The document discusses quality improvement approaches for healthcare management in resource-constrained settings. It introduces the '5S-CQI-TQM' model which incorporates 5S principles for organizing the workplace, continuous quality improvement (CQI) using the PDCA cycle, and total quality management (TQM). The model was piloted in hospitals in Bangladesh and found to be cost-effective for driving continuous quality improvement in challenging resource environments. Key benefits included improved processes, employee satisfaction, and patient outcomes. Ongoing challenges to implementation are also discussed.

1. ‘5S-CQI-TQM’ in Healthcare Management
Col Dr Zulfiquer Ahmed Amin
M Phil, MPH, PGD (Health Economics), MBBS
Armed Forces Medical Institute (AFMI)

2. Introduction
The basic characteristics of service delivery in our hospitals are
characterized by:
– Long waiting time
– Overcrowding
– Unhygienic and disorganized work environment
– Wastage
– Lack of knowledge transfer

3. Many Hospitals do not look at patients as human being
●Dignity
•Basic human needs
•Prompt attention in care and treatment
•Confidentiality
•Communication
•Autonomy
• Participatory decision making

4. Disorganized Hospital
•Long waiting time for consultation and other services
•Doctor or nurse cannot be contacted during emergencies
•Medical errors
•Hospital acquired infection
•Inaccurate pathological test results
•Test result is lost
•Poor record keeping system
•Failing supply system
•Hospital accidents
• Inability to conflict management
• Lack of practice of sanitation

5. Situations in developing countries
-To run health facilities, resources are needed. These include
financial, human, materials and infrastructure resources. It is
commonly found in developing countries that both government
health facilities and private health facilities are facing serious
resource shortage.
-There is a chronic shortage of government subsidy funds.
Unavailability of sufficient health insurance cover to the population
compounds the financial resource problem of the health facility.
Cost recovery through cost sharing is insufficient.
-The number and skill mix of the health workers is insufficient.
-The infrastructure is dilapidated.

6. All these constraints lead to deterioration in effectiveness and
quality of services manifested by poor preparedness in the delivery
of services, poor standards, poor or no increase of service packages,
inequity in service provision and insufficiency in clients’ satisfaction.
The answer to this lies with how we manage the available resources
and work environment.

7. To address this dilapidation in healthcare, for the past 10 years
global health policy has slowly shifted focus among three areas:
access, cost, and quality of medical care. Each area has successively
received concentrated attention, often at the expense of the other
two. The situation can be viewed as a slowly rotating triangle that
sequentially brings one after another of its vertices into principal
focus.

8. Access of Iron Triangle
For example, in USA, access to care received primary attention
during the late 1960’s and early 1970s. That period saw the
implementation of major federal initiatives intended to guarantee
that all Americans could easily obtain high-quality health care.
Medicare and Medicaid were introduced, and hospitals and
medical schools were given federal monies for health care and
health education programs of every description.

9. But during the late 1970s the federal government and private health
financiers noted the high and increasing costs that grew from earlier
'access to care' initiatives. The triangle turned. Emphasis shifted
from a primary focus on access to a primary focus on cost. Cost
control efforts were extended to physicians as well as hospitals. To
lower the cost of the care, simultaneously reduce access and quality.
Health budget $3.3 trillion (26% of GDP), or $10,348 per person in 2016 in USA
Cost aspect of Iron Triangle

10. Quality aspect of Iron Triangle
In spite of billions of dollars of money spent worldwide, most of the
healthcare is seen to be ineffective, inefficient and inadequate.
The triangle is changing—it may no longer be acceptable to
concentrate primary attention on a single vertex. The value of health
care the highest possible quality at the lowest reasonable cost-is
now the demand of time.

11. Quality health care is defined as "the totality of features and
characteristics of a healthcare service that bears its ability to satisfy
stated or implied needs.“

13. Quality Improvement
"The combined and unceasing efforts of everyone to make the
changes that will lead to better patient outcomes (health), better
system performance (care) and better professional development
(learning)". This may be done with noticeably significant changes or
incrementally via continual improvement.

