TALK 1

METHODOLOGI
OF QA STUDY

Dr Zaharimah Abdul Kadir
Timbalan Pengarah Perubatan III

Hospital Tuangku Ja’afar
Seremban

QUALITY ASSURANCE CYCLE

Problem
identification

Re- Problem
evaluation Prioritization

of the
Problem

Implement QUALITY Problem
ation of ASSURANCE Analysis
Remedial
Actions CYCLE

Identificati Quality
on of Assuranc
e Study
Remedial
Actions

Introduction

Introduction to subject matter
 The issues
 The equipment
 The present process and its problem

Introduction…Neopuff

 Self-inflating bag is used to provide PPV during
newborn respiratory management at delivery,
most of the time resulting in intubation.

 When HR<60 and/or during respiratory distress
at birth

 Neopuff TM T-piece resuscitator was acquired in
2008, solely for transportation of babies between
centers

Introduction…open access

• Upper GI cancer is the 2nd most lethal
cancer in the world

• Adeno Ca of esophagus – fastest growing
incidence of all cancers

• Poor prognosis due to late presentation
• Early gastric cancer: 5 years survival

rate>90%

QUALITY ASSURANCE CYCLE

Problem identification

Re- Problem
evaluation Prioritization

of the
Problem

Implement QUALITY Problem
ation of ASSURANCE Analysis
Remedial
Actions CYCLE

Identificati Quality
on of Assuranc
e Study
Remedial
Actions

LIST OF OPPORTUNITY FOR
IMPROVEMENT/PROBLEMS

i. Identify a process to improve.
Process: a series of tasks that provide a product or a
service.

ii. Identify the process owner
Process owner: the lowest ranking person that can
authorize a change to a process.

LIST OF OPPORTUNITY FOR
IMPROVEMENT/PROBLEMS

iii. Select a process for improvement: Criteria
• Felt to be important by staff, clients or administration
• Within your control and authority to change
• Benefits of improvement will be greater or equal to the

cost and effort to improve it
• Potential for value/impact
• Data is relatively easy to obtain

QUALITY ASSURANCE CYCLE

Re- Problem Problem Prioritization
evaluation identification
Problem
of the QUALITY Analysis
Problem ASSURANCE

Implement CYCLE
ation of
Remedial
Actions

Identificati Quality
on of Assuranc
e Study
Remedial
Actions

METHODS FOR SELECTING A
PROCESS

• Brainstorming
• Surveys: administration, clients, staff
• Studies
• Prioritization
• Voting
• Multiple voting/nominal group
• Decision matrix

RANKING BY SCORE
1= LOW, 2 = MEDIUM, 3 = HIGH

Problem S M A R T Score

Prioritization

No Problems Votes

Selection of opportunities for improvement

Issues SM A R T Total
26 22 27 28 22 125
Care of cerebral palsy patients 25 23 25 26 25 124

High intubation rate during
newborn
resuscitation:recognizing,
understanding & solving the
conundrum

Audit of hypothermia in newborns 22 19 20 24 17 102
17 18 13 82
Audit of transportation of the 19 15
critically ill child 14 71

Parent satisfaction in NICU 13 13 14 17

Reason for chosen

• Seriousness
• Measurable
• Appropriate
• Remediable
• Timeliness

SERIOUSNESS

Might cause morbidity,
permanent disability and
mortality

Causing stress to patients and
family

Impact on patient, staff,
community and organization’s
image

Seriousness

• Serious adverse effects of invasive intubation
and mechanical ventilation on babies (upper
airway injury, retinopathy of prematurity,
intraventricular heamorrhage) increase risk of
mortality and long term morbidity

• It also increase parental dissatisfaction/anxiety,
nursing care, procedures, costs and length of
stay

Seriousness

• Benign disease of the upper GI and lower GI like polyps,
benign ulcers and inflammatory lesions which if
diagnosed later may lead to patients presenting to ETD
with complication of the disease like colon-toxic
megacolon, perforated gastric ulcer, variceal bleed,
bleeding ulcer and carcinoma.

• Average waiting time from the symptoms to referral till
endoscopy was 6-8 months

• These complications may lead to mortality and morbidity
with prolonged hospital stay and increased health cost.

