Using Quality Assurance principles in emergency planning Leaders Using Quality Assurance principles in emergency planning

Task for this afternoon Think about quality in disaster management Defining what quality is What does this mean for disaster programs? What are some principles in improving quality? How can these be used in disaster programs? Applying this at St David’s hospital

Defining Quality What does “Quality” mean?

Defining Quality The Degree of Excellence—the dictionary definition Excellence implies--- It is made of good materials It is better than other similar things to which it is compared Meets expectations people have of it It does what is intended of it The results are worth the investment (value for money) To achieve excellence takes work

Doing the right thing Quality is sometimes said to be doing the right thing in the right way

Doing the right thing Thing Way Quality is sometimes said to be doing the right thing in the right way Thing wrong right wrong Way right

Doing the right thing Thing Way Wrong thing Wrong way Quality is sometimes said to be doing the right thing in the right way Thing wrong right Wrong thing Wrong way wrong Way right

Doing the right thing Thing Way Wrong thing Wrong way Right thing Quality is sometimes said to be doing the right thing in the right way Thing wrong right Wrong thing Wrong way Right thing wrong way wrong Way right

Doing the right thing Thing Way Wrong thing Wrong way Right thing Quality is sometimes said to be doing the right thing in the right way Thing wrong right Wrong thing Wrong way Right thing wrong way Right way wrong Way right

The right thing at the right time Quality is sometimes said to be doing the right thing at the right time

The right thing at the right time Quality is sometimes said to be doing the right thing at the right time Thing wrong right wrong Time right

The right thing at the right time Quality is sometimes said to be doing the right thing at the right time Thing wrong right Wrong thing Wrong time Right thing wrong time Right time wrong Time right

The right thing at the right time Quality is sometimes said to be doing the right thing at the right time Thing wrong right Wrong thing Wrong time Right thing wrong time Right time wrong Time right

Right thing and right time Both have a major importance for disaster managers Many problems with disaster management

Improving efficiency and effectiveness Assessing the performance gap What could be achieved

Improving efficiency and effectiveness Assessing the performance gap What could be achieved Our vision— where we could be

Improving efficiency and effectiveness Assessing the performance gap What could be achieved What is presently being achieved Our vision— where we could be Where we are now

Improving efficiency and effectiveness Assessing the performance gap What could be achieved What is presently being achieved } The Performance Gap

Improving efficiency and effectiveness The challenge: Close this gap with accessible resources Assessing the performance gap What could be achieved What is presently being achieved } The Performance Gap

Improving efficiency and effectiveness We may have to change the way we do things to get here Assessing the performance gap What could be achieved What is presently being achieved } The Performance Gap

A famous person said… If you continue to do things the same way as you always have, you will ___________________ ___________________.

Meeting expectations Activities may Fall short of expectations Meet expectations Exceed expectations What are expectations? Whose expectations? Disaster managers Politicians Ordinary citizens Changing expectations—how to do?

Defining Quality by standards Many definitions which often overlap Quality is measured by standards and performance Q = P S Quality is measurable against standards But who sets the standards?

Where do we get the standards? International standards PAHO FEMA Country standards Organizational standards Standards change

Where do we get the standards? International standards PAHO FEMA Country standards Organizational standards Standards change

Where do we get the standards? International standards PAHO FEMA Country standards Organizational standards Standards change

Creating a vision for excellence Where do you want to go? What do you want your organization to be What do you want its quality to be? How are you going to get there Make up you own standards Or adapt others for your needs Be prepared to change these regularly

Thinking about quality Quality methods got started when inspection wasn’t doing it

Thinking about quality Quality methods got started when inspection wasn’t doing it More inspectors stopped faulty products leaving the factory, but did not improve their quality

Looking for ‘root causes’ Industry started looking for root causes of poor quality The cause turned out usually to be in the process of making something If we want to make something better we look at the individual steps needed to make it

Looking for ‘root causes’ Industry started looking for root causes of poor quality The cause turned out usually to be in the process of making something If we want to make something better we look at the individual steps needed to make it not usually at changing the people Processes 85% Causes of poor quality People 15%

Emphasis on quality has brought changes in management styles From an inspection—small “span of control” structure

Emphasis on quality has brought changes in management styles From an inspection—small “span of control” structure

Emphasis on quality has brought changes in management styles From an inspection—small “span of control” structure To a more ‘horizontal” team-based management structure

Emphasis on quality has brought changes in management styles From an inspection—small “span of control” structure To a more ‘horizontal” team-based management structure

What has this meant for disaster management? We have a much more ‘decentralised’ structure More work is being done as teams Less by committees These teams may cross various functions Practice and drills are needed more than ever There is a greater sense of accountability to the “users” “Stakeholders” part of almost all activities now

