Analysis on the problems and countermeasures of the standardization of hospital QCC in China
Review Article

Analysis on the problems and countermeasures of the standardization of hospital QCC in China

Tingfang Liu, Dan Zhang, Huimin Shi

Institute for Hospital Management of Tsinghua University, Tsinghua University, Beijing 100084, China

Contributions: (I) Conception and design: T Liu; (II) Administrative support: T Liu; (III) Provision of study materials or patients: D Zhang; (IV) Collection and assembly of data: H Shi, D Zhang; (V) Data analysis and interpretation: H Shi; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Tingfang Liu. Senior Adviser of Dean of Institute for Hospital Management of Tsinghua University, Professor, Graduate Student Supervisor, Tsinghua University, Beijing 100084, China. Email: liutf@mail.tsinghua.edu.cn.

Abstract: Standardization, which determines whether the effective measures of QCC can develop into a standard operation procedure, is an important part of QCC. It can maintain the positive effects of hospital QCC. Through analyzing questionnaires and the materials of the participants in the National Quality Control Circle Competition of Chinese Hospitals [2013–2014], we find and sum up the problems of the standardization of hospital QCC. Combining with relevant research data and putting forward the concept of open QCC, we construct the flowchart of the standardization of hospital QCC in order to standardize the process and methods of the standardization of hospital QCC.

Keywords: QCC; standardization; open mechanism


Received: 29 August 2016; Accepted: 06 September 2016; Published: 15 November 2016.

doi: 10.21037/jrh.2016.09.06


QCC is an activity in which the junior staff focuses on the questions they found in the hospital and make autonomous improvement. Using the new and old seven approaches, the employees form a group to explore the effective measures to solve the problems. After confirming the effective measures, it is important to standardize these effective measures and form standard operation procedures, standard operating guidelines and related institution and norms. Only in this way can the effective measures be popularized to the relevant departments in the hospital and then the achievements of the QCC can be properly implemented.


Current research on the standardization of hospital QCC

Some scholars carried out some research on the standardization of hospital QCC. Wang et al. [2012] defined the standardization as “decompose each operation procedure and each action of the ongoing work on the basis of investigation and analysis of the workflow, and then improve the process and optimize the operation procedures in order to achieve safe environment and efficient process” (1). Liu [2012] pointed out that the standardization is defined as “revise the standard instructions, train the employees in the same department to learn, observe and implement the new standards, and monitor the effects of implementing the new standards” (2). Zhu [2011] noted that when the effective measures are approaches to improve the workflow, it is necessary to set up new standard operating guidelines or revise the existing standard operating guidelines. These guidelines should be included in the hospital’s document control system, and be reviewed at regular intervals. He pointed out that common problems in the standardization phase include: there is the description of the standardization, but there isn’t the standard operating guideline; the standard operating guidelines are not included in the hospital’s document control system; the members of the QCC set up new standards, but they forget to revise or obsolete the existing standard operating guidelines; the hospitals don’t set up the internal review mechanism; and so on (3). Tsong [2008] made a comprehensive study of the standardization. The study covered the definition, purpose and system of the standardization, standards classification and dos and don’ts of drawing up standard operating guidelines. He proposed the key points of the standardization are: list effective improvement measures, standardize these effective measures and the standards should be included in the daily management system of the department (4,5).

To summarize, the study currently focuses on the definition, precautions, problems and basic steps of hospital QCC. Research in this area is relatively small and there is little research on how to promote the standardization of hospital QCC systematically. Only the standardization is done well, can QCCs maintain the effect. The standardization of hospital QCC is studied in this paper. We sum up the problems of the standardization of hospital QCC and construct the flowchart of the standardization of hospital QCC in order to standardize the process and methods of the standardization of hospital QCC.


Research materials and methods

Through analyzing 280 questionnaires on current status of hospital QCC in China and the materials of the 357 participants in the National Quality Control Circle Competition of Chinese Hospitals [2013–2014], which was held by Institute for Hospital Management of Tsinghua University and China Federation for Hospital Quality Control Circle, we perform the research.

The materials of the National Quality Control Circle Competition of Chinese Hospitals [2013–2014]

In this paper, the sample data comes from the first National Quality Control Circle Competition of Chinese Hospitals (96 cases) and the second National Quality Control Circle Competition of Chinese Hospitals (261 cases). To facilitate statistical analysis, we design a data extraction form to extract useful information from the 357 cases, such as district of the hospital, name of the hospital, level of the hospital, theme of the QCC, the problems of the standardization, and so on.

