility and encouraging
their participation in quality teamwork, such as quality circles and quality committees, was found
to significantly increase job involvement, job satisfaction, career satisfaction, and organizational
commitment, all of which are crucial for effective QMS involvement.

According to a study, ensuring staff receives quality training, both internal and external, and
regularly informing them of new practices related to emerging quality issues, involving
employees in planning and scheduling activities, and promoting communication with clients are
all critical factors for the success of a QMS.

A study has been conducted to examine the factors that affect the implementation of Quality
Management Systems (QMS) in hospitals. The study identified staff resistance among those who
have been working in the hospital for a long time, the lack of standard methods, and limited time
for QMS activities such as meetings and document writing. Additionally, the study highlighted
the negative attitude of staff towards documenting procedures, especially in nursing, due to
perceived time-wasting when feeding systems instead of providing direct patient care. Despite
this, establishing and formalizing working procedures were identified as crucial factors in
implementing QMS. From a constant quality perspective, investments in assessments and
monitoring are necessary to prevent healthcare mistakes. It is impossible to manage something
effectively and efficiently if one does not have a good understanding of it.

Quality management system in the case of Yeka Abado Healthcare

Center
Yeka Abado Healthcare Center was established in 2017 by the Bureau of Addis Ababa Health
Office in 2010 and is presently under its supervision. The facility is quickly developing and
expanding its services in a short period of time. The primary objectives of the healthcare center
are to provide primary and emergency treatment and to create public awareness among the
people residing in the surrounding area.

From what we have observed, the institution appears to be situated near Yeka Abado
Condominium and covers a sizable area. They have a well-defined process map for their patients,
including estimated treatment times. The list of services they offer has been posted for customers
seeking their assistance, allowing them to understand the types of services available. The waiting
area is spacious and clean, with ample seating and a television for entertainment. Additionally,
the ramp for the upstairs area is well-organized and makes it easy to push or pull a wheelchair.

The compound management is impressive with well-organized spaces, beautifully planted

gardens, a well-furnished pharmacy store, a well-designed office for the human resource
manager and medical director, and a meticulously organized record room supported by a digital
data system.

According to the study, Yeka Abado healthcare center has only partially implemented its quality
management system. The research identified five variables that are significantly associated with
the institution's quality management system. These variables include the availability of a
functional quality committee, regular and standardized monitoring of employee quality
improvement activities, clear communication of the quality mission, training for managers on the
value of the quality management system, and employee perception of the significance of quality.
It was found that the implementation of the quality management system in the institution is still
significantly associated with these variables.

The study has found that the implementation of QMS is lacking in several areas. Overall, the
findings suggest that institution management needs to focus on communicating the mission and
importance of QMS, allocating specific budgets for QI activities, improving the employee
monitoring system, and providing support to quality committees to achieve successful QMS
implementation.

It is possible to explain the aforementioned outcome as a consequence of the fact that quality
management tends to flourish more efficiently in smaller healthcare organizations. These
institutions are characterized by less bureaucracy and are more conducive to the employee
empowerment approach to quality management. Additionally, QMS-related tasks are typically
more narrowly defined in small organizations as opposed to larger ones.
The study found a significant association between the quality management system and
managerial training on the system. It was observed that managers who undergo QMS training
have a better understanding of the system and are better equipped to implement it effectively,
taking into account the context and culture of the hospital. Additionally, the qualitative study
revealed that top managerial commitment towards QMS is a major determinant factor in its
successful implementation in healthcare.

The findings of this study reveal that a systematic and standardized monitoring system for
professional activities related to quality improvement is significantly associated with the
implementation of a quality management system. Additionally, the study suggests that an
employee monitoring system is a determining factor for the participation of professionals in
qualitative studies. These results can be attributed to the fact that the presence of such systems
can enhance the involvement of professionals in quality improvement activities, which is a
crucial driver for the implementation of a QMS. Moreover, both the quantitative and qualitative
findings indicate that budget allocation for quality improvement activities is a key determinant
for QMS implementation. Specifically, the quantitative study found a significant association
between budget allocation and the implementation of a quality management system, which can
be explained by the fact that a specified budget for QI activities facilitates the implementation of
the system.
We have conducted a study in the organization called Yeka Abado, Woreda 14 healthcare center
as we stated in previous paragraphs. Yeka Abado is a large public condominium in the city with
a total population of close to 100,000.

