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Sandro C. Esteves, MD., PhD.
Director, ANDROFERT
Andrology & Human Reproduction Clinic
Campinas, BRAZIL
What is Total Quality
Management (TQM)? 
Life Summit 2014 - ART TQM Forum, CHINA
ISO 9001:2008
Outline
o TQM definition
o Applying TQM in Healthcare and IVF
•  Performance Management
•  Quality Management
•  Risk Management 
o How to evaluate success of an IVF
center according to TQM 
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
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2014 MARCH
ANDROFERT
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
SC ESTEVES, 3
2014 FEBRUARY
ANDROFERT
Definitions
TOTAL
Complete; absolute;
comprehensive 


MANAGEMENT
Administration; the
process of dealing
with or controlling
things or people

QUALITY
Characteristic; nature; 
essential character; 
something that distinguishes 
ANDROFERT
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ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
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o It varies from person to
person, and it’s influenced
by feelings; 
o Existing only in the mind;
imaginary
Quality is
subjective…
ANDROFERT
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ANDROFERT
The only objective and measurable
aspect of quality is the PROCESS


Process = Any activity or set of activities that uses
resources to transform raw material, supplies and
labor (inputs) into products or services (outputs) 
ANDROFERT
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ANDROFERT
Process within the organization that
will ensure that the service provided is
performed in a standardized way, and
that results are analyzed and
improvements are done constantly,
to guarantee a service of excellence
with consistent and stable results
ANDROFERT
androfert.com.br
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Process

service standardized 

results analyzed
improvements constantly done
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
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ANDROFERT
IVF is process-based, so TQM
can be applied to IVF
ANDROFERT
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Why a Process is so Important
for Quality
Every work is a set of interrelated processes;
Every process is subject to variation;
The key to the ongoing improvement is
systematically tackling and reducing
processes’ variations
ANDROFERT
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2014 MARCH
ANDROFERT
Key points (1)
The only objective and measurable aspect
of quality is the PROCESS

