Approaches To Quality Control, The Toyota Production System, And Health Care Quality Improvement

Differences between Quality Control and Quality Assurance

Deming, Juran and Ishakawa approaches agree that the sole purpose of organizations are to stay in business resulting to stable communities and serving the needs of the community (Hackman & Wageman, 1995). Their works do differ. First difference is in the impact that quality has in organizations. Juran and Ishakawa believed that quality leads to cost reductions as compared to poor workmanship. Deming believes that the production of quality goods and services will merely affect the cost but it is important for the long term running of the business (Hackman & Wageman, 1995). The other difference is related to the running of the organizations. Deming and Juran believe that organizations are interdependent and that problems need to be sorted out by members of the different functional teams. However, Ishakawa holds that cross functional teams should not set the direction of the organisation but rather individual teams need to have their own goals and objectives. According to Ishakawa organizations are less system-oriented (Hackman & Wageman, 1995).

The structures of these approaches differ in that Deming’s approach is characterized by fourteen points of management (Best & Neuhauser, 2005). Juran’s approach is composed of ten steps for quality improvement. Another difference is that they all have different preferred analytical tools. Deming is associated with the PDCA approach. PDCA stands for plan, do, check and act. Juran worked with the Pareto principle that is used to identify main contributors to a problem. Ishikawa is identified with the famously used fishbone diagram that assesses the root causes and effects of a problem (Hackman & Wageman, 1995).

Traditional activities focused on inspection that was carried out at the end of the process (Berwick, 1993). This differs from Deming, Juran and Ishikawa approaches in that these activities occur at every stage of the production process. They are continuous. Another difference is that they seek to understand to underlying production processes while the traditional activities are concerned with the outcomes. Problems in the traditional approaches were attributed to inefficiency of the people. This is contrary to the new approaches that hold that problems arise from poor job design, leadership failures or unclear purposes (Berwick, 1993).One main element is the avoidance and reduction of waste. This is achieved through the production of only needed products which are of the best quality. This leads to a major reduction in costs (Fritze, 2016). Other elements include; hejunka/product levelling, kaizen and standardization. The other elements are kanban or just in time concept and autonomation or jidoka (Fritze, 2016).

Key Elements of the Toyota Production System

Standardization forms the base of the production process as it stipulates the materials, activities and duration to be taken. The just in time concept ensures that the needed materials are available at the needed time. This ensures a progressive process. As the process continues, hejunka allows for its visualisation and identification of problems. This brings about autonomation which ensures the problems are assessed and dealt with. Kaizen can be applied in every stage in order to ensure that quality goods are produced. This brings out the overall waste avoidance and reduction, cost reduction, quality goods and efficient personnel and process (Fritze, 2016).

Toyota has been widely regarded as a leader in quality management for decades and yet since 2009 Toyota has been in serious trouble over quality control, issuing recall notices for millions of vehicles. Explain possible reasons for this failure

First there was a change of focus from quality to growth. This made them to disregard safety and meet the growth standard set in 1998 at 15% (Cole, 2011). Another reason could have been the disbanding of the Customer First task force that was key in the regulation and maintenance of quality of cars produced (Cole, 2011). This reflect that Toyota became more organization oriented rather than customer oriented. There were conflicts between the management. This could be attributed to the problem as Deming did relate poor leadership to being the cause of problems (Best & Neuhauser, 2005). Another reason could be the influence of media which propagated the issue to be more than it was. The more they reported on the recall and the quality problems, the more the public’s perception changed making it hard for Toyota to recover (Cole, 2011).

1. a) What is health care quality?

Health care quality is the provision of good services that help in serving and meeting the needs of the community bringing about both patient and provider satisfaction and a general well being of the society (Luce, Bindman, & Lee, 1994). It is associated with increased quality of life, reduced incidence and prevalence of diseases and decreased mortality.

1. b) Why do these authors consider quality improvement an important aspect of health service management?

