PSP-One Hosts Dialogue with Dr. A.F. Al-Assaf, Executive Healthcare Training Academy, University of Oklahoma Health Sciences Center

PSP-One runs a series of dialogues with professionals working in public or private-sector health who are committed to quality improvement. This “Champions of Quality” series is a way for our community to learn from knowledgeable leaders.

“If you want one year of prosperity, grow grain. If you want ten years of prosperity, grow trees. If you want 100 years of prosperity, grow people.” - Chinese Proverb

Dr. A. F. Al-Assaf is Professor and Director of the MPH Degree Program, Executive Healthcare Training Academy, University of Oklahoma Health Sciences Center. Dr. Al-Assaf is a physician and a consultant in preventive medicine and quality management with strong quantitative and analytical skills.

He provides advice on healthcare quality and systems design, implementation, assessment, and improvement in the U.S. and other countries worldwide. Dr. Al-Assaf also assists health organizations coordinate projects, plan for quality initiatives, design performance improvement projects, and deliver training in tools and methods of data management in both the inpatient and the outpatient settings.

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Read this dialogue, and then send your own comments, questions, and other input to info@psp-one.com.

“Management commitment is really important -- active commitment and participation providing resources, being champions and being role models are essential.”

Question: What have we learned?

Dr. Al-Assaf:

The importance of accreditation
The first major achievement in improving the quality of health services has been the globalization of accreditation, which has been very powerful since the 1990s. Accreditation is always important because it fulfills ideas and purposes. If you look at the brief history of accreditation – the United States was the first country to establish an accrediting body in 1951. From 1951 until the early 1970s, the only other country that developed an accreditation system was Canada. From the early 1970s to the 1990s, only two or three other countries added accreditation standards. From 1990 until now, there are more than 50 countries that have acquired accreditation and it has become part of their healthcare system.

Some of the standards of the prominent accrediting bodies are really wonderful in that they specifically say that leaders, directors, and governors of organizations should become familiar with quality tools and techniques. These accrediting organizations get people trained and educated on principles of quality, tools of quality, and how you implement quality. Making standards like these, emphasizing training and education on quality, definitely puts quality in the forefront. For example, one competency area identified by the Accreditation Council for Graduate Medical Education (ACGME) was familiarity of medical residents with quality. This expectation resulted in residents completing a performance improvement project by the end of their residency program. This orients providers about quality, and by making regulators aware of this field and methodology, pushes people more toward quality.

The need for measures and standards
Ministers of Health of different countries say that their hands are tied, especially in the private sector, and that they don’t have any measurable instruments or specific standards that enable them to visit a private hospital and tell that hospital that they aren’t doing a good job. There are no local standards to say that the hospitals are not doing a good job. When we inspect hospitals, we have to know what we are inspecting them for and what are the standards and reasons for which we are inspecting the hospital. Even in a government hospital, if a hospital administrator isn’t doing his or her job right, how can we measure what a good job is without criteria. That’s when governments begin to think of accreditation. It gives them a measuring stick, a background to rely on, and in the long run it improves patient care. It’s a win-win situation. And those people who perform well get rewarded. Those that don’t perform well by accreditation standards are moved aside. That’s an incentive for improvement. Regulators as well can measure performance adequately and help improve care. Governments, however, should not waste time developing standards when standards have already been developed by others. They should just implement existing standards and be the local measurer or regulator of those standards.

Also in response to accreditation and performance improvement, national indicators for performance are being developed for hospitals, home health care, physician practices, and nursing care. Healthcare facilities can then measure their performance against those indicators and publish them. Improvements would allow them to attain a competitive edge.

The role of the consumer in decision making
A major achievement in improving quality has been the role of the consumer in medical decision-making and delivery of care. More and more consumers are pressuring providers, organizations, and even government to get them involved in decision-making and improvement. The US government has established a website, (www.talkingquality.gov) that is primarily to inform consumers about quality, and previously that had been unheard of.

