EVALUATION OF PERFORMANCE & QUALITY

EVALUATION OF
PERFORMANCE &
QUALITY
BY : SANA SAIYED

Approaches to Evaluation of the Success of Quality
Management System
What is QMS : Quality management system :
• It is a collection of business processes focused on achieving quality policy and
quality objectives to meet customer requirements.
• It is expressed as the organizational structure, policies, procedures, processes and
resources needed to implement quality management.

The Evaluation of Outcome impact of QMS can be
internal or External.
INTERNAL EXTERNAL
Statistical:
Comparison of data about Hospital Performance.
(Eg: OPD attendance, volume of investigation, bed occupancy, bed turn over
interval, and the financial performance indicators)
This investigation tell about level of acceptance of facilities by patients and the
level of utilization of service
Involves inspection/survey by external agencies and evaluation in the form of ISO
certification, NABH or JCI accreditation or rating of hospital services by the rating
agencies such as CRISIL.
ISO: International Organization for Standardization
NABH: National Accreditation Board for Hospitals & Healthcare by Providers.
JCI: Joint Commission International
CRISIL: Credit Rating Information Services of India Limited
Audit Based
Evaluating the success through mechanism of internal audit of services.
(Eg: Medical audit, Nursing audit, Equipment audit)
This approach will give a professional view of the extent of quality improvement
in the process of delivery of care as well as equipment efficiency and utilization.
Stastical and audit based approach if carried out sincerely and objectively can be
useful.
Direct Approach – Patient Satisfaction Surveys
Evaluation through a system of regular feed back directly from the patients and is
the most effective approach
Direct feedback from the patients would be the best approach. Evaluation by
external agencies, can have salutary effect in that it validates and lends more
credibility to internal evaluation.

EVALUATION THROUGH STATISTICAL
APPROACH
Steps of Evaluation :
1. Developing suitable criteria and stand for evaluation.
2. Collecting base line data related to criteria before starting the program of quality management.
3. Collecting the data related to criteria after the review period.
4. Comparison with the baseline data collected before the start of start program/review period.
5. Measuring the change (positive/negative) and its extent.
Success of Quality management system in a hospital can be judged by ascertaining the
amount improvement taken place in he quality of services delivered in the hospital. Steps
for process of evaluation involved are mentioned above

The result of Stastical analysis can be validated by the yard sticks most
effective, such as given below :
1. Quality management program in the hospital is patient centric the evaluation objective can be
obtained from the feedback from patients/public in the form of satisfaction surveys and complaints
received.
2. Level of increase in business as shown by the facility utilization statistics and the financial
statistics.
3. Rating by the independent rating agencies.
4. In long run by :
• Reduction of wastage and improvement in utilization leading to decrease in cost of service.
• Improvement in staff satisfaction and morale as reflected in renewed sense of pride and reduction in
employee turnover rate.

CRITERIA AND STANDARDS FOR EVALUATION : INDICATORS FOR
EVALUATION
 Patient Care Related Criteria (Errors, death, negligence, incidence of nosocomial infections, sampling errors,
validation of test)
 Criteria Related to Work Load (Bed occupancy rate, Bed turnover interval, average length of stay, OPD daily
attendance)
 Criteria Related to Promptness of Service (Response time of ambulance during emergency, OPD consultation
time, Complaint of delay in admission or discharge)
 Criteria Related to Performance if Support Services (Incidence of food related complaints, complaint of patients
about lines and HK)
 Criteria Related to Facility Maintenance (Collapse of building, plaster off ceiling/walls, instance of lifts getting
stuck, power failure)

 Criteria Related to Equipment Management ( Equipment requiring breakdown maintenance, complication due to
equipment failure)
 Criteria Related to Safety Management (Accidents of patients/staff/visitors due to trip slip and fall, breach of
physical safety/security of patients)
 Criteria Related to HR Management (Employee turnover rate, employee grievance rate, disciplinary cases,
incident of absenteeism)
 Criteria Related to Legal Compliance ( Faculty compliance rules and regulations)
 Criteria Related to Financial Performance (Daily revenue, P&L Statements, rate of return, ratio analysis)
CONT…

Evaluation through Medical Audit
Objectives :
1. To improve the quality of record generated.
2. To improve the quality of patient care.
3. To stimulate the practice of scientific medicine.
4. To estimate the sub standard practices.
• Medical Audit is also called Peer review or clinical Audit.
• Defined as evaluation of medical care in retrospect through review and analysis of medical records.
• Aim is accessing the quality of care given to the patients as well as the quality of records generated.

