Background

Guangzhou concord cancer Centre (GCCC) is a comprehensive cancer hospital specializing in cancer diagnosis and treatment, prevention, research, and training in addition to proton therapy expertise. It is committed to, and has actively driven, innovation in quality and patient safety improvements. GCCC also has strong ties to the research and academic quality and patient safety community through the world-class well established healthcare facility like Mayo Clinic and MDA Cancer Centre for Quality Improvement & Patient Safety as well as our Practice Based Research & Innovation (PBRI) program. Excellence is the guidepost for our commitment to performance improvement, patient safety as well as excellent patient experience.

Concept of Quality for international research and misconception in some health sectors

A Review of literature was conducted by using the key words “Healthcare Quality” “Patient Experience” Healthcare Operation”, we realized that there is no consensus has been reached among scholars on the definition of quality management，however, its current interpretation is to manage the process of care [1]. Different author defines quality in different ways even well-established scholars have different understanding and concept of quality, the reason for such debate is lacking of consensus on how to define it [2].

The best practice for quality entails the medical services/ products that meet patient basic needs and expectations. Another definition however incorporated both specification and customer satisfaction simultaneously [3,4]. Most of understandable concepts of quality management measuring model is referred as structure process and outcome [5].

However, the current situation in some healthcare sectors in China do not have the overview picture of systematic quality improvement program, until 2005 ministry of health published a guideline stated there must be two prongs of approach for quality management mechanism which is hospital and departmental level quality improvement program. Studies showed most of the hospitals in China still do not have an independent quality department, instead, medical affair, infection control departments and nursing service are utilized to develop separated quality improvement activities [6]. There is lacking comprehensive quality improvement yearly plan not to mention long term quality improvement goals and objectives. The primary task of quality improvement activity is simply focusing on medical record documentation, research showed the main obstacles for healthcare sectors are: no SMART (Specific Measurable Achievable Relevant Time-bounded) quality metrics based on organization strategic direction or best practice on selection of key quality indicators; the quality improvement method is purely random audit rather than systematic approach utilizing quality improvement tools; no hospital vulnerability study to identify risk nor risk management program; But emphasizing individual performance rather than hospital quality performance as well as focusing code of professional conduct only [6].

Developing a long-term yearly quality planning

It is a new undertaking for most of organizations to develop a multi-year quality plan, as so many hospitals are mainly focusing on a one-year horizon rather than 5-to-10-year projection. Moreover, we all know that majority of the quality initiatives require resources and an organizational culture change senior leadership behavior change which so often requires an incremental approach, therefore, quality improvement achievement cannot reasonably be attained in a single year. Also, if the desired performance target is unrealistic, it will be even more challenging to achieve from the short span of a one-year step. To be able to accomplish a longer vision organization need to include the longer-term view of organizational strategic plans priorities and directions.

Strategies and Directions

Hospital organizational structures are differed from one another based on the culture mission vision core value and leadership. But successful organizational structures consider characteristics such as connection to strong senior and board leadership [7].

We aim to promote patient centered care model and support the sustainable provision of safe, effective, and efficient care, equitably delivered by competent providers in response to patient needs, preferences, and values. Our expectations are well outlined and driven by the expectation of advancing quality excellence in GCCC.

Structure Governance Leadership Direction and Culture

Quality is not a standalone component it is always integrated into care delivered and customer’s experience. Achieving best possible outcome for patient while exceeding experience and services are primary concerns. [8] To provide an excellent care and patient experience require a high performing teams that can provide personalized and precised safe treatment, and to become such team that requires an effective leadership and effective leadership requires the understanding the various roles and responsibilities and authority of individuals in organization and how those individuals work together as an effective team in a collaboration manner, collectively and individually to serve as a key structural entity to maximize the value by matching up mission and vision to quality and patient population the organization intends to serve. [9]

Senior leaders sit at the top of a corporation’s organizational chart, and their leadership helps set the direction of the organization and guide quality-improvement planning and efforts allocate resources to facilitate the whole system wide improvement programs. Many studies found an adherent link between leadership and commitment to a quality-improvement processes overcome perceived obstacles and communications barriers among organization. In particular, the ingratiation of all quality management and initiatives results in tangible patient outcomes. All quality improvement plan should be approved by hospital safety and quality committee where safety culture forester and endorsed by Chief Executive officer or hospital present in our case. Quality Improvement programs are led by delegated quality director and implementation plan are executed by all other departments of the organization and performance are overseen by quality and safety committee.