Questionnaires

To investigate the status of implementation of the hospital QCC in China, we sent out 300 questionnaires in Tongji Hospital of Tongji Medical College of HUST, People’s Hospital of Jilin Province and Shanghai Pudong Hospital and we recalled 280 effective questionnaires. The effective recovery ratio of questionnaires is 93.33%. The respondents of the questionnaires are nurses, medical doctors, medical technicians, executives and support staff who had participated in QCC. The survey includes the status of implementation of theme selection, real cause verification, strategy formulation and standardization of hospital QCC in China. For further analysis we extracted the information about the standardization from the questionnaires.


Results

Through analyzing 280 effective questionnaires and the materials of the participants in the National Quality Control Circle Competition of Chinese Hospitals [2013–2014], we find and sum up the problems of the standardization. The following are the main questions.

The description of the standard operation is simple and unspecific and the operability is not strong

The description set up in the standardization of the QCC should be able to give a clear and specific guideline to the field work. Through reading the standard operating guidelines, the medical staff can clearly understand the standard operation procedures. But in the cases we analyzing, up to 49.02% of the standardization is too simple and unspecific. These include: in the step of standardization, the members of the QCC only draw simple flowcharts, and they don’t detail the operation procedure in depth; the members explain the operation procedure beyond the flowchart, but the explanation is too simple. In 5.32% of the cases, the description of the standardization only includes a few words and doesn’t become a system. These could lead to the result that the standards set up in the QCC are not operational and instructive and then the popularization and implementation of the standards could be cramped.

The flowchart is not standard

Flowcharts use simple symbols and a few words to describe the operation procedures. They should be logical, intuitively clear and easily explicable. And the layout of the flowcharts should be clear. The irregularities of the standardization of the QCC basically behave in: the flowcharts of 21.57% of the cases are too simple to clearly describe some key procedures; the flowcharts of 3.36% of the cases are too complex to clearly identify the process; the drawing of the flowcharts of 38.10% of the cases are not standard, such as the starting point can not be determined, the process symbol is not standard, the process and the explanation of the process mixes together, and so on. These non-standard flowcharts would perplex the field operation personnel who refer to the flowcharts and then the flowchart will become a mere formality.

There is the description of the standardization, but there isn’t the standard operating guideline

There is the description of the standardization in 28.29% of the cases, but the standard operating guideline is not set up. It is mainly shown in the following aspects: members of the QCC draw flowcharts, but they don’t work out standard operating guidelines to specifically explain the flowcharts; members don’t work out standard operation procedures and standard operating guidelines, and they only give simple text description on the basis of the practical operation process; members of the QCC formulate standard sheets (patients with indwelling catheters risk assessment form, health education sheet), but they don’t set up standard operating guidelines to further explain the extent of application of the sheets; members of the QCC set up the specifications of the medical supply (elastic chest strap, injection location cards), but they don’t draw up standard operating guidelines to define the material, quality requirements and sizes more specifically. On the basis of the establishment of the standard operation procedures, standard operating rules, standard sheets or standard specifications, we should establish standard operating guidelines and the guidelines should be approved, numbered, published and promoted by the administrative authority. Only in this way, can the fruits of the standardization be consolidated and utilized to the maximum extent.

There is something inappropriate to standardize but actually it is standardized

Standardization is to formulate standard operating guidelines on the basis of the effective measures in the QCC. We find that there is something inappropriate to standardize in 14 cases. In these cases, the members of the QCC standardize some steps or improvement measures of these cases. For example, an improvement measure of a case is to improve the strange surroundings of the operating room so as to reduce the children’s anxiety so that they could cooperate during operation. In this process of QCC, the members survey the children’s preferences, set up improvement actions, divide the surgical area and evaluate the effect. They standardize these improvement measures. This is a one-time process. When the children are satisfied with the new circumstance, the process ends. And when new question emerges in the future, the employees should formulate new methods on the basis of the existing improvements and the methods in this QCC is no longer applicable. Therefore, process and improvement measures of this type are not suitable for standardization.