14. A successful QI program always incorporates the following four key
principles:
• QI work as systems and processes
• Focus on patients
• Focus on being part of the team
• Focus on use of the data
System: A set of things working together as parts of a mechanism.
Process: A series of actions or steps taken in order to achieve a particular end

15. QI Work as Systems and Processes
To make improvements, an organization needs to understand its own
delivery system and key processes.
A system is a set of things working together, as parts, interconnected
with each other, to form a complex whole.
Processes are operations and activities that mediate the relationship
between the input factors and its outcomes.
The concepts behind the QI approaches recognize that both resources
(inputs) and activities carried out (processes) are addressed together
to ensure or improve quality of care (outputs/outcomes).

17. key components of healthcare delivery system comprises inputs,
processes, and outputs/outcomes:

19. Focus on Patients
An important measure of quality is the extent to which patients’
needs and expectations are met, which includes:
• Systems that affect patient access
• Care provision that is evidence-based
• Patient safety
• Support for patient engagement
• Coordination of care with other parts of the larger health care
system
• Cultural competence, including assessing health literacy of
patients, patient-centered communication, and linguistically
appropriate care

20. At its core, QI is a team process. Under the right circumstances, a
team harnesses the knowledge, skills, experience, and perspectives
of different individuals within the team to make lasting
improvements. A team approach is most effective when:
• The process or system is complex.
• No one person in an organization knows all the dimensions of an
issue.
• The process involves more than one discipline or work area.
• Solutions require creativity.
• Staff commitment are needed.
Focus on Being Part of the Team

21. Focus on Use of the Data
Data is the cornerstone of QI. It is used to describe how well current
systems are working; what is the gap between the expected and the
existing performance, what happens when changes are applied, and
to document successful performance.
Using data:
● Separates what is thought to be happening, from what is really
happening.
● Establishes a baseline.
● Reduces implementation of ineffective solutions.
● Indicates whether changes lead to improvements.
● Allows comparisons of performance both quantitatively and
qualitatively.

22. ‘5S-CQI-TQM’ is the mode of cost-effective QI in healthcare service
delivery.
5S-CQI (Kaizen)-TQM is a management technique to improve
productivity and quality on a continuum scale. It was introduced in
Japan after the World War II in a war-ravaged country to revive
economy. It is mostly suitable in resource strained situations, like
the third world countries. In Bangladesh, this approach was
introduced in 2011, and the process is now being implemented in
more than 120 hospitals. 5S-Kaizen-TQM is a Govt program
supported by JICA, UNICEF, WHO and GIZ
5S-CQI (Kaizen)-TQM
Japan International Cooperation Agency (JICA)
German Society for International Cooperation (GIZ) Deutsche Gesellschaft für Internationale Zusammenarbeit

25. 5s
5S is a system, uses a list of five Japanese words for organizing
spaces, so work can be performed efficiently, effectively, and safely.
This system focuses on putting everything where it belongs and
keeping the workplace clean, which makes it easier for people to do
their jobs without wasting time or risking injury.
There five 5S phases are translated to:
In some quarters, 5S has become 6S, the sixth element being safety.
5S is the initial step towards establishing Total Quality Management
(TQM).

28. Sort (Seiri)
-First step towards 5S journey.
-Make work easier by eliminating obstacles.
-Reduce chances of being disturbed with unnecessary items.
-Remove all parts or tools that are not in use.
-Segregate unwanted material from the workplace.
-Define Red-Tag area to place unnecessary items that cannot
immediately be disposed of. Dispose of these items when possible.
-Need fully skilled supervisor for checking on a regular basis.
-Waste removal.
-Make clear all working floor except using material.
-Floor will be Epoxy Flooring (If possible).

31. Set in order (Seiton)
-Arrange all necessary items so that they can be easily selected for
use.
-Prevent loss and waste of time by arranging work station in such a
way that all tooling / equipment is in close proximity.
-Make it easy to find and pick up necessary items.
-Ensure first-in-first-out (FIFO) basis.
-Make workflow smooth and easy.
-All of the above work should be done on a regular basis.
-Place components according to their uses, with the frequently used
components being nearest to the work place.
- Use 5s-tools to set the working place.