Studies further shows that top management’s physical presence, visibility and concern for quality improvement were associated with transformational leadership and demonstrated that leadership directly impacts the commitment of an organization to quality improvement. GCCC adopted periodic senior leadership rounding to encourage patient and staff to speak up both positive and negative feedback so that we are not only be able to identify improvement opportunities but also enhance staff and patient satisfaction in the spirit of nurturing safety culture. The definition of safety culture involves the interaction of attitudes, beliefs, and behaviors of members of the workforce that influence their commitment to organization’s safety management. [10] Common interpretation is “The way things are done around here” [11] probably is more meaningful.

Positive safety cultures in health care have strong leadership to drive and prioritize the safety of all. Commitment from leadership and management in this context is important because their actions and attitudes influence the perceptions, attitudes, and behaviors of members of the workforce throughout the organization. [12]

Apart from sound leadership that drive safety culture, strong commitment to safety culture nurtures the acknowledgement that things can go wrong, and mistakes can be made in workforce, so the ability to recognize, respond to or give feedback about and be heard is prominent for safety and quality improvement in healthcare organizations.

Clinical governance is of equivalent importance to financial, risk and other business governance and it is usually run by a group of experts sitting in hospital committee or sub-committees with strong academic qualification and abundant leadership skills as well as experience to govern organization to cautiously choose the right person to do the right thing at the right time with the right materials and methodology. This robot system involves in a complex set of leadership behaviors, policies, procedures and monitoring the improvement mechanisms that are directed towards ensuring good clinical outcomes. As such, the clinical governance system or structure need to be conceptualized within corporate governance system. As Guangzhou Concord Cancer Centre is adopting such model which means the chairman of hospital safety and quality committee and the head of hospital quality safety department are also remembers of corporate subquality committee member. This is called a system within a system that is clinical governance system within corporate governance system. [13] In addition, high performance hospitals often have a well-designed pivotal internal structure and external governance entity to support quality improvement. Normal external structure refers an entity or processes impact hospital which has no control of. The example is local ministry of health accreditation as well as corporate managing board expectations. However, the internal structure refers hospital quality improvement committee and subcommittees or organizational chart that reflects the functionalities of each department.

There are normally four levels of hospital leadership hierarchy [14], please refer the figure1

Structure, Governance Leadership and Direction

Goals & Objectives

Study shows that some organizations struggle with a desire to address so many improvement opportunities at one time, recommendation is however, the effort to attain cultural change and sustainability can be considerable and focus on a small number of goals guided by SMART mnemonic, that is Specific, Mensurable/Meaningful, Achievable, Relevant/Result-oriented and Time-bounded, may have more impact in the end than a broad set of goals and objectives that overwhelm the organization.

Strategic Quality Goals: 3S

Quality Strategic Plan advances the quality aspects of the hospital’s strategic directions and elevates three specific goals that are core to achieving quality excellence. The three goals of our quality plan are 3S which are Safe Care, Seamless Care, Sustainable Care, which meet Joint Commission International requirement for safety and continuous quality improvement expectation.

Safe care: We will provide care that keeps our patients and providers safe.

Seamless care: We will ensure seamless transitions in care for our patients

Sustainable care: We will focus on ensuring that the services that are available for our patients today continue to be available in the future.

Three important enablers (quality culture, digital health, and advanced analytics) have been identified as essential elements to advance our three strategic quality objectives. Strengthening our capability in each of these areas will be vital not only to achieve our goals but to support all quality improvement work at Concord Medical Annual priorities based on the above quality goals and enablers will be identified yearly for implementation.

Quality culture: We will continue to develop the people, skills, conditions, and systems to enable continuous quality improvement and safety.

Digital health: We will use interactive information and communication technologies to build a virtual health network with and for our patients.

Advanced analytics: We will use new and innovative data analysis and reporting tools to support evidence-informed quality improvement. All operational strategies and critical decisions should be made based on data rather than passion or preferences.