 
= set of activities that uses resources to
transform inputs into outputs 
TQM is a process ensuring that service is
performed in a standardized way, and that
results are analyzed and improvements are
done constantly, thus guaranteeing a
service of excellence with consistent and
stable results
ANDROFERT
androfert.com.br
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ANDROFERT
ANDROFERT
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ANDROFERT
Applying TQM in Healthcare
ANDROFERT
androfert.com.br
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ANDROFERT
Resources,
training and
opportunities
for staff to
develop and
improve 
OHSS, multiparity, biosafety,
health issues 
QM
system
Applying TQM in IVF
ANDROFERT
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ANDROFERT
QMS: ISO 9001:2008
Determine needs and expectations of customers
and others (legislation, professional societies, etc.)
Mission
Establish a quality policy, quality objectives, and
quality indicators for the organization, 
QM focus
Determine processes/procedures to achieve the
quality objectives; Identify and provide necessary
resources
Process
Determine means to prevent nonconformities (NC)
(variation) and eliminate their causes; Register
quality actions; Verify compliance
NC;
Registering;
Auditing
Establish and apply methods to measure
effectiveness/efficiency of each process
Monitoring
Establish and implement a process that involves all
personnel for continuous improvement
Continuous
improvement
Mission Statement
Define who your patients are
WHO
Define what you do, and the services you
provide
WHAT
Define how you do it: methods used,
philosophy, objectives, etc.
HOW
ANDROFERT
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Our mission is to help couples with conception difficulties
become parents, especially when the difficulty is partially
or totally related to men, through counseling, diagnosis
and treatment, offering personalized professional service
of excellence, and using all available technologic
resources
Quality Management Focus
Brief, simple and direct statements that
define the focus of your quality
management system
Quality
Policy
Objectives of each statement of your
quality policy (they have to be
measurable)
Quality
Objectives
How you monitor your quality objectives
(tools to check if your objectives, and
therefore your policy is being achieved)
Quality
Indicators
ANDROFERT
androfert.com.br
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ANDROFERT
QMFocus
ANDROFERT
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ANDROFERT
Processes and Procedures
Any activity or set of activities that uses
resources to transform raw material,
supplies and labor (inputs) into products or
services (outputs) 
Process
Sequence of steps to execute a task
Important for standardization and
replication
Procedure
ANDROFERT
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ANDROFERT
ANDROFERT
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ANDROFERT
!
ANDROFERT
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ANDROFERT
Non-conformities
Every deviation
from what is
established.
Important to
identify
inconsistencies,
weaknesses,
and
improvement
opportunities
Registering Quality Actions &
Auditing
Actions taken to improve the service
provided
Improvement
Actions
Actions taken to avoid a potential non-
conformity detected before it actually
happen
Preventive
Actions
Actions taken after a non-conformity has
been detected to correct it
Corrective
Actions
ANDROFERT
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ANDROFERT
ANDROFERT
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ANDROFERT
Registeringquality
actions
Auditing
Verify conformity
Main
Objective
Processes, Procedures, 
Documents and Records
Types
ANDROFERT
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ANDROFERT
Continues…
Secretary!
answers!the!
phone!
Is!it!a!new!
patient?!
Wants!general!
information?!
Secretary!gives!
homepage!and!
email!address!
Wants!to!
schedule!semen!
test?!
Secretary!
verifies!type!of!
test!
Secretary!
schedules!
Wants!to!
schedule!
appointment?!
Secretary!
verifies!medical!
preference!
Yes!
Yes!
Yes!
No!
No!
Yes!
No!
ANDROFERT
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ANDROFERT
Auditing
Monitoring Quality
Indicators
ANDROFERT
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ANDROFERT
Continuous Improvement
Fabiola Bento, MBE
Quality Manager, ANDROFERT
Establish unity of
purpose and direction of
the internal environment
Create an environment
where people are fully
involved in achieving the
organization’s objectives
ANDROFERT
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ContinuousImprovement
ANDROFERT
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ANDROFERT
•  Know your patients
•  Define the processes to meet their
expectations
•  Define your goals and objectives, so that your
procedures and processes help you achieve
them
•  Measure your performance and your patients’
satisfaction periodically to detect changes and
new demands
ANDROFERT
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•  Involve all personnel in continuous
improvement
•  Make changes, adjustments, and improvements
based on facts and not on assumptions
•  And, last but not least, satisfy your patients!
ANDROFERT
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ANDROFERT
What a TQM guarantees is… 
Key points (2)
ANDROFERT
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ANDROFERT
o A very well-organized workflow
o Excellence in service provided
o Focus on patient needs and

satisfaction
o Continuous improvement 
o  Increased operational efficiency

and profitability
ANDROFERT
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ANDROFERT
How to evaluate success of an
IVF center according to TQM 


Is your
Center
Successful?
ü Development of 298 quality indicators
ü Twenty-four indicators selected based on
consensus of importance; Six quality dimensions
ANDROFERT
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ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
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ANDROFERT
Consensus Quality Indicators
Safety 
•  Complications, Errors/Mistakes, Procedures/Techniques/Medication
Effectiveness 
•  Live birth rates according to age groups and time periods
Patient centeredness 
•  Psychological counseling/support available, individualized treatment, patient
discussion groups, information, effective communication
Efficiency 
•  Diagnostic work-up prior to IVF, Clinic website with information, number of care
providers relative to number of patients
Timeliness 
•  Focus on urgent consultation and waiting time; average duration of waiting time
before and during treatment, and after failed attempt
Equity 
•  Explicit criteria for treatment indication, vision of the clinic concerning ethical
limitations, protocols in accordance with international/regulatory guidelines
Adapted from Dancet et al. HR 2013
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
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ANDROFERT
Top 3 Quality Indicators of Infertility Care
How professionals and patients perceive them?
Dancet et al.
Hum Reprod 2013
0% 20% 40% 60% 80% 100%
Doctors/embryologists
Nurses
Patients
Safety
Effectiveness
Patient-centeredness
ANDROFERT
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ANDROFERT
ANDROFERT
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ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
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ANDROFERT
Fertility care providers considered success rates
(effectiveness) to be the most important factor,
while patients valued the physicians’ attitudes
(patient-centeredness) the most
ANDROFERT
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ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
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2014 MARCH
ANDROFERT
Prove it, but
take into
account what
our needs are!
n Established 2009
n 100 babies born
n Few credentials experience
n IVF first treatment line
n No poor responders
n Record of errors/pat. complaints
n High multiple PR
n Advertise a lot 
n  Established1994
n  >1,000 babies born
n  Lots of credentials/experience
n  All treatment options available 
n  Individualized approach
n  Rare errors/patient complaints
n  Low multiple PR
n  Educational marketing 
Doctor ‘Look Good’ 
PR/cycle = 50%
ANDROFERT
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ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
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ANDROFERT
Pregnancy rates not enough
Doctor ‘Look Bad’
PR/cycle = 30%
ANDROFERT
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ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
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Input Process Output
Efficiency
indicator
Effectiveness
indicator
Resources
Process Mapping
ANDROFERT
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Infertile
couple IVF cycle Pregnancy
Efficiency
indicator
Resources Clinic A = 40%
Clinic B = 40%
Pregnancy
Example 1 

