Quality Assurance in Hospital Management: Quality Tools Described With Their Uses

Hospitals if see from out seem to be a place filled with chaos. But there are certain rules, and tools to make the functioning smooth. This article shares the tools with examples. The problems at the hospital are solved with data they have. The data is shaped in right manner for better usage. Let’s understand this with an example. There is a ward that is short on medicine at night. There is an outpatient department where patients have to wait. They have to wait for forty-five minutes before a routine consultation. Then there is discharge summary that requires to be prepared, the slides past noon every day. This might look like a problem, there is delay and waiting , etc that requires to be solved. The seven tools will be used to correct these issues. This is the tip of the iceberg, with deep understanding students get to know about other roles in healthcare.

The seven tools were formalised in industrial quality management and later adopted across healthcare because they share one property: they are simple enough for a frontline team to use without a statistician, yet powerful enough to separate the few causes that matter from the many that do not. At the HOPECON X Jeevan Parul pre-conference workshop, organised by the Parul Institute of Public Health with the Consortium of Accredited Healthcare Organisations (CAHO) and Parul Sevashram Hospital, participants worked through all seven against live hospital cases. This article uses those same healthcare examples.

Before the detail, here is the full set in one place. Each tool answers a different question about a problem.

• Check sheet: a structured tally for collecting data as it happens. Answers: how often, and what kind?
• Pareto chart: a ranked bar chart that shows which few causes create most of the problem. Answers: what should we fix first?
• Cause-and-effect (fishbone) diagram: a branching map of possible causes grouped into categories. Answers: what could be driving this?
• Histogram: a bar chart of how often values fall into ranges. Answers: how is this spread out, and where are the outliers?
• Run chart and control chart: a line of a measure plotted over time. Answers: is this getting better, worse, or staying stable?
• Scatter diagram: paired points showing whether two things move together. Answers: is there a relationship between these two variables?
• Flowchart: a step-by-step map of a process. Answers: where exactly does this process break, loop or hand off?

Healthcare quality has a measurable definition. One framing taught at the workshop reduces it to a single equation: quality equals the performance of the hospital divided by the expectation of the patient. If the score sits above one, the hospital is doing more than the patient expected. A score of exactly one means it is only meeting expectations. Below one is a failure to meet them. The seven tools are how a hospital moves that ratio in the right direction, because they let a team see performance clearly instead of arguing about it from memory.

They also map cleanly onto the work. Check sheets collect the raw field data. Histograms help a team understand the data once it is collected. Pareto charts set the priorities for management. Scatter diagrams, fishbone diagrams and control charts are used for deeper analysis. The flowchart becomes the final output, the new standard operating procedure that locks in an improvement. Knowing which tool does which job is half the skill.

A check sheet is the humblest of the seven and often the first used, because nothing can be improved until it is counted. In the workshop case, a team examined delays at an outpatient registration counter and simply tallied each occurrence as it happened: seven billing queries, six incidents of a slow registration system, five late patient arrivals, three doctor schedule changes and two moments when a counter was unavailable. On its own, each entry is trivial. Together, over a morning shift, the sheet shows which delay category is actually frequent, which is exactly what a team needs before it spends money or staff time fixing the wrong thing.

It is important to know what requires attention first. A Pareto chart works on to rank the causes from most to least frequent. It happens to point out the crucial parts that might have led to the problem.

A hospital analysing delayed discharge summaries across fifty cases found doctor unavailability behind eighteen, pending clinical investigations behind twelve, incomplete documentation behind eight, nursing information delays behind five and pharmacy issues behind four. Ranked visually, the top causes dominate, which tells management where the first intervention should land.

The same logic applies to patient dissatisfaction. In a separate case of four hundred outpatient complaints, long registration time accounted for one hundred and eleven, roughly twenty-eight percent of the total, insufficient available doctors for one hundred, and insufficient counter staff for ninety-three. Addressing only those top three resolved about seventy-six percent of all complaints. That is the point of a Pareto chart: it stops a team from spreading thin effort across ten small issues when three large ones carry most of the burden.

Every diagram or tools has the purpose to show the reason behind delays, errors, etc. This diagram shows the cause-effect hence named as fishbone. It is named fishbone due to its shape. It works on to relating with many causes of a single issue back to categories so that nothing gets missed. The causes help to sort into people, process, environment and technology. This helps to see whether the staff is inadequate, the training given is sufficient or not, fatigue under people, poorly designed drug labels under process or environment. And complex electronic-system errors under technology. It doesn’t point out based on one issue. The errors are laid out on ratio basis, that is nurse to patient ratio.