Strategic Operational Objectives: 3E

Healthcare operations in its most fundamental approach are no different from operations in other industries. Conceptually, ‘operations’ should be viewed as a process of value creation and ‘value’ must be defined from the perspective of the ‘customer’. The objective of a structured approach to operating system is 3E to ensure that all operating processes attains the highest possible level of EFFICIENCY; ensure that all operating processes is EFFECTIVE in delivering the operation objectives; and ensure that all operating processes create the EXPERIENCE that customers prefer.

Selection of Quality framework And Performance Monitoring Indicators

A good performance hospital always develops a system approach tracking performance indicators against aligned quality goals, it is also deemed as crucial aspect of quality plan and one of the most challenging component to complete. Quality department head or chief quality officer in the hospital always serves as an expert of the field to identify indicators that will be used to measure progress of performance requires thoughtful consideration of many factors.

There are several models to measure quality permanence in healthcare service, the first person Donabedian, the developer of the Model of Care [15,16], is recognized as the first person to have made a study of quality in healthcare. Specifically referring to healthcare services, Donabedian [17] stated that the possibility of quality of healthcare improvement depended on both the technical and interpersonal quality of healthcare services. Technical care is about the medical treatment aspects of patient care, while interpersonal care is about communicating with the patient about his or her treatment [18]. Donabedian proposed using a set of three connected items together, namely, structure, process, and outcome to measure the quality of healthcare service. Accordingly, he defined structure as the facility settings, qualifications of providers and managerial systems which often times refereed as available hospital resources through which clinical services can take place. Whereas the process is the activity put into healthcare practice, and outcome refers to returning to its initial position or survival of the patients. [19] It is important to include structure, process and outcome measures in a Quality Plan in order to measure the success of improvements made across the spectrum. By reviewing specific and targeted activities, it is easier to get an idea of where weaknesses may exist and to target them as part of a concentrated approach.

Measures should be significantly influenced by the availability of reliable data follows the ACCURATE principle.

A: Actionable/Accurate

C: Complete

C: Cost-effective

U: Understandable

R: Relevant

A: Accessible

T: Timely

E: Evidence-based

Best practice recommended to have fewer indicators that are strong and reliable which have credibility with stakeholders than introduce too many metrics. Consideration should be given when select the metrics due to different perspectives of different stakeholders and their definitions of quality improvement. A commonly used framework is to classify all indicators as high level which is institutional-wide to measure the overall organizational performance and its effectiveness of whole system strategies, they usually are more outcome-driven operationalization. Whereas the measurement of hospital committees and Senior Executive Team responsibilities are often specific and targeted activities and progresses which includes measures of outcome, process and structure mostly refers resources used by the hospital to deliver programs and services to patients.

After literature review the fact is there are different models available for measuring quality in healthcare organization, one should choose the most appropriate model that would be in accordance with the unique nature of the services in each organization. It was confirmed in the literature that every country, and even every healthcare service organization, should have its own framework for measuring the quality of healthcare service.

The most recent healthcare literature focuses on the development of quality frameworks that incorporate various dimensions of care. These dimensions include access, safety, efficiency, effectiveness, and patient centeredness, among others. Most frameworks are guided by alignment with organizational strategy, evidence-based, supported by strong leadership, and aimed at promoting excellence in all levels of an organization (Caramanica et al. 2003). In reviewing of GCCC’s strategic direction, quality and operational approach we decided to adopt IOM’s (Institution of medicine) six domains of quality performance as ultimate key performance measuring framework for excellence, STEEEP entails the followings:

Safety — no needless death, injury, pain or suffering for patients or staff.

Timeliness — waste no one’s time; no unnecessary waiting.

Effectiveness — care and service will be based on best evidence, reflected by patient values and preferences

Efficiency — remove all unnecessary processes or steps in a process; streamline all activities.

Equity — all care and service will be fair and equitable — the system will treat all patients equally.

Patient Centeredness — all care and service will honor the individual patients — their values, choices，culture, social context and specific needs.

