PDCA

Introduction

Quality Improvement Project (QIP) is the name used now as an umbrella for all problem-solving activities in the healthcare environment. In the past, this has encompassed terms such as Quality Control Circle (QCC), Quality Improvement Team (QIT), process re-engineering etc imported from non-medical industries using Total Quality Management (TQM), and more recently, 6-Sigma frameworks.
Later, the medical world imported risk management processes such as Root Cause Analysis (RCA), Failure Mode and Effects Analysis (FMEA), and Human Factors Analysis and Classification System (HFACS), often modifying and adapting them to the clinical environment (eg. hospital-FMEA → HFMEA).

Here, on our website, we have struggled through the various stages as they became popular, culminating in our own "Mini-Q" design, which basically is a no-frills approach to quality improvement: just fix-it, using the PDCA-cycle to implement and maintain improvements.

The latest hospital accreditation manual also reflects these trends, and has removed reference to specific frameworks by name (such as Quality Control Circle) or by number (10 projects for A grade), and now simply inspects projects that document improvement (1.4.4).

Instructions for QIP:

• The QIP project should be completed within the period from Jan 1 ~ Oct 31.
• Projects must use the PDCA cycle to implement and followup improvements.
• All methodologies are acceptable: quality control circle (QCC), quality improvement team (QIT), business process management (BPM), re-engineering, FMEA, RCA ...
• Projects must be registered on the IPB website to qualify for the annual contest at that hospital. Because all contests already have money prizes allocated, in principle, individual quality points are not given to the member to avoid double-dipping. However, in order to promote excellence, members who participate in a project that passes the preliminary selection process (uploaded document review and project site inspection) and is selected for the final oral presentation will be eligible for quality points, providing they personally complete their own online member contribution and comment area.
  1. 1. Go the the [TQM/EditQCC §] and create a new QIP by typing in the emp_codes for the members of the team From 2012, only until June 30
     • Any team member may start a new online QIP project (must login first).
       An employee may only be a member of ONE ACTIVE project each year ('Quality is better than Quantity')
     • Any team member may edit the QIP project materials (must login first) up until the final report is uploaded online in October.
     • From 2012, team members must have at least ONE year of work experience.
     • Team members may be added or deleted throughout the course of the project, but employees who resign will be automatically deleted from the date the resignation takes effect.
       The person logged-in and editing team material may not delete himself, since he is the creator of the project; hence the whole project would be lost. (If this situation does arise and the logged-in person needs to leave the project, please contact Panda by email)
     • Teams should consist of a minimum of 3 and a maximum of 11 active members.
     • All hospitals (main Nanguo campus, league hospitals, non-league advisory hospitals) now coordinate using the same system. No longer is a difference made whereby larger hospitals use Quality Control Circles and smaller hospitals use Mini-Q.
  2. 2. During the active period, add to the website material as content becomes available using the structured template: [Topic : Objectives : Methods : Results : Conclusions]. The dates of the edited material will be taken into consideration when assessing the length and continuity (CQI = Continuous Quality Improvement) of the project.
  3. 3. During the month of October but before the active period closes (midnight Oct 31), upload your full document (Word file containing graphics, a group photo, before and after improvement photos, and appropriate references)from the IPB website [Files/Upload].
     • Access will be automatically restricted by the system to cease at midnight Oct 31 or as soon as your file has been uploaded successfully, whichever is earlier.
       Warning: the system will block multiple uploads from the same project, so make sure you only upload your final document after all revisions have been made and ratified by all team members AND after all members have completed their own online comments about the project!
     • Once a project document file has been uploaded successfully, all access to editing functions for that project will cease, and the project will be flagged as 'closed'. Applying the principle that quality comes from 'doing the right thing right the first time', all access to editing functions for that project will cease from then on. Your chance to make any amendments will be during the site visit.
     • The document file must be successfully uploaded for the project to be entered in the annual hospital and league competitions.
  4. 4. Team members may collaborate on the editing of team members and QIP details, but each member must personally complete the final section discussing personal experience. This has two parts:
     • one is asking for an assessment of the member's individual contribution to the project
     • the second is asking for commentary on the scheme as a personal growth experience, mentioning lessons learned and making suggestions for future improvements in the administration.
     • Members may add to their online notes from the start of the project right up until the project document is uploaded as in item 4 above. Online access ceases once the project document has been uploaded successfully.

Exclusions from onsite PDCA reporting

• 5S is manadatory participation by all departments, aiming for a clean pleasant environment at all times. Half-yearly site visits will be conducted at all hospitals without prior notification. Departments are expected to have internal inspection programs on a weekly and monthly basis
• Employee Suggestions should be made through the intranet specialist software, but all completed entries will automatically qualify for the annual contest and be referred to the reviewing judges
• Clinical indicator bundles, Team Resource Management (TRM), Rapid Response Teams (RRT) and other initiatives have their specialist areas elsewhere and do not need to be documented on the PDCA webpage

Annual Contests: Timetable

1. November week 1: preliminary screening of document reports
2. November week 2: site visits of selected projects
3. November week 3: hospital finals - oral presentation and selecting of representatives for the league finals
4. November week 4: league finals - hospital winners compete
5. December week 1: annual Q&S results presentation. League winners on stage.