Quality Indicator = Effectiveness
ANDROFERT
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Infertile
couple IVF cycle Pregnancy
Efficiency
indicator
Resources
Pregnancy
Clinic B > A
Clinic A = drug 1
Clinic B = drug 2
+3 oocytes retrieved with drug 2 by same dosage
Pregnancy
(cumulative)
Clinic A = 45%
Clinic B = 55%
Example 1

Quality Indicator = Effectiveness
ANDROFERT
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ANDROFERT
Infertile
couple IVF cycle
Pregnancy
(per ET)
Efficiency
indicator
Clinic A = 40%
Clinic B = 40%
Resources
Example 2 

Quality Indicator = Safety
ANDROFERT
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ANDROFERT
Infertile
couple IVF cycle Pregnancy
Efficiency
indicator
Clinic A = 40%
Clinic B = 30%
Resources
Clinic A = cCOS
Clinic B = iCOS
Clinic A = 10%
Clinic B = 0%
OHSS
(moderate/
severe)
Clinic B > A
Example 2 

Quality Indicator = Safety
ANDROFERT
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ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
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ANDROFERT
Non-
obstructive
azoospermia
IVF cycle Pregnancy
Efficiency
indicator
Clinic A = 40%
Clinic B = 30%
Resources
Example 3 

Indicator = Patient-centeredness
ANDROFERT
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ANDROFERT
Non-
obstructive
azoospermia
IVF cycle Pregnancy
Efficiency
Effectiveness
Clinic A = TESE/donor sperm
Clinic B = micro-TESE
Clinic A = 20%
Clinic B = 30%
Pregnancy
(biological
offspring)
Clinic B > A
Example 3 

Indicator = Patient-centeredness
Resources
Quality cannot be determined by a single parameter
such as pregnancy rates
Effectiveness, safety and patient-centeredness are
amongst the most important quality indicators in
infertility care, but the latter is often neglected by
doctors/nurses/embryologists
TQM offers an opportunity to rethink our systems
and fully address all quality dimensions of
infertility care, including our customers’ needs

Key points (3)
ANDROFERT
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ANDROFERT
ANDROFERT
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ANDROFERT
Patient-
centeredness
Increase
patient
satisfaction
PregnancyPregnancy
Results of
satisfaction
surveys
Safety
Reduce
errors /
mistakes
PregnancyPregnancy
Number of Non-
conformities
registered
Effectiveness
Increase
pregnancy
rates
PregnancyPregnancy
Cumulative
pregnancy
rates
Quality
Dimension
Quality
Objective
Indicator
ANDROFERT
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ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
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ANDROFERT
Patient-
centeredness
Guarantee
biological
offspring
PregnancyPregnancyNo. cases using
sperm bank
Safety
Reduce
multiparity
and OHSS
PregnancyPregnancy
No. embryos
transferred per
cycle; No. cycles
using iCOS
Effectiveness
Increase
PRs
(biological)
in NOA
PregnancyPregnancyNo. NOA cases
with micro-TESE
Quality
Dimension
Quality
Objective
Indicator
“The real voyage of discovery
consists not in seeking new
landscapes, but in having new
eyes.”