Quality Management Methodology: FOCUS-PDSA

GCCC approaches to quality improvement and patient safety in compliance with the JCIA (Joint Commission International Accreditation) cycle for improving performance: design, monitoring performance through data collection, analyzing performance, and improving and sustaining improved performance.

Find Organize Clarify Uncover Start Plan Do Study/Check Act (FOCUS-PDSA) Model: Whenever GCCC staff are engaged in performance improvement and patient safety initiatives, they must begin by listening to all customers (the voice of the consumer which usually refer to internal and external customers), focus on the processes that these customers experience (the voice of the process), and then use statistical process control methods to evaluate the variation that lives within the processes.

Find: a process improvement opportunity, sources of improvement opportunities:

• Sentinel Events Reports
• Leadership rounding
• Closed Records Audit
• Morbidity and Mortality Reports
• News Media Stories
• Observations

Organize: a team who understands the process

• Identify Internal/ External customers to the process
• Organize a team that knows the process
• Include technical guidance and support people as required

Clarify: the current knowledge of the process

• Identify customer’s needs
• Identify boundaries
• Draw the actual flow of the process
• Identify areas and functions that affect the process
• Identify the best way for the current process to work

Uncover: the root cause of Variation/ Poor outcome

• Identify the major causes of variation or poor quality
• Identify key measurable characteristics
• Identify what, where, when and how the data be collected
• Decide on type of causes “common cause versus special

cause variation

• Find out which cause of variation can be changed to improve the process

Start- The PDSA/PDCA Cycle

• Identify the proposed process portion to be improvement
• Write the mission statement
• Identify the most feasible changes to the process Plan: The Improvement
• Identify what process improvement to be piloted
• Set predictions
• Plan to carry out the cycle (who, what, where, when)
• Plan for data collection

Do: Put the plan into action:

• FOCUS-PDSA

Study: Evaluate and re-evaluate the effectiveness of the plan:

• Analyze the data
• Compare data to predictions
• Summarize what was learned
• Decide whether the process was improved from the

customer’s point of view

Act: Determine what the next steps are to improve performance:

• To hold the gain
• Adopt
• Adjust
• Or abandon the change then, Ø Modify the plan and retest.
• Standardize parts of the process that improved
• Decide on next steps to continuously improving this process

Whether individuals or teams are pursuing improvement, new design or redesign projects or using other acknowledged problem-solving methods including Root Cause Analysis (RCA) and FOCUS-PDSA is the model to be used.

Figure 2: Continuous Quality Improvement Structure in GCCC.

Communication Model

The biggest concern in healthcare service that impact safety and quality is effective communication, it can greatly either help or hinder, and quality improvement management is no difference, as it is well recognized that the quality plan for improvement is aims to inspire, motivate and attain sustained cultural change, it is really imperative that communication with both internal and external stakeholders is equally important, there are various communication tools that are available. Apparently, a well-designed information flow model needs to have visibility and transparency with staff and management at all levels. The below diagram illustrates GCCC information flow model that connecting all level in the organization.

The Quality Information Flow Model

Discussion and Conclusion

The current quality management in China are too narrow, overemphasizing the quality of healthcare quality only as far as the functional aspects of hospital administrative structure, while (external customers-patients) of the services and patient experience were concerned and paying too little attention. Hence, inputs generated from both development of strategic quality plan integrated with patient experience are vital for building an appropriate framework for measuring the quality of healthcare services.

The existing quality management tools can be utilized, however, international quality frameworks and tools might be incongruent with the healthcare context of developing countries because of the cultural and economic differences. But China is blooming economically very rapidly therefore, internal and external customers as well as payers’ expectation are becoming higher. The review was in favor of finding an appropriate tool that not only focusing on financial risk management, but safety quality and patient experience are all integrated when exploring of business opportunities and quality plan. Moreover, there should also be a continued effort to redefine the quality measure model further and to study the complex issues of service quality in the healthcare setting.

In general, generic development of only business plan or short-term quality plan are no longer sufficient for measuring the quality management in healthcare services. It is strongly recommended then that healthcare sectors especially high end private hospital should develop their own approach for long term or multi-years of quality plan for managing monitoring measuring the quality of healthcare services to excel excellence to satisfy both internal customer (staff and patients) and external customers (Payers and vendors or contracted physician)

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