There are vague sentences in the description of the standardization

The description of the standardization should be clear and the language shouldn’t be abstract and ambiguous. But in 14 cases, there are vague sentences language. It includes: “charge the PDA in time”, “give appropriate financial penalty based on the price of lost equipment”, “give the corresponding small punishment to the employee who are responsible for causing defects of the indwelling catheter management”, and so on. Such terms as “in time”, “appropriate” and “corresponding small punishment” could not give a clear explanation or quantitative definition, and thus the operability of the description of the standardization reduces. For example, “charge in time” can be quantified as “when the remaining power is less than 20%, the nurses have to charge the PDA”. Another example is “appropriate” financial penalties, and in this example, the penalty ratio can be specified as 5% or 10% which is based on the price of the lost devices. These quantitative descriptions can increase the applicability and certainty of the standards.

The standards set up in the QCC are not popularized to relevant departments in the hospital

Through analyzing 280 effective questionnaires, we find that 31.43% of the respondents respond that they don’t popularize the standards to the whole hospital or relevant departments. Because of that the results of the QCC are limited in this QCC or department, and the utility of QCC can not be maximized.

The standards are not integrated with the hospital or department-level regulations

In total, 14.64% of the respondents respond that they don’t integrate the standards set up in the QCC with the existing rules and regulations. This can cause problems and conflicts in the field work. Firstly, through the integration, we can use the new standard to replace some inapplicable clauses in existing rules and regulations to achieve regulatory amendments. Secondly, only the standards being integrated with the regulations, can they become universally applicable standards, have authority and be really used in the departments in the hospital. This integration requires review and approval by the competent authorities.

The standards were not continuously improved in practice

Altogether, 2.86% of the respondents respond that they don’t improve the standards set up in the QCC. Although this proportion is small, it is very worthy of attention. QCC itself follows the concept of PDCA cycle, and the standardization of the QCC should be improved in practice. When new situation emerges and some provisions of existing standards are not suited to current situation, we should review and revise the standards. Sometimes even when the original standards are totally inappropriate to the status quo, we should repeal the standards.

Lack of standardization

There are 4.76% of the cases lack of standardization, which is a great loss to the hospitals and departments. The purpose of implementing the QCC is to improve the field operations and enhance the quality of medical care. After setting up the countermeasures and implementing them for a period of time, we should confirm the validity of the countermeasures by collecting the data or other means. The confirmed effective measures should be translated into the standard operation procedures or rules and regulations in the hospital or the department. Therefore the short-time QCC can bring long-term positive effects on improving workflow and optimizing operational procedures. Considering factors above, the standardization can not be missing in QCCs.


Discussion and recommendations

Through analyzing questionnaires and the materials of the participants in the National Quality Control Circle Competition of Chinese Hospitals [2013–2014], we find that there are some problems of the standardization of Hospital QCC. And in the existing studies the definition and process of the standardization is too general to clearly guide the members of the QCC to carry out the standardization. For the reasons above, combining with relevant research data, we put forward the concept of open QCC and construct the flowchart of the standardization of hospital QCC (as shown in Figure 1).

Figure 1 The flowchart of the standardization of hospital QCC.

Draw up standard operating guidelines

The standardization of the QCC can not only stay in the description of the standards or draw a flowchart. Members of QCC have to formulate or revise the standard operating guidelines. Considering the familiarity with the standards, the guidelines should be set up by the members of QCC. Exemplification of the standard operating guidelines is shown in Figure 2, and this exemplification applies to standardize the operation procedures. Standardization is divided into different forms. It includes standardizing the operation procedures, standardizing the sheets, standardizing the specifications of the medical supplies, and so on. We can modify the contents of the standard operating guidelines based on different forms. If it is to standardize the sheets, the contents can be modified as: purpose, the extent of application, the content of the work, the sheet, the instructions of the sheet and supplementary provisions. If it is to standardize the specifications of the medical supplies, the contents can be modified as: purpose, the extent of application, the content of the work, the specifications and the description of the materials of this medical supply, the instructions of this medical supply and supplementary provisions. The standard operating guidelines should be formulated for each hospital according to the actual situations. However, the whole hospital should use unified standard operating guidelines to facilitate the eventual inclusion in the hospital file system.

Figure 2 The example table of standard operation procedure of hospital QCC.