Quality improvement is important in health care as it is a vital aspect of the society as it deals with life. Various reasons have been cited for quality improvement. First, Quality improvement brings about an open and supportive culture that facilitates learning. This helps to build a relationship that is characterized by trust, respect and cooperation. It also helps to bring about transparency which ensures that quality services are provided. Another reason is that it ensures integrated care in that it encourages multidisciplinary service provision. Custome/patient participation is key in that it helps the organization to understand his/her needs. It is also important as it brings about provider satisfaction in that it changes the view of one’s job to one that has meaning and brings joy. It also facilitates growth of knowledge and skills through medical education (Leape, et al., 2009).

Necessary Conditions for Quality Improvement

There is a need for leaders to be part and parcel of the improvement action. This is due to the effect and impact they have on organizations. Substantial investment is also needed in quality improvement. The worry on cost shouldn’t be a hindrance as quality helps in the reduction of costs. Respect of the healthcare workers is necessary as it ensure they are motivated and committed to be part of quality improvement as is builds on trust and cooperation. For one to understand the needs of the community/ customer there is need for open dialogue between the producer and the customer. Theoretically grounded tools should be used during assessment so as to ensure only factual information is collected and analysed. There is also need for organizations that facilitate quality improvement. This signifies the structures and managerial approaches should enable this action (Berwick, 1993).

Adverse events (AE) are defined as an injury or complication that is not intentional and causes disability, death or longer hospital stay and is not caused by the disease of the patient but rather healthcare management (de Vries, Ramrattan, Smorenburg, Gouma, & Boermeester, 2008).  

Use the readings provided to describe the commonest types of adverse events. Why do you think there is variation across the studies in the types of adverse events described?

Adverse effects (AEs) can be divided into operative and non-operative. Examples of operative AEs are wound infection, technical complications and surgical failure. Drug complications, diagnostic and therapeutic mishap and procedure examples of non operative AEs (Brennan, et al., 1991). These complications are mainly attributed to negligence which is care that is below the expected standard (Brennan, et al., 1991)

The difference in the epidemiology of AEs could be attributed to a number of reasons. First, there are methodological differences whereby some AEs are included in one study and excluded in another. Another methodological difference is the use of different data collection procedures. There is also definition difference leading to the underestimation of AEs. This was seen in the Harvard study. Insufficient information on outpatient cases leads to the underestimation of AEs. The studies were carried out at different times. Learning and interventions may have been implemented and bring about variation.

Are all adverse events preventable? Explain your answer and provide examples of preventable and non preventable adverse events.

Majority of the effects are preventable as they occur as a result of negligence, physician error and cognitive error. Stringent measures can be put in place to reduce the level of negligence. Physician error and cognitive error can be prevented through effective information and decision support system, collaboration among the staff and provision of protocols. Wound infection is an example of a preventable AE as it occurs through lack of proper cleaning and monitoring. Other examples of preventable AEs are diagnostic mishap and therapeutic mishap that might occur due to lack of information or knowledge.

Variations in Adverse Events across Studies

Some AEs are not preventable. These might have been through lack of knowledge of both the patient and physician or due to unavoidable circumstances. Examples of this are allergic reactions to drugs which the patient had not been exposed to previously and marrow depression as a result of antitumor drugs (Brennan, et al., 1991).

 Read the summary of findings and recommendations from the Bristol and Bundaberg reports and from one other report from the readings above.

3.1 Use a table format to identify common themes or contributing factors to the adverse events described in the Bristol, Bundaberg and one other report.