Parts of Quality Assurance

Parts of Quality Assurance Quality Design Quality Assurance Quality Improvement Quality Control

Parts of Quality Assurance Quality Design Trying to fix existing activities Quality Assurance Quality Improvement Quality Control

Parts of Quality Assurance Quality Design Trying to fix existing activities Inspecting for compliance Quality Assurance Quality Improvement Quality Control

Parts of Quality Assurance Building quality in from the beginning Quality Design Trying to fix existing activities Inspecting for compliance Quality Assurance Quality Improvement Quality Control

How can these new approaches affect disaster mgmt Time to look again at each part of the disaster cycle Quality design New plans and new systems (can we do it in a new and better way?) Quality improvement Changing policies (fixing things, applying lessons learnt) Quality control We assure quality by certifying standards are met

Disaster Phases in a disaster mitigation preparedness rehabilitation The disaster cycle mitigation preparedness Disaster rehabilitation response

Disaster Phases in a disaster mitigation preparedness rehabilitation Quality Assurance methods can be used at each point Phases in a disaster The disaster cycle mitigation preparedness Disaster rehabilitation response

Principles of Quality Assurance Ø Focus on needs of the users Ù Strengthen the process through which services are provided Ú Use of data to improve services Û Teams to improve quality Ü Improving communication

Ø Focus on the needs of the user Who are the users of our services? What does the user want and need for our service? How do we know this? Get control of quality close to the user Establishing a dialogue between providers and users to meet needs of the user A system has both internal users and external (ultimate) users. Unless needs of internal users are meet, then the ultimate user is not likely to have needs satisfied

Ø Focus on the needs of the user Who are the users of our services? What does the user want and need for our service? How do we know this? Get control of quality close to the user Establishing a dialogue between providers and users to meet needs of the user A system has both internal users and external (ultimate) users. Provider User

Ø Focus on the needs of the user Who are the users of our services? What does the user want and need for our service? How do we know this? Get control of quality close to the user Establishing a dialogue between providers and users to meet needs of the user A system has both internal users and external (ultimate) users. Provider User External or ultimate customer

Ø Focus on the needs of the user Who are the users of our services? What does the user want and need for our service? How do we know this? Get control of quality close to the user Establishing a dialogue between providers and users to meet needs of the user A system has both internal users and external (ultimate) users. Provider User Internal customers External or ultimate customer

Ø Focus on the needs of the user Who are the users of our services? What does the user want and need for our service? How do we know this? Get control of quality close to the user Establishing a dialogue between providers and users to meet needs of the user A system has both internal users and external (ultimate) users. Provider User Internal customers Unless needs of internal users are meet, then the ultimate or external user is not likely to have needs satisfied External or ultimate customer

Ø Focus on the needs of the user How does this apply to disasters? Who are the stakeholders in disaster management? Who are the internal customers? What are their needs? What is being “provided” and “used” Who are the external customers How do we know? Can the external users judge quality? or is that the job of the disaster professional only?

Ø Focus on the needs of the user This is the role of “Assurance” in “Quality Assurance” Basic standards are used to ensure quality The user is “assured” of the quality of services Building a sense of trust

Ù Strengthen the process through which services are provided input 1 2 3 4 5 6 output outcome impact Quality Assurance depends on a systems approach In order to have good outputs, outcomes and impact… The inputs must be appropriate The process effective and efficient This type of approach very suitable for disaster planning Standardization and error-proofing of the process Aim is to reduce variation

Ù Strengthen the process through which services are provided Inspectors here cannot improve the process Ù Strengthen the process through which services are provided process input 1 2 3 4 5 6 output outcome impact Quality Assurance depends on a systems approach In order to have good outputs, outcomes and impact… The inputs must be appropriate The process effective and efficient

Ù Strengthen the process through which services are provided input 1 2 If the inputs are inappropriate or substandard, then increasing the amount is not going to improve quality

Ù Strengthen the process through which services are provided input 1 2 3 Cloudy or unclear activities lead to poor or inconsistent results

Ù Strengthen the process through which services are provided ? input 1 2 3 ? ? Cloudy or unclear activities lead to poor or inconsistent results Uncertain steps lead to a breakdown in the process

Ù Strengthen the process through which services are provided 5 6 7 ? output outcome impact input 1 2 3 4 5 6 7 8 Parallel processes often have an uncertain outcome Even if both processes work, this adds uncertainty and inefficiency Unnecessary steps reduce the efficiency

Ù Strengthen the process through which services are provided 2 5 input 1 3 4 6 output outcome impact Look for error prone steps Steps where things often fall apart Or need extra attention to make them work