We prepared interviews and site observations for the healthcare center to collect relevant data to
translate into pieces of information. It has the same positive result to implement QMS among
those who try to put job standardized flow chart posted in the front position. Another opportunity
for improvement they put an external customer feedback collection system for every section. The
healthcare center has above 105 employees 90% of whom are health professionals. We
interviewed 28 employees based on general questions which will be raised in the healthcare
institution regarding the quality management system. The interview and questionnaire results are
mentioned in the table below.

activity Yes No They don’t know

qty % qty % qty %
The center has Budget 19 6 3
quality
Awareness QMS 22 3 3
Center’s Mission on 25 0 3
quality
Departmental 15
monitoring
Quality committee 20 5 3
Employee monitoring 28 0 0
Employee training 5 20 3
Managerial training 4 21 3

From the study results, we observed that top leadership commitment is critical to the
implementation of QMS in the center. As we know that the organization’s management needs to
establish a leadership that will guide the quality change initiative process. The findings of the
study indicate that the employee training program on QMS significantly influences the
implementation of the Quality Management system at Yeka Abad healthcare center. Training of
the staff is of the utmost requirement for the success of QMS implementation. Training the
employees provides them with the required knowledge on quality and the important information
about the organization’s quality mission, vision, core values, and other general required
information.

It is crucial to train staff in quality management to ensure high-quality service delivery. This
provides them with an understanding of QMS processes and the necessary skills to participate in
the program. In addition, research has shown that organizational culture has a significant impact
on the implementation of Quality Management at the center. The study's findings indicate that
the organization's culture affects the implementation of the Quality Management system in
several ways.

Moreover, effective communication has a significant impact on the implementation of Quality

Management at YAHC. The study found that communication allowed stakeholders inside and
outside the organization to gain a deeper understanding of quality and how it can be managed. It
is essential to include all players in quality management and ensure the top management's
involvement in Quality Management. This aligns with Deming's theory, which emphasizes the
importance of top leadership commitment, positive corporate culture, staff education, training,
and effective communication channels in implementing QMS in any organization.

Recommendation

To Yeka abado health care

➢ The center management should focus on communicating how the center’s quality mission
with stakeholders and professionals across the whole organization.

➢ YAHC management should give attention to how to escalate training opportunities for quality
members and professionals on Quality and quality-related issues.
➢ Highly focus on strategies on how to improve quality improvement and how to provide
patient-focused care and a compliant receiving and analysis system.

➢ The CENTER should allocate a specified budget for a quality improvement system and give
awareness to professionals on how to improve their hospital quality.

To Addis Ababa Health Bureau and Federal Ministry of Health

➢ Strengthen and follow HEALTH CENTERS’ quality implementation status through external
audit and also give technical support.

➢ Facilitate and arrange training schedules for managers on quality and quality members to
ensure that all sides of the CENTERS, the organizational structure, management style, training,
communications, compensation and promotion systems, and systems, procedures, and processes
reflect QM values and principles.

➢ Also, they have to decide the cut point for the standards to say whether the quality was
implemented or not.

Reference

1. Ethiopian federal democratic republic of Ethiopia. Ethiopian national health care quality

strategy: transforming the quality health care in Ethiopia, 2016-2020.

2. Ethiopian federal democratic republic Ministry of health, Ethiopia hospital management

initiatives: Ethiopian hospital reform implementation guidelines.2012, 2, 2012.

3. Elizabeth., Kari A. H, Laura A. R Hospital quality improvement in Ethiopia:

A partnership–mentoring model. International Journal for Quality in Health Care 2008;

Volume 20, Number 6: pp. 392–399

Our group a first year master of quality and productivity students at Saint Marry

University. We brought this questioner to you to assess implementation of quality management

system in Yeka Abado health center. Therefore your honest and genuine participation by
responding the questions is highly appreciated and helpful to attain the study objective. You may
have your own contribution to the success of this study. Your name will not be written on this
form and no individual response will be reported to anybody. Hence, your answers are
completely confidential. You don’t have to answer any question that you don’t want to answer
and you may refuse to answer all of the questions.

Part one : Background information

1. Profession of the participant?

1. Physician

2. Health officer

3. Nurse

4. Midwife

5. Laboratory technician

6. Pharmacist

7. Other……………………………………….

2. Sex

A. Male

B. Female

3. Age …………………………………

4. . Educational background?

1. Diploma

2. Degree

3. Msc and above

Other…………………………………

questions Yes no I don’t

know
6. Mission regarding quality care delivery

7. Quality plan of the hospital

8. Departmental quality plan

9. Budget for quality improvement