MEASURABLE

Process clearly defined: starting and ending
points

Indicators identifiable with
problems

Data collected to quantify extent of
problem

Measurable

• Intubation rate of babies < 24 hours of life (%) =

Number of intubated babies x
< 24 hours in delivery room or NICU/SCN
100
Number of babies being resuscitated
with PPV in delivery room

Measurable

• Waiting time is measurable
The waiting time for endoscope is the
time from decision for scope by the
Medical Officer till the time of the
endoscope is done

APPROPRIATE

Related to Objective Improvements
core consistent initiative within

business with our control
organization

al goals

Appropriate

• Neopuff is practiced in many centers as recommended
by Australian and New Zealand Resuscitation Councils

• Open access give chance for healthcare providers
including MO, Family physician and GI endoscopist to be
able to scope earlier, diagnose and treat the lesion
earlier

• Benefit the patients :Early diagnosis leads to early
treatment

REMEDIABLE

Resource Solutions Within the
and are capacity of
expertise possible the group
available

Remediable

• Intubation rate can be reduced by using early CPAP
intervention with Neopuff

• 37% of 104 infants in the early residual functional
capacity intervention (Neopuff) group intubated within 72
hours of age vs 51% of 103 (self-inflating bag)

• Intubation rate of babies <34 weeks reduced significantly
from 63.6% (before application of early CPAP) to 23.8%
(after application of early CPAP)

REMEDIABLE

• Identification of high risk patient using validated
criteria

• The changes in work process is not affecting
many areas of care and personnel

• Reduce the process of referral

TIMELINESS

No current operational, financial
or political issues which might
affect the success of the project

Socially, ethically
acceptable

The whole cycle does not
take very long

TIMELINESS

• Self inflating bag has been used for decades
• Accumulating evidence since 2001 support the

use of Neopuff
• 30 bedded NICU will be operational in WCC
• The issue of delay in diagnosis is seriously

affecting the prognosis therefore it needs to be
addressed immediately

QUALITY ASSURANCE CYCLE

Problem
identification

Re- Problem
evaluation Prioritization

of the QUALITY
Problem ASSURANCE

Implement CYCLE
ation of
Remedial Problem Analysis
Actions

Identificati Quality
on of Assuranc
e Study
Remedial
Actions

QUALITY ASSURANCE CYCLE

Problem
identification

Re- Problem
evaluation Prioritization

of the
Problem

Implement QUALITY Problem
ation of ASSURANCE Analysis
Remedial
Actions CYCLE

Identificati Quality Assurance
on of Study

Remedial
Actions

QA STUDY..

• Systemic verification of a quality problem
and analysis of its causes

• To verify that a problem exists and
analyze its possible causes to choose
appropriate remedial actions

• The whole process from problem
identification to re-evaluation

Type of study

1. Non-experimental
1.1 Descriptive: Systematic collection and presentation of

data to give a clear picture of a particular
situation
 Quantitative
 Qualitative

1.2 Analytical: Aims at determining and testing the relationship

between several variables to suggest possible
causes of problem
 Retrospective
 Cohort

2. Experimental

PROPOSAL FOR QA PROJECT

• Title
• Group name and members
• Problem identification and opportunity for improvement
• Prioritization & chosen /refined topic
• Situational analysis/ literature review
• Opportunity statement
• Quality factor analysis/cause-effect analysis
• Process of care
• Model of good care

PROPOSAL FOR QA PROJECT

• QA study: Methodology
• Objectives: General and specific
• Type of study
• Term definition
• Inclusion and exclusion criteria
• Proposed indicator and standard
• Plan for data collection (proposed formats)
• Plan for data analysis
• Gantt’s chart
• References

Create opportunity statements

What is an opportunity statement:
 A descriptive name of the process
 An identification of clear boundaries within which

the improvement efforts will be focused
 An indication of who will benefit from its result
 An indication of what the current system causes

and what improvement might look like
 An indication of why it is important to work on

now

PROBLEM STATEMENT

A complete problem statement should describe
* the problem and its significance for
the quality of care
* possible causes and contributory
factors
* rationale of the study
* scope of the study
* how to use the results to solve the
problem

An outline of an opportunity statement

“ An improvement opportunity exists with ……..(name of
the process) beginning with ….and ending with …… The
current process causes ……and improvement should
result in ……for the …..(client). The process is important
to work on now because……”

An opportunity for improvement exists in the surgical unit,
beginning with the scheduling of surgery and ending
with completion of surgery. In 24% of the cases,
someone must be sent to obtain additional items,
thus causing delays. An improvement should result in a
reduction of delays.