Strengthen the process through which services are provided 3 6 4 input output impact 1 outcome 5 2 Circumstances often strain the process Process for emergencies must be robust Must be able to be easily adjustable for new circumstances

Ú Using data to improve quality Data is the key to quality, as quality definition must be measurable Data is needed for all aspects of disaster management Disaster programmes must have their own information system a base for quality improvement activities What have we learnt from the last disaster? Does our disaster plan need updating? What is our state of preparedness? How is recovery progressing? Are mitigation measures being implemented? Statistical and analytic tools for data use

Ú Using data to improve quality All projects need to have clear objectives Data critical for monitoring progress Data central for the evaluation of the project outcomes “SMART” Objectives belong in every project Data key to better project management Risk assessments (new computerized programs) Vulnerability assessments Careful analysis of previous events Need for archiving data

Û Use teams for better quality Most quality improvement methods depend on teams Teams are usually more effective than the individual As management becomes more horizontal, bigger spans of control have developed Less supervision possible Role of a supervisor changes to facilitator to assist teams in problem solving In some things, particularly the quality control activities, teams not used Self-directed work teams becoming more common

Û Use teams for better quality Teams may be— Functional: consisting of people working in a particular activity or department These usually function easily—everyone is familiar with the tasks Cross functional: these teams are formed to tackle problems which cut across organizational boundaries Making these work is much harder since there are many new faces, and ground to guard Teams are not committees

Û Use teams for better quality Well functioning teams need to have— People who work in the process People who control the process Leadership to keep the team moving The team process may take time to get moving efficiently; this is normal though frustrating Teams have ups and downs, also normal If teams are already part of management and work structures, build on these existing teams for quality issues Don’t start new teams & create parallel structures

Teams have their ups and downs …and this is completely normal

Ü improving communication Poor communication is at the bottom of much low quality Communication not the strong point of public health personnel Science seems to breed a certain arrogance about the need for communication “Let the numbers speak for themselves.” But there is a lot of competition to be heard Disaster management, more than about anyone else needs good communication

Ü improving communication Several forms of weak communication Poor communication to the public Public look to disaster offices for information Often this is not provided-relying on the police or others The absence of information is rumor Controlling rumor is really hard

Ü improving communication Results are that public is at risk What we know we don’t share Sometimes it is because we don’t know how to share We don’t know what people are thinking In some emergencies, the police or the army, take responsibility for public information People forget about the disaster managers

The disaster management office had little to say after this national disaster

Ü improving communication Communication within the organization and between organizations Disaster management by its nature involves many groups Keeping them together on the same page may be hard Staff are commonly unaware of organizational goals & activities Communication moves down well, but bottom-top communication often poor Feedback is generally poorly managed Managers often don’t listen, and workers don’t tell unpleasantries A “listening organization” has the greatest advantage

Organizational communication

Conclusion There are many definitions of quality But whatever definition used—it must be measurable There are no systems in which quality cannot be improved Quality assurance has three components Quality Design, Quality Improvement, Quality Control Certain basic principles apply to improving quality Meeting the needs of the user Improving systems and processes Use of data Use of teams Improving communications

Exercise - St David’s Hospital 500 bed hospital with full specialty and diagnostic facilities The building itself is a one-storey masonry structure, constructed in 1965 Built as a series of ward building connected by covered walkways In the 2002 tropical storm there was severe damage to the roof structure for several wards. Several wards flooded because of poor drainage. With electric lines down, and no adequate standby power the theatres, several wards and the laboratory were without power.

St David’s Hospital Main entrance Maternity ward ambulanceentrance Laboratory Radiology Theatre CSS Casualty ward Admin Poly clinic Other services, kitchen, chronic diseases Morgue workshop Main entrance Male Medical ward Female Medical ward Male Surgical ward Female surgical ward Paeds ward

St David’s Hospital A major problem during and after the storm was poor communications There were no radio connections with the police and fire brigades. Neither was their radio commutations with St John’s Ambulance or its vehicles incoming with injured. Within the hospital it was difficult to communicate with wards until the electricity was restored

St David’s Hospital The major problems was the lack of a practiced disaster plan. This was particularly evident in the causality ward and the theatre The hospital administration were unsure of their role Problems in the hospitals of St Paul, and particularly St Jude were similar. These hospitals were newer, and did not suffer the same physical damage as St David’s. The absence of practiced disaster plans was the same as in St David’s The lack of clear emergency roles meant the response did not go smoothly.

Exercise At St David’s Hospital there is a need to improve the hospital disaster plan Your team has to plan the process This is what you need to do— Define what quality means in this plan What are the needs of the users of this plan? Who are they? How will you use the systems approach in making the plan? What data will you need? What teams will you constitute and how will you use them? What is the role of communications in the plan?