Themes	Bristol	Bundaberg	Liverpool
Leadership	· Lack of leadership in providing direction regarding the paediatric cardiac surgeries	· Management laxity in assessment before employment · Lack of response after whistle blowing	· Lack of proper procedure for recruitment
Monitoring approaches	· Lack of monitoring systems put in place	· Lack of monitoring approaches	· Lack of accountability and openness · Lack of monitoring system in place
Physician’s competency	· Lack of hospital requirements regarding skills and knowledge and consultants	· Lack of competency to perform surgeries · Negligence	· Lack of proper assessment before decision making · Negligence
Communication between the organization and customers	· Lack of communication to the parents and the public	· Lack of openness and response to Dr. Patel’s negligence and lack of competency	· Lack of communication with the patients regarding the removal of body parts
Standardized care	· There was a lack of standards for paediatric cardiac surgery	· Compromised patient care	· Lack of proper examination · Unethical and illegal withholding of body parts
Organized system	· Lack of cooperation between health care professionals · Lack of facilities to perform open heart surgeries	· Disregarding of information by management · Lack of clinical governance practices	· No proper system to regulate the need of histological examination hence they were overlooked · Lack of premises and equipment for
Safety	· Unsafe practices and lack of resources	· Unsafe practices and negligence	· Carrying out of unethical and illegal practices

Why are causal factors associated with adverse events identified as either systems or individual issues? Why are contributing factors classified as either system or individually based?

Causal and contributing factors are identified as either systems or individual. This helps to provide a better understanding. System factors are issues associated with the structure and leadership of the organization. It looks at resources present at the hospital. This helps one to isolate issues regarding the organization and focus interventions on that. The individual factors are factors that are attributed to either the physician or the patient. These include behaviours, personality, skills, knowledge, motivation and cultural competency.

All of the hospitals that were the subject of inquiries were subject to formal accreditation. Why were the problems identified during the inquiries not identified through accreditation?

First there was a lack of proper guidelines for assessment and recruitment. For institutions that had, they were not followed due to a need and a lax by the management. Secondly, there was a lack of monitoring system in place in these institutions. This led to the lack of accountability and taking responsibility of the health care providers and organization. Lack of openness was another problem in that issues were not articulated. Communication and collaboration between the health care professionals and the patients and family members was lacking. This was profound to the extent of not seeking consent before performing a procedure.

How effective do you think public inquiries are in achieving long term improvement in the quality and safety of health services? Provide some reasons for your answer.

Public enquiries are effective in bring about quality improvement. Public inquiries are important in that they provide an avenue for issues to be discussed. They help create awareness on issues. They are also important in getting organizations to respond to concerns. Like in the case of Bundaberg, it helped the assessment and evaluation of the increased number of deaths. Through public inquiries, causal and contributing factors are identified. This provides a platform to solve the problems and bring about long term improvement in quality and safety of health services.

Preventability of Adverse Events

4.1 What is a ‘blame free’ culture?

It is a culture where individual actors are not responsible for the actions believed to deserve condemnation. It is believed to be the intervention for the uncovering and reduction of errors (Collins, Block, Arnold, & Christakis, 2009).

 4.2 How is a ‘blame free’ culture different from a ‘just culture’? Why is the distinction important?

A blame free culture is associated with highly hierarchical functional systems which inhibits one from speaking out against evils or errors as one is afraid of condemnation. This is associated with an increase in errors (Collins, Block, Arnold, & Christakis, 2009). This is the clear difference with just culture in that in just culture one is free to speak out against errors so that they can be managed and provides a platform for learning and improvement. This change is important as it brings out the clear impact that both cultures have on healthcare.

4.3 Why does Berwick believe that traditional approaches to quality control and quality assurance contribute to a ‘blame culture’?

Traditional quality control and quality assurance hold on to inspection as a measure of quality. This is highly associated with the picking of low quality goods/ services and discarding them while retaining the good quality ones. This also occurs in service production. Healthcare providers feel an intense need to prove their competencies. According to Berwick, blaming is one way of separating oneself from an error or a problem (Berwick, 1989). This contributes to the blame culture in organizations.

 4.4 Why are doctors in particular likely to self blame?

Doctors are guided by the do no harm ethical principle. Aside from this, the medical field has high standards accorded to it due to its life or death nature. This puts a heavy responsibility on the doctor. Just as he is responsible for the health of the patient, he/ she is responsible for the errors that may occur in care provision (Radhakrishna, 2005).