The timing of tests, and related things requires an approx time. The histogram groups do emphasis on ranges and shows what is the frequency of the each range. It reveals the shape of the process. The timings are observed from the 30 laboratory turnaround time. A team could see that most of the tests get completed between fifty to seventy minutes. Where 12 observations are there in the fifty-to-fifty-nine range and seven in the sixty to sixty nine range. There is long right hand tail stretching toward one hundred and twenty-nine minutes. This is just an example but a lab usually takes an hour but the result is usually given after twice as long. There is a specific, investigable failure hiding in the tail.

Hygiene is the most important thing that any healthcare center shall have. The purpose of run chart is to measure time. The control chart puts up the statistical limits to separate normal variation from a real signal. Hand hygiene was maintained for 12 weeks. Along with a unit seeing the figure going up from 82% in week one to 90% by 12th week. When the percentage is increasing, we can see the infection control steps are working smoothly. Rather than just sitting and thinking that it will work out or not.

The clinical labs are the specialised versions. The Levey-Jennings chart tracks daily quality checks. It focuses on finding any deviation beyond three standard deviations. As soon it reaches beyond three the machine flags it. After getting to know the issue, it needs to be solved as early as possible, before patients’ results come out.

A scatter diagram is something that explains observations with two variables and whether they move together. Here the number of daily outpatients are linked to average time required, a team maintains one hundred and twenty visits. This takes around 18 minutes of waiting for patients. When the visit increases that is when the visits are 175 the waiting time also increases coming around 24 mins.

And during peak times, the waiting increases upto 38 min when patients are 270. The workshop also discussed the discipline that builds a good work, good analyst from a careless one. Where association is not causation. Waiting time also depends upon how many doctors are on duty. Hence, we understand that a scatter diagram shows the cause rather than proving one.

Every flowchart shows step-by-step processes. Here, the discharge process is shown from start to end. It starts with the doctor’s decision and approval that the patient is fit. Once the check is given by the doctor the patient might be consulted through medication. Then comes billing and counselling. Through this, the fallouts or delays can be found out and corrected. The functions are cross-departmental. The nurse ward, clinical pharmacologist, the pharmacy and billing all have to go in sequence and this where flowchart helps a lot for smooth functioning.

Also Read: PDCA and PDSA tools used for Quality Improvement.

Yes, the tools do fit together. There are seven quality control tools. They go hand in hand. You cannot pick one for smooth functioning. As we look or dig deeper the functions start with teams collecting a check sheet, understanding the spread sheet with a histogram. Where importance is pointed out through a Pareto chart.Using a fishbone diagram and scatter diagram causes are found out. The stability is measured through a control chart and standardises the fix with a flowchart. These functions are looked by the bodies who give accreditation.

Students working with these tools, or processes get to learn how an actual hospital functions. They get an idea of healthcare operations and they get habituated before entering the real scenarios.

The seven tools sit inside the quality-management teaching at the Parul Institute of Public Health, and the HOPECON X Jeevan Parul workshop that supplied the examples in this article was run for Master of Hospital Administration scholars alongside the Consortium of Accredited Healthcare Organisations and Parul Sevashram Hospital. Parul University is NAAC A++ accredited with a 3.55 CGPA, and its healthcare teaching is anchored by a working hospital system, which lets students apply quality tools to real processes rather than textbook abstractions. Dr. Geetika Madan Patel, Vice President and Medical Director at Parul University, has consistently framed healthcare quality and patient safety as central to how the university trains the next generation of hospital leaders. Learn about how hospitals work with healthcare management,  hospital administration, and BBA in healthcare management.

The frameworks themselves are public-domain quality-management concepts; at the workshop they were presented by visiting healthcare-quality resource persons including Dr. Dhanya Michael and Dr. Babu Narayanan, with Ms. Payal Thakker, founder of MedmarQ Healthcare and a certified assessor for NABH and NQAS, among the invited experts. Parul University faculty including Dr. Partha Sarthi Ganguly and Dr. Damini Joshi hosted the session.

Also Read: Different Types of Actions Taken For Issues That Have Surfaced or Will Surface.