Accountability
Another issue, and I hope this continues to happen, is the accountability of healthcare providers. By accountability, I mean accountability in the area of measuring quality and measuring performance, and not just institutional providers, but practitioners as well. More and more initiatives in the United States and other countries are measuring performance and encouraging people to defend their position on quality. Relying on data in measuring performance and comparing outcomes has become very prevalent. Therefore, as a provider, you are now gauged by your productivity score or your performance data thus making you more accountable to your customers.

Commitment of Leaders
The most important and paramount step is the commitment of management and top leaders. As W. Edwards Deming wrote, “Management commitment is really important. It’s either there or quality will never happen.” Active commitment and participation, providing resources, being champions and role models are essential. Without management commitment it is very, very difficult to move toward success. In particular top level commitment must be there. Again, Edward’s advice to top-level managers: “If you can’t be there, send no one”. Top managers provide resources, bring momentum, and instill pride.

Investment in patient safety
The World Health Organization (WHO) has considerable influence and WHO recently added patient safety as their top priority, encouraging countries around the world, including developing countries, to sponsor programs and activities in this area. Our accrediting bodies, such as, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Committee for Quality Assurance (NCQA) and others have also made patient safety a top priority. In fact, JCAHO for example, publishes an annual list of National Priorities for Patient Safety and requires accredited Healthcare Organizations to show evidence of compliance to these priorities see: (www.jcipatientsafety.org/show.asp?durki=10289).

Importance of team effort
Making delivery of health care a “team effort” rather than just a physician effort is another achievement in improving quality. For a long time physicians thought that they were it; we saw patients, assessed what patients had, we ordered treatment, and somebody executed the treatment. This isn’t the case anymore; it’s a team effort. Even the diagnosis, assigning of treatment, and follow up are all team efforts. We’re moving more and more towards that.

Raising quality to a level of specialization
Raising quality to the level of specialization whereby health professionals are specializing in this field just like any other field of study. Several organizations are credentialing professionals on a voluntary basis in Healthcare Quality. There is even an American Board in Quality Assurance and several Fellowships as well.

Question: What needs to be accomplished?

Dr. Al-Assaf:

Develop Long-term Training Strategies
People have to sit down and say in five to 10 years this is what I’m going to achieve. The training strategy should be developed so that it maximizes ownership of that strategy. A strategy should be well thought out so people can really look up to and achieve it. If not a strategy, there should at least be an annual plan for what needs to be done in the next year and who is going to do it, how we’re going to do it, and when are we going to do it. Another related issue is the creation of a national cadre of expert trainers. Donor organizations often come to a country and say “We want to increase your awareness in such field or training in such field”. Yet most of the time we don’t take it to the next step, which is creating local experts. Therefore, once they leave, everything falls apart. Organizations and countries should identify a group of people early on and push them to become trainers or local experts to sustain education, training and awareness activities.

Provide Incentives
Incentives don’t have to be monetary. Make incentives as achievable and feasible as possible. Make the achievement of training in quality part of the appraisal process or for a promotion. Make quality one of the subjects that has to be met for any physician or nurse to be re-licensed, in terms of continuing medical or nursing education. But make training accessible and part of the standards for credentialing and accreditation. Make it an incentive for people to go and train.

Recognize the Importance of People
Investing in people is crucial. Quality in a sense is people. That’s how you achieve quality, with people. Build good infrastructure with good people that are well trained, educated, and sensitized. As the Chinese Proverb states: “If you want one year of prosperity, grow grain. If you want ten years of prosperity, grow trees. If you want 100 years of prosperity, grow people.” Therefore invest heavily in your workforce.

Identify a good cadre of volunteers
Find volunteers who are willing to spend time and effort to study and identify areas for improvement. These are your champions and facilitators.

Acknowledge Physician Champions
Physicians involved in the area of performance improvement and quality are very important. They provide momentum to the process of improvement and would give further credibility to your quality related activities.

Determine standards
Choose any standards that are well written and thought-out and follow them. Setting and following standards will decrease variance, improve uniformity and sharpen expectations. They provide you with a tool for monitoring performance and improving outcomes. They are also useful in positive competition where comparisons between competitors are necessary to encourage continuous innovations and improvement.