4.5 What quality improvement and quality management activities require an ‘open’ or ‘just’ culture to be effective?

Quality improvement requires a just culture to be effective. This is due to the fact a just culture promotes openness and communication. This is important in error or problem identification allowing for the management and control of errors. A just culture also helps in the reduction of fear from health care providers. Fear is the main cause of the withholding of information by healthcare providers as they are afraid of condemnation and the consequences that will follow (Leape L. L., 1994). A just culture also promotes collaboration among healthcare providers as it allows one to freely share and deliberate upon an issue bringing about effective supportive clinical decision making.

Common Themes in Different Reports regarding Adverse Events

5.1 The use of evidence based health care is often cited as a means of ensuring clinical effectiveness. (McSherry and Pearce, 2007; Wolff and Taylor, 2009). Using the readings provided and your own research, provide examples of how evidence based health care practice (EBP) may improve clinical effectiveness and describe the limitations and criticisms of EBP.

Evidence based health care practice has been defined as’ the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients’ (Timmermans & Mauck, 2005). This is the current trend in health care deliver and it has received a lot of focus internationally. It is the knowledge and skills that health care providers gain through experience and practice. This is also received through research (Sackett, Rosenberg, Muir Gray, Haynes, & Richardson, 1996). Evidence based care is known for its positive outcomes. These include; increased patient safety, improved clinical outcomes, reduce healthcare costs, and decreased patient outcomes variation (Black, Balneaves, Garossino, Puyat, & Qian, 2015).

First, evidence based care (EBC) is associated with the availability of factual information. This information is derived through researches and experience. This helps health care professionals to assess and understand the community’s needs and tailoring their services to meet these needs (Moreno-Casbas, 2015). Information on epidemiology of diseases and conditions, their causes and risk factors is identified and guides the implementation of interventions. This is associated with the general well being of the community. Organizations like World Health Organization and CDC rely on evidence based data in the development of health care guidelines.

EBC is associated with the development and increase of the knowledge base and skills of health care providers (Sackett, Rosenberg, Muir Gray, Haynes, & Richardson, 1996). Data collected informs them on the effective interventions in the management of various conditions. This helps tailor trainings, seminars and conferences where evidence based data is presented. Health care providers are able to find out new changes in the environment and how this influences one’s health. An example of this is the impact of lifestyle change on the prevalence of chronic diseases.

Patient satisfaction is an important outcome of evidence based care. This is also brought about by the implementation of the best proven interventions for the management of various conditions. The interventions implemented have been standardized and evaluated with objective measures (Mullen & Streiner, 2004). This leads to better clinical outcomes and less hospital stays.

It does have some limitations. First it disregards the beliefs and values of the patient. It focuses on the data collected rather than the different needs of the patients. Another limitation is that there some areas where there is insufficiency of data. This affects the implementation of EBC. EBC is criticized for its cookbook approach. This means that interventions are based on the data researched and published rather than on one’s expertise and knowledge (Mullen & Streiner, 2004).

There is general agreement about the need to place patients at the centre of their own care, and at the centre of the health system. At the same time there is also agreement that health care organisations and health care professionals find this difficult. What are the benefits of and barriers to patient/person centred care? In your answer include discussion about how a patient’s cultural background may make a difference to their experience of health care.

Patient centred care has become the new trend in health care where the patient if the main focus of care. It has been associated mainly with both patient and provider satisfaction as the outcomes of its implementation. Patient centred care is highly dependent on the establishment of a therapeutic relationship.

Patient satisfaction is brought about by the inclusion of patient participation and engagement (Coulter & Cleary, 2001). The patient is involved in every step of patient care, i.e. planning, decision making and implementation. This inclusiveness makes the patient to feel respected and dignified. Patient participation has also helped in the fostering of therapeutic relationships between the patient and the health care provider. It is through this relationship that empathy, emotional support and respect are expressed. This builds on mutual trust and cooperation.