Outcome of successful Medical Audit Program:
1. High Quality medical record, complete, correct, and as per the prescribed format.
2. Increased accountability of the staff.
3. Reduction in the incidence of avoidance complications, morbidity and mortality.
4. To suggest the corrective measures.
Process of Medical Audit :
 Medical program must be documented as an integral part of the QMS implemented and all medical/nursing staff
must be fully acquainted with the program.
 The program should have clearly laid down scope and broad guideline about the system of functioning.
 The methodology adopted should be scientific, practical and aimed at yielding concrete results in terms of the
objectives of the program.
 Documentation
 Medical Records department has to ensure that the records required are made available at the date/time fixed.

Indicators of Effectiveness of the Program
1. Improvement in the quality of records generated as assessed from the number of observation by
the committee.
2. Drop in the incidence of the problems studied after the implementation of the corrective
measures.
3. Improvement in the quality of patient care as observed from –
 The decrease in number of observation by the committee
 Decrease in avoidable complication such as site infection death rate, ALS, medication errors.
 Increase in Patient satisfaction rate.

Evaluation Through Nursing Audit
Objectives :
1. To improve the quality of nursing care.
2. To stimulate the practice of safe and scientific nursing.
3. To estimate the substandard nursing practices, if any.
4. To improve the quality of nursing care records.
Nursing audit is the evaluation of quality of nursing care being provided to the patients of
the hospital. The audit of nursing can not only provide evaluation of a very important
component of patient care but can also be a valuable tool for improvement of nursing care
as well as overall quality of patient care.

Process of Implementation of Nursing Audit Program
 A documented policy of making nursing audit an integral part of the quality management system.
 Nursing audit process ,ay include both the quality of nursing documentation as well as the quality of nursing care
provided to the patient.
 There should be a documented (structured) format and all nurses should be trained in generating the records as per
the prescribed format.
 The hospital must have a written protocols on every important activity. procedures applicable to the work of the
nurse.
Indicators of Quality of Nursing Audit Program :
1. Level of Satisfaction of patients/relatives
2. Number of complaints from the physicians.
3. Incidence of medication errors.
4. Incidence of avoidable complication
5. Number of observation by Nursing Audit Committee

Evaluation through Equipment Audit
Benefits of Equipment Audit
1. It can provide critical evaluation of the process of acquisition and utilization of the
equipment's in the organization.
2. It gives information about all equipment's, what are actually operational and what are not.
3. It gives feedback about the causes of non functioning of the equipment.
4. Brings out the defects in the system and lead to possible remedial measures that can be taken.
5. Can lead to optimum resource allocation and utilization and thereby improvement in
satisfaction of staff, patients as well as the management.

Process of Equipment Audit
1. Equipment should be a part of quality management system of hospital.
2. The committee must be constituted by an administrative order and its role, responsibilities functions and working
procedures must be documented.
3. List of the equipment's should be available of the equipment's performing as well as ones with the error.
4. Committee should develop a documented system of functioning.
5. There should be documented criteria and standard of performance by which measurement can be done.
6. The procedure should be documented.
Indicators for Quality of Audit
1. Decrease in the equipment down time
2. Increase in utilization level
3. Decrease in the frequency of breakdown.

Evaluation through Patient Satisfaction Survey
Process :
1. Methodology of Survey (Structured Questionnaire, discharged interview, complaint/suggestion box)
2. Processing of the Survey Feedback.
3. Comparison with the pre determined Standards.
4. Action of Feedback
5. Dissemination of Information to the Staff
6. Periodic (Quarterly) Review of the Satisfaction Level
Feedback from patients/Public through on going program of patient satisfaction survey, can
be a very effective tool for improvement of quality of service and level of satisfaction of
patients. Continuous feedback enables the management to tailor the services to the patients
requirements without much problem and better business and enhanced staff satisfaction is
obtained.

EVALUATION OF PERFORMANCE & QUALITY

EVALUATION OF PERFORMANCE & QUALITY

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