Marcel Proust
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
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ANDROFERT

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What is TQM

  • 1. Sandro C. Esteves, MD., PhD. Director, ANDROFERT Andrology & Human Reproduction Clinic Campinas, BRAZIL What is Total Quality Management (TQM)? Life Summit 2014 - ART TQM Forum, CHINA ISO 9001:2008
  • 2. Outline o TQM definition o Applying TQM in Healthcare and IVF •  Performance Management •  Quality Management •  Risk Management o How to evaluate success of an IVF center according to TQM ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 2 2014 MARCH ANDROFERT
  • 3. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION SC ESTEVES, 3 2014 FEBRUARY ANDROFERT
  • 4. Definitions TOTAL Complete; absolute; comprehensive MANAGEMENT Administration; the process of dealing with or controlling things or people QUALITY Characteristic; nature; essential character; something that distinguishes ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 4 2014 MARCH ANDROFERT
  • 5. o It varies from person to person, and it’s influenced by feelings; o Existing only in the mind; imaginary Quality is subjective… ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 5 2014 MARCH ANDROFERT
  • 6. The only objective and measurable aspect of quality is the PROCESS
 Process = Any activity or set of activities that uses resources to transform raw material, supplies and labor (inputs) into products or services (outputs) ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 6 2014 MARCH ANDROFERT
  • 7. Process within the organization that will ensure that the service provided is performed in a standardized way, and that results are analyzed and improvements are done constantly, to guarantee a service of excellence with consistent and stable results ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 7 2014 MARCH ANDROFERT
  • 8. Process service standardized results analyzed improvements constantly done ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 8 2014 MARCH ANDROFERT
  • 9. IVF is process-based, so TQM can be applied to IVF ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 9 2014 MARCH ANDROFERT
  • 10. Why a Process is so Important for Quality Every work is a set of interrelated processes; Every process is subject to variation; The key to the ongoing improvement is systematically tackling and reducing processes’ variations ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 10 2014 MARCH ANDROFERT
  • 11. Key points (1) The only objective and measurable aspect of quality is the PROCESS = set of activities that uses resources to transform inputs into outputs TQM is a process ensuring that service is performed in a standardized way, and that results are analyzed and improvements are done constantly, thus guaranteeing a service of excellence with consistent and stable results ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 11 2014 MARCH ANDROFERT
  • 12. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 12 2014 MARCH ANDROFERT Applying TQM in Healthcare
  • 13. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 13 2014 MARCH ANDROFERT Resources, training and opportunities for staff to develop and improve OHSS, multiparity, biosafety, health issues QM system Applying TQM in IVF
  • 14. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 14 2014 MARCH ANDROFERT QMS: ISO 9001:2008 Determine needs and expectations of customers and others (legislation, professional societies, etc.) Mission Establish a quality policy, quality objectives, and quality indicators for the organization, QM focus Determine processes/procedures to achieve the quality objectives; Identify and provide necessary resources Process Determine means to prevent nonconformities (NC) (variation) and eliminate their causes; Register quality actions; Verify compliance NC; Registering; Auditing Establish and apply methods to measure effectiveness/efficiency of each process Monitoring Establish and implement a process that involves all personnel for continuous improvement Continuous improvement
  • 15. Mission Statement Define who your patients are WHO Define what you do, and the services you provide WHAT Define how you do it: methods used, philosophy, objectives, etc. HOW ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 15 2014 MARCH ANDROFERT Our mission is to help couples with conception difficulties become parents, especially when the difficulty is partially or totally related to men, through counseling, diagnosis and treatment, offering personalized professional service of excellence, and using all available technologic resources