Emphasize outcomes
Process is important, but achievement is crucial. Consider the bottom line and what should be accomplished and what to aim at. This practice is cost effective and more attractive especially to donor groups and regulators.

Question: What changes need to be made to improve quality in private sector health?

Dr. Al-Assaf:

Base funding on achievement
Unfortunately funding is happening in fields that aren’t showing any progress. You have to ask what has been accomplished then look at the results and achievements for tangible outcomes that impact and improve our care process and patient outcomes. Without that outcome, there should be no more funding. Don’t keep rewarding people for not achieving anything. Funding should be based on outcomes, tangible improvement, and measurable impact. Fund project and organizations based on merit.

Credential practitioners in quality but consider the costs
The top limitation for healthcare quality implementation is cost; whether it is for improvement projects or the building of the infrastructure in quality. In fact, most certification programs for individuals in healthcare quality cost between $400 and $600, which is a lot of money in many countries. Added to that, donor organizations unfortunately haven’t gotten into the idea of sponsoring people to take a certification exam. This is something that donors should think of in the future because the preparation and materials become costly for individuals. Also, most of the individuals interested in being certified are practitioners and it takes a lot of work and time to devote to this activity. But appropriate credentialing adds to the credibility of the individual and the institution where they work.

Expand knowledge of certification boards
Another hurdle is the knowledge of the existence of these certification boards. Not much has been done in the area of advertising outside of the United States. It may be that they don’t advertise because of the cost barriers.

Where to learn more about becoming certified in field of quality
Please refer to the PSP-One website for a description of six boards that lead to certification.

Recognize board limitations
Boards are primarily oriented to American practice until they find a market or need for their service in other countries. The result will be the establishment of international standards. Boards will add international standards as they find a demand for their product.

Increase access to materials
The reading materials, the cost and access to the materials are problematic because there are no specific reading materials to prepare the candidate for certification. There is no one specific book that will meet the objective. I would suggest that you do an internet search for topics of your interest in this field; but I would recommend one to two books and read the fundamentals first; if interested, then read from more books. I would also encourage people to go to the Institute of Medicine website and read the variety of reports they have published recently (during the last five years) on healthcare quality, medical errors and other topics. see:(www.iom.edu). Another informational website administered by the US government is (www.talkingquality.gov).

Emphasize training
Local country experts and providers must be trained to sustain program efforts and build the infrastructure within their countries. Benchmarking and organization of methods or mechanisms enabling people to learn from each other is really paramount. Study tours and exchanges, learning what other people are doing and bringing it back to your own country is important. Participating in international conferences and organizing “study” visits to regional countries can be very useful in terms of learning from others and finding methods and approaches for emulating and implementing locally.

Expand accreditation
Accredit not only hospitals, but all facilities, including primary care facilities, laboratories, pharmaceuticals, behavioral health facilities and nursing homes, if present. Positive things will happen at all levels as a result, even globally. Accreditation should become the mechanism for improving care.

Empower consumers
Make consumers involved in the care and delivery of services and decision-making. Make information available and easily accessible. Organize town hall meetings and publish targeted newsletters to educate your consumers on what they need and what their rights and responsibilities are. Let them learn what it takes to deliver quality care and run a quality organization.

Provide incentives for quality
The United States government is working on, but hasn’t found a solution for, the question of how we pay for quality. How do we identify high performers and motivate them to become performers of quality. Paying for quality should be an area of global concern and will be the area of future research and expansion.

Question: If a person would like to become certified or earn a credential in the field of “Quality” what are the different certification boards?

Dr. Al-Assaf:

1. American Society of Quality The oldest (started in 1946) and largest organization offering quality certification is the American Society of Quality. ASQ originally started as quality experts and manufacturers sought ways to sustain the many quality-improvement techniques used during WW II. They originally certified quality engineers and have since evolved into healthcare and other fields. They provide certification in several areas, listed below. Please visit their website for additional information on the cost and requirements for different types of certification.

Read Dr. Al-Assaf's full response in the Question & Answer Forum.

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