Patient centred care is also associated with provider satisfaction. This is important as it brings about motivation and commitment among the health care providers. Patient centered care enables the providers to fully understand the needs, values and preferences of the patient. This results to patient tailored treatment interventions. This is characterized with positive clinical outcomes, increased quality of life and increases adherence to treatment (Consumers Health Forum of Australia, 2016).

Better communication and flow of information has been noted (Coulter, 2006). This is facilitated by the therapeutic relation between the patient and the health care provider. This enables the patient to better understand the condition, risk factors and interventions for management. This also ahs a positive outcome of the adherence rate to treatment by patients.

Patient centred care has faced a number of barriers. The first barrier is organizational structures. A lot of changes have to be mad to both the structure and the working of health care providers. The other barrier is time constraints whereby health care professionals find it hard for them to focus solely on one patient. Professional attitude is the other barriers whereby healthcare professionals find themselves going back to not having interest in the patient’s values and preferences(Moore, Britten, Lydahl, Naldemirci, Elam, & Wolf, 2016).

Cultural differences affect patient centred care. It affects both the patient and the provider. Culture affects language, health seeking behaviour, symptom presentation and also adherence to treatment (Almutairi, 2015). Language differences do affect communication and hinders effective care provision. Culture affects the health seeking behaviour and adherence to treatment in that there are cultures that do not believe in seeking professional advice when sick. As a health care provider, it is paramount to be culturally competent so as to better understand our patients.

What is clinical governance? Why do you think clinical governance is context dependent? From your reading what are some of the barriers to change that organisations will need to address in order to ensure the effective adoption of clinical governance within the organisation? What do you think are the challenges for leaders in achieving successful change? (no more than 500 words)

Clinical governance is defined as a systematic and integrated approach that reviews the responsibility and accountability of clinical activities leading to their quality and safety. This is responsible for positive clinical outcomes and the overall well being (Braithwaite & Travaglia, 2008). Clinical governance is comprised of four approaches that help in the measurement and improvement of quality of health care. The approaches are quality assessment, quality assurance, clinical audit and quality improvement (Buetow & Roland, 1999).

Clinical governance is context dependent. This is brought about by the different organizational culture that exits. Each organisation has its own system and its own goals and objectives to achieve. These two factors determine the running of the organization. The mode of communication, level or risk taking and innovation, degree of central direction, authority hierarchies, competitiveness, person orientation and outcome orientation differ from one organization to another. This makes it difficult for the clinical governance applied in one organization to be applied in another.

For effective clinical governance, organizations need to implement the following changes. First there is need for regulations that limit the amount of risk allowed. This puts a limit in the activities to be done to attain the maximum potential. It allows for the right procedures to be followed. The second barrier is that there is need to have restrictions on the autonomy of providers. This allows for all healthcare providers to put aside their own goals for the goals of the organizations. The other change is to allow for team work rather than working alone. Team work is important as it provides better communication, better flow of information and an effective clinical decision support. This also provides an avenue for monitoring and assessment as the health care providers are able to review each other’s work. There is also a need for system arbitration for clinical malpractice. We should focus on improving the whole system and not the individual. When we create an environment that favours growth of the health professionals, ensure the availability and accessibility of resources and the implementation of both top-down and bottom- up management approach, we are able to have safer and quality care. Lastly there is a need for the simplification of the rules and regulation enacted on the health professionals. His will help to create an environment where they can share and even voice out errors and issues. This will provide a platform for leaning and improving (Amalberti, Auroy, Berwick, & Barach, 2005).

Leaders have a big challenge in achieving successful change. This has been attributed to the time constraints, a need for training courses on quality improvement and monitoring, change in hierarchy levels and interprofessional collaboration. This has made it difficult for the whole system to come to place.

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