  • 16. Quality Management Focus Brief, simple and direct statements that define the focus of your quality management system Quality Policy Objectives of each statement of your quality policy (they have to be measurable) Quality Objectives How you monitor your quality objectives (tools to check if your objectives, and therefore your policy is being achieved) Quality Indicators ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 16 2014 MARCH ANDROFERT
  • 17. QMFocus ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 17 2014 MARCH ANDROFERT
  • 18. Processes and Procedures Any activity or set of activities that uses resources to transform raw material, supplies and labor (inputs) into products or services (outputs) Process Sequence of steps to execute a task Important for standardization and replication Procedure ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 18 2014 MARCH ANDROFERT
  • 19. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 19 2014 MARCH ANDROFERT
  • 20. ! ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 20 2014 MARCH ANDROFERT Non-conformities Every deviation from what is established. Important to identify inconsistencies, weaknesses, and improvement opportunities
  • 21. Registering Quality Actions & Auditing Actions taken to improve the service provided Improvement Actions Actions taken to avoid a potential non- conformity detected before it actually happen Preventive Actions Actions taken after a non-conformity has been detected to correct it Corrective Actions ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 21 2014 MARCH ANDROFERT
  • 22. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 22 2014 MARCH ANDROFERT Registeringquality actions
  • 23. Auditing Verify conformity Main Objective Processes, Procedures, Documents and Records Types ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 23 2014 MARCH ANDROFERT
  • 25. Monitoring Quality Indicators ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 25 2014 MARCH ANDROFERT
  • 26. Continuous Improvement Fabiola Bento, MBE Quality Manager, ANDROFERT Establish unity of purpose and direction of the internal environment Create an environment where people are fully involved in achieving the organization’s objectives ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 26 2014 MARCH ANDROFERT
  • 28. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 28 2014 MARCH ANDROFERT
  • 29. •  Know your patients •  Define the processes to meet their expectations •  Define your goals and objectives, so that your procedures and processes help you achieve them •  Measure your performance and your patients’ satisfaction periodically to detect changes and new demands ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 29 2014 MARCH ANDROFERT
  • 30. •  Involve all personnel in continuous improvement •  Make changes, adjustments, and improvements based on facts and not on assumptions •  And, last but not least, satisfy your patients! ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 30 2014 MARCH ANDROFERT
  • 31. What a TQM guarantees is… Key points (2) ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 31 2014 MARCH ANDROFERT o A very well-organized workflow o Excellence in service provided o Focus on patient needs and satisfaction o Continuous improvement o  Increased operational efficiency and profitability
  • 32. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 32 2014 MARCH ANDROFERT How to evaluate success of an IVF center according to TQM 
 Is your Center Successful?
  • 33. ü Development of 298 quality indicators ü Twenty-four indicators selected based on consensus of importance; Six quality dimensions ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 33 2014 MARCH ANDROFERT
  • 34. Consensus Quality Indicators Safety •  Complications, Errors/Mistakes, Procedures/Techniques/Medication Effectiveness •  Live birth rates according to age groups and time periods Patient centeredness •  Psychological counseling/support available, individualized treatment, patient discussion groups, information, effective communication Efficiency •  Diagnostic work-up prior to IVF, Clinic website with information, number of care providers relative to number of patients Timeliness •  Focus on urgent consultation and waiting time; average duration of waiting time before and during treatment, and after failed attempt Equity •  Explicit criteria for treatment indication, vision of the clinic concerning ethical limitations, protocols in accordance with international/regulatory guidelines Adapted from Dancet et al. HR 2013 ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 34 2014 MARCH ANDROFERT