Following are precautions in formulating standard operating guideline: (I) not all the effective measures in the QCC can be standardized, and the selection of the object of the standardization must be discussed with reserve; (II) generally the procedures which are repeated many times and operated by many persons and the sheets which are required with a large amount are suitable as the object of the standardization; (III) don’t put irrelevant content into the standardization; (IV) the standards should be specific and the members of QCC should use numbers to quantify the description in formulating the standard operating guidelines, and they shouldn’t use ambiguous words such as “appropriate”, “in time” and so on; (V) formulating the flowchart should be standard, and the flowcharts can not be too simple or too complex. When we draw the flowchart, we should pay particular attention to the following: (I) use unified symbols (as shown in Figure 3); (II) the start and the end of the process should be very clear (the “Start” symbol can appear only once, and the “End” symbol can appear multiple times); (III) there is only one indication arrow under the same path; (IV) the complex flowchart can be divided into several smaller flowcharts; (V) the dead cycle shouldn’t appear; (VI) minimize cross flow lines.

Figure 3 Frequently-used symbols in the flowchart.

The consulting about the standard operating guideline

The standard operating guidelines are drawn up on the basis of the effective measures and actual situations. They may not be considered in detail. Furthermore, taking into account the particularity and the complexity of medical activities, the standardization of QCC in hospitals should be more cautious than that in companies. Therefore, the open QCC mechanism can be introduced. Members of QCC can consult relevant persons about the appropriateness of the standard operating guidelines and thus the half closed QCC system can develop into an open system. The persons who are included in the open QCC mechanism can be selected according to the extent of application of this standard and generally the members of the same department who are out of the QCC, staff and leaders in relevant departments and competent leaders of the hospital are included in the open QCC mechanism. We should pay special attention to the selection of the persons out of the QCC and the relevance between them and the content of the guidelines. These people should participate the QCC activities moderately in order to guarantee provision of practical opinions and suggestions, without destroying the autonomy and initiative of the members of the QCC. The introduction of open QCC mechanism can propose amendments to the standard operating guidelines and make the guidelines more adapted to the actual work. This step also lays a good foundation for the popularizing and the implementing of the standards.

Check and approve the standard operating guidelines, number them, bring them into the file system and publish the guidelines

According to different ranges the standard operating guidelines are related to, relevant competent authorities are responsible for the checking, approving, numbering and publishing of the standard operating guidelines. Once the standard operating guideline is published, it has the authority, and relevant departments should implement the standard. The standards set up in QCC should be integrated with the existing regulations and rules in the hospital. And in the integration establishing new standards and revising or repealing the existing standards are of equal importance.

Popularize and implement the standards

After the standard operating guidelines are published, the staff in the hospital should popularize and implement the standards and thus the standards can have desired effect. Otherwise the standard operating standard may be turned into a dead letter. Only do the field staff completely understand the contents of the standards, can they be able to work according to the standards. Therefore it is necessary to constitute the education and training plan. Through education and training, relevant departments and personnel can understand the specific content of the standard operating guidelines, and they will attach more importance to the guidelines.

Revise the standard operating guidelines continuously or repeal them

With advances in technology standards should be constantly revised and the standard operating guidelines set up in QCC are also the same. In the implementation of the standard operating guidelines, if they are not applicable with the change of scene, the staff should report to the competent authorities and revise them in time. When the standard is completely inapplicable, the guidelines should be repealed and the new standard operating guidelines should be formulated on the basis of the new situation. Thus, the standardization of the QCC really follows the PDCA cycle.


Acknowledgements

None.


Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.


References

  1. Wang L, Wang Y, Zhang X, et al. The Application Value of the QCC Management in medical institutions. Herald of Medicine 2012;31:823-6.
  2. Liu T, Liu Y. editors. Chinese Hospital QCC Operation Manual. Beijing: People’s Medical Publishing House, 2012:25.
  3. Zhu S. editor. The Theory and Practice of Quality and Patient Safety Management in Medical Institution. Taipei: Farseeing Publishing Group, 2011:77-81.
  4. Tsong CS. editor. Q-PAT Method. Guangzhou: Guangdong Economy Publishing House, 2008:109-17.
  5. Tsong CS. editor. The Standardization Practice in Companies. Shanghai: Fudan University Press, 2008:1-36.
doi: 10.21037/jrh.2016.09.06
Cite this article as: Liu T, Zhang D, Shi H. Analysis on the problems and countermeasures of the standardization of hospital QCC in China. J Res Hosp 2016;1:20.

Refbacks

  • There are currently no refbacks.