46. Shine/Sweeping (Seiso)
-Clean your workplace on daily basis completely or set cleaning
frequency time to time.
-Prevent machinery and equipment deterioration.
-Keep workplace safe and easy to work.
-Keep workplace clean and pleasing to work in.
-When in place, anyone not familiar to the environment must be
able to detect any problems within 50 feet in 5 sec.

50. Standardize (Seiketsu)
-Establish procedures and schedules to ensure the consistency of
implementing the first three ‘S’ practices.
-Develop a work structure that will support the new practices and
make it part of the daily routine.
-Ensure everyone knows their responsibilities of performing the
sorting, organizing and cleaning.
-Use photos and visual controls to help keep everything as it should
be.
-Review the status of 5S implementation regularly using audit
checklists.
-Ensure standardizing color codes for usable items.

52. Sustain (Shitsuke)
-Also translates as "do without being told".
-Perform regular audits.
-Training and discipline.
-Training is goal-oriented process. Its resulting feedback is necessary
monthly.
-To maintain proper order, ensure all defined standards are being
implemented and heard.
-Follow the process, but also be open to improvement

55. Targets of 5-S principles
• Zero changeovers
• Zero defects leading to higher quality
• Zero waste leading to lower cost
• Zero delays leading to on-time delivery
• Zero injuries thus promoting safety
• Zero breakdowns bringing better maintenance
• Zero customer complaints, i.e., client satisfaction
• Zero red ink, i.e., betterment of organization’s image

56. Benefits of 5s

57. Kaizen (Kai„Zen) is a Japanese term taken from words 'Kai', which
means ‘change’ and 'zen' which means ‘better’. Kaizen (or ‘continuous
improvement’) is an approach of constantly introducing small
incremental changes in a business in order to improve quality and/or
efficiency. This approach assumes that employees are the best people
to identify room for improvement, since they see the processes in
action all the time.

59. Properties

66. PDCA Cycle
KAIZEN process is divided into four sequential categories: plan, do,
check (Study), and act (the PDCA cycle). In the planning phase,
people define the problem to be addressed, collect relevant data,
and ascertain the problem's root cause; in the doing phase, people
develop and implement a solution, and decide upon a measurement
to gauge its effectiveness; in the checking phase, people confirm the
results through before-and-after data comparison; in the acting
phase, people document their results, inform others about process
changes, and make recommendations for the problem to be
addressed in the next PDCA cycle.

68. TQM
Total quality management, or TQM, can be summarized as a
management system for a customer-focused organization that
involves all employees in continual improvement.
TQM is based on the participation of all members of an organization
in improving inputs, processes, products, services, and the culture in
which they work.
TQM is a process which embraces the conscious striving for zero
defects in all aspects of an organization's activities or management
with workforce co-operating in the processes, developing, producing
and marketing quality goods and services which satisfy customers'
needs and expectations first time and every subsequent time.

74. ES= Employee Satisfaction
PS= Patients Satisfaction
CI= Continuous Improvement

75. Context of Bangladesh

76. Principles of 5S and a participatory KAIZEN (Continuous Quality Improvement:
CQI) process was introduced in the four district hospital namely Narsingdi,
Satkhira, Jessore and Pabna as pilot test.
(Baby Friendly/ Women Friendly)

77. CIPRB: Center for Injury Prevention and Research, Bangladesh

78. FPCST: Family Planning Clinical Supervision Team

80. Challenges in Quality Improvement

81. Conclusion

82. As customers’ expectations rise, patient care becomes more
complex, and resources continue to shrink, hospitals are finding that
traditional approaches to defining, organizing, and staffing quality
assurance functions are no longer adequate.

83. In a resource poor set-up, 5S-CQI-TQM approach for continuous
quality improvement is the most cost-efficient, lasting and easy to
materialize approach for quality improvement. “Continuous quality
improvement” or “total quality management” are names for a
philosophy of management that aims to help organizations of all kinds
improve performance through eliminating poor quality during
production or delivery of the product or service rather than through
trying to fix the results after the product has been made or the
service given.