  • 35. Top 3 Quality Indicators of Infertility Care How professionals and patients perceive them? Dancet et al. Hum Reprod 2013 0% 20% 40% 60% 80% 100% Doctors/embryologists Nurses Patients Safety Effectiveness Patient-centeredness ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 35 2014 MARCH ANDROFERT
  • 36. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 36 2014 MARCH ANDROFERT Fertility care providers considered success rates (effectiveness) to be the most important factor, while patients valued the physicians’ attitudes (patient-centeredness) the most
  • 37. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 37 2014 MARCH ANDROFERT Prove it, but take into account what our needs are!
  • 38. n Established 2009 n 100 babies born n Few credentials experience n IVF first treatment line n No poor responders n Record of errors/pat. complaints n High multiple PR n Advertise a lot n  Established1994 n  >1,000 babies born n  Lots of credentials/experience n  All treatment options available n  Individualized approach n  Rare errors/patient complaints n  Low multiple PR n  Educational marketing Doctor ‘Look Good’ PR/cycle = 50% ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 38 2014 MARCH ANDROFERT Pregnancy rates not enough Doctor ‘Look Bad’ PR/cycle = 30%
  • 39. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 39 2014 MARCH ANDROFERT Input Process Output Efficiency indicator Effectiveness indicator Resources Process Mapping
  • 40. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 40 2014 MARCH ANDROFERT Infertile couple IVF cycle Pregnancy Efficiency indicator Resources Clinic A = 40% Clinic B = 40% Pregnancy Example 1 
 Quality Indicator = Effectiveness
  • 41. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 41 2014 MARCH ANDROFERT Infertile couple IVF cycle Pregnancy Efficiency indicator Resources Pregnancy Clinic B > A Clinic A = drug 1 Clinic B = drug 2 +3 oocytes retrieved with drug 2 by same dosage Pregnancy (cumulative) Clinic A = 45% Clinic B = 55% Example 1
 Quality Indicator = Effectiveness
  • 42. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 42 2014 MARCH ANDROFERT Infertile couple IVF cycle Pregnancy (per ET) Efficiency indicator Clinic A = 40% Clinic B = 40% Resources Example 2 
 Quality Indicator = Safety
  • 43. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 43 2014 MARCH ANDROFERT Infertile couple IVF cycle Pregnancy Efficiency indicator Clinic A = 40% Clinic B = 30% Resources Clinic A = cCOS Clinic B = iCOS Clinic A = 10% Clinic B = 0% OHSS (moderate/ severe) Clinic B > A Example 2 
 Quality Indicator = Safety
  • 44. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 44 2014 MARCH ANDROFERT Non- obstructive azoospermia IVF cycle Pregnancy Efficiency indicator Clinic A = 40% Clinic B = 30% Resources Example 3 
 Indicator = Patient-centeredness
  • 45. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 45 2014 MARCH ANDROFERT Non- obstructive azoospermia IVF cycle Pregnancy Efficiency Effectiveness Clinic A = TESE/donor sperm Clinic B = micro-TESE Clinic A = 20% Clinic B = 30% Pregnancy (biological offspring) Clinic B > A Example 3 
 Indicator = Patient-centeredness Resources
  • 46. Quality cannot be determined by a single parameter such as pregnancy rates Effectiveness, safety and patient-centeredness are amongst the most important quality indicators in infertility care, but the latter is often neglected by doctors/nurses/embryologists TQM offers an opportunity to rethink our systems and fully address all quality dimensions of infertility care, including our customers’ needs Key points (3) ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 46 2014 MARCH ANDROFERT
  • 47. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 47 2014 MARCH ANDROFERT Patient- centeredness Increase patient satisfaction PregnancyPregnancy Results of satisfaction surveys Safety Reduce errors / mistakes PregnancyPregnancy Number of Non- conformities registered Effectiveness Increase pregnancy rates PregnancyPregnancy Cumulative pregnancy rates Quality Dimension Quality Objective Indicator
  • 48. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 48 2014 MARCH ANDROFERT Patient- centeredness Guarantee biological offspring PregnancyPregnancyNo. cases using sperm bank Safety Reduce multiparity and OHSS PregnancyPregnancy No. embryos transferred per cycle; No. cycles using iCOS Effectiveness Increase PRs (biological) in NOA PregnancyPregnancyNo. NOA cases with micro-TESE Quality Dimension Quality Objective Indicator
  • 49. “The real voyage of discovery consists not in seeking new landscapes, but in having new eyes.” Marcel Proust ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 49 2014 MARCH ANDROFERT