Opportunity statement

• There is a need to provide early endoscopy
services for early detection of upper GI cancers

• There is a need to reduce intubation rate in
order to prevent muiltiorgan complications
associated with mechanical ventilation,
decrease length of stay, improve patient’s care
and parental satisfaction as well as for economic
reason

LITERATURE REVIEW

Source of literature:
• Text books
• Scientific journals
• Conference
• Local, state and national statistics
• Reports on QA study

HOW DOES LITERATURE REVIEW
HELPS

• Clarify our problem
• State the study objectives
• Check the implicit standards
• Set explicit criteria and standards
• Suggest suitable study methods
• Find appropriate remedial actions
• Avoid duplication of work

Examples of literature review

• Comparison of three manual ventilation devices using an
intubated mannequin

Hussey SG, Ryan CA, Child Fetal Neonatal Ed 2004;89;F490-F493

• Nasal CPAP or intubation at birth for very preterm infant

Morley CJ, Davis PG N Engl J Med. 2008 Feb 14;358 (7):700-8

• Koong HN et al. Gastric cancers in Singapore: poor
prognosis arising from late presentation. Aust NZJ Surg.
1996

OBJECTIVES OF THE STUDY
• General objective
• Specific objective

GENERAL OBJECTIVE

• To verify whether the problem exist
and to analyse its cause

SPECIFIC OBJECTIVE

i. To verify the existence of the problem
ii. To ascertain the probable causes of the

problem
iii. To formulate remedial measures
iv. To re-evaluate the effectiveness of the remedial

measures
v. Consist of concrete , specific intended actions

(What to do in the study and its outcome)

OBJECTIVE OF THE STUDY

General objective:
• To determine whether the use of Neopuff will have

desirable effect in reducing intubation rate of newborn
<24 hours of life

Specific objective:
• Whether reduction of intubation rate among these babies

will affect the length of NICU stay, mortality rate
• Effects of the use of Neopuff on number of patients on

mechanical ventilation and nasal CPAP, ventilation days,
overall inborn neonatal mortality rate and VLBW survival
rate

CRITERIA

• Condition to fulfill to define an indicator
• Can be used to define the sample limits
• Decided by peer decision or consensus
• May be implicit or explicit

2 types - included as sample
 Inclusion criteria - not included as sample
 Exclusion criteria

INCLUSION AND EXCLUSION CRITERIA

Inclusion Exclusion criteria
 Neonates who require  Babies who do not

assisted ventilation require assisted
for the management ventilation at birth
of respiratory distress  Newborn with major
at birth congenital anomalies
 No major congenital
anomalies

INDICATOR AND STANDARD

Standard Indicator
• Measurement of good • An objectively defined

care through one or more measure of quality
indicators • A measurable variable
• An agreed upon level of
excellence; an (data) relating to
established norm structure, process or
• Acceptable lowest limit outcome
• The achievable target • Usually expressed in the
considered to indicate form of rates (%)
quality
• Line dividing good from
poor quality
• Verify problem exist

INDICATORS

• Intubation rate of newborn <24 hours of
life

• Length of NICU stay
• % of patient with waiting time < 2 weeks

for endoscopy appointment from first
presentation to ETD/OPD/Specialist clinic
• Rate of early cancer detection

OPEN ACCESS ENDOSCOPE SERVICE
FLOWCHART-PROCESS AND PERSONNEL

1 Patient whose MARKS’ Quadrant Primary care centre

Score > 10 medical officers

2 Fill up FORM A Primary care centre

medical officers

3 Call SOPD and get the appt by Surgical specialist

phone clinic staffs

4 OGDS at HTJ HTJS surgeons

(within 2 weeks)

POSITIVE NEGATIVE
FINDINGS FINDINGS

Treat at Tuanku Treat at the
Ja’afar Hospital respective centers

Routine neonatal Intubate & PPV with
resuscitation at self-inflating bag

birth .
.
Intubate & PPV .
with self- .
.
inflating bag