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Managing healthcare quality using combined SWOT and the analytic hierarchy
process approach

Article  in  International Journal of Healthcare Technology and Management · July 2008

DOI: 10.1504/IJHTM.2008.019675

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Prasanta Kumar Dey Seetharaman Hariharan

Aston University University of the West Indies, St. Augustine
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 Int. J. Healthcare Technology and Management, Vol. 0, No. 0, 0000 1

111
2 Managing healthcare quality using combined SWOT
3 and the analytic hierarchy process approach
4
5
Is Prasanta K.
Dey cited as
the correct
Prasanta K Dey*
corresponding
author? Thanks Aston Business School, Aston University, Birmingham B4 7ET, UK
E-mail: p.k.dey@aston.ac.uk
6 *Corresponding author
7
8 Seetharaman Hariharan
Please supply
e-mail address Anaesthesia and Intensive Care, The University of the West Indies,
for
Seetharaman St. Augustine, Trinidad
Hariharan.
Thanks E-mail:
Abstract: Improving healthcare quality is a growing need of any society.
9 Although various quality improvement projects are routinely deployed by the
1011 healthcare professional, they are characterised by a fragmented approach,
1 i.e. they are not linked with the strategic intent of the organisation. This study
2 introduces a framework which integrates all quality improvement projects with
3 the strategic intent of the organisation. It first derives the strengths, weaknesses,
opportunities and threats (SWOT) matrix of the system with the involvement of
4 the concerned stakeholders (clinical professional), which helps identify a few
5 projects, the implementation of which ensures achievement of desired quality.
6 The projects are then prioritised using the analytic hierarchy process with the
7 involvement of the concerned stakeholders (clinical professionals) and
8 implemented in order to improve system performance. The effectiveness of the
method has been demonstrated using a case study in the intensive care unit of
9 Queen Elizabeth Hospital in Bridgetown, Barbados.
2011
1 Keywords: analytic hierarchy process; healthcare services; project prioritising;
2 quality management; SWOT matrix.
3
Reference to this paper should be made as follows: Dey, P.K. and Hariharan, S.
4 (0000) ‘Managing healthcare quality using combined SWOT and the analytic
5 hierarchy process approach’, Int. J. Healthcare Technology Management,
6 Vol. 00, Nos. 0/0, pp.000–000.
7
8 Biographical notes: Prasanta Kumar Dey is a senior lecturer at Aston Business
School in the UK. He was previously with the University of the West Indies,
9 Barbados, and the Indian Oil Corporation Ltd, India. He has a PhD in
30 Engineering, a Master’s in Industrial Engineering and Management and a
1 Bachelor’s in Mechanical Engineering. His research interests include
2 performance measurement and management in manufacturing and services
3 industry, project management, risk management, and supply chain management.
He has published extensively in internationally refereed journals. He is the
4 co-editor of International Journal of Energy Sector Management.
5
6 Seetharaman Hariharan is a senior lecturer in anaesthesia and intensive care with
7 the University of the West Indies, St. Augustine, Trinidad and Tobago. After
gaining his MBBS degree, he has had experience in internal medicine for six
8
9
40
Copyright © 0000 Inderscience Enterprises Ltd.
 2 P.K. Dey and S. Hariharan

111 years. He obtained a post-graduate MD degree in India and worked as a senior

2 registrar with the Queen Elizabeth Hospital, Barbados. His research interests
include quality management practices in healthcare, healthcare performance
3
measurement, and clinical research in critical care. He has published widely in
4 peer-reviewed international journals.
5
6
7
8 1 Introduction
9
1011 Today’s healthcare services use Continuous Quality Improvement (CQI), Total Quality
1 Management (TQM), process reengineering, benchmarking, supply chain Management
2 (SCM), and Six Sigma in order to improve performance. There is evidence of increasing
3 interest in deploying quality programs in healthcare. In a recent survey, healthcare CEOs
4 expressed a 62% likelihood of launching a new quality initiative in the next year,
5 compared with 52% for manufacturing CEOs, 31% for education top administrators, and
6 35% for other services CEOs (Weiler, 2004). These programmes are centred on employee
7 commitment, customer evaluation and process improvement (Gowen et al., 2006).
8 Although quality management tools and techniques have successfully been applied in the
9 manufacturing and industrial services sector, they have been adapted recently to
2011 healthcare (Barry and Smith, 2005).
1 CQI concept has been applied in healthcare by many researchers in the Emergency
2 Department (Fernandes and Christenson, 1995, 1996; Re and Krousel-Wood, 1991).
3 Data-Attitude-Tools (D*A*T), Deming’s PDCA cycle, Utilization Review and
4 Management have been suggested for quality improvement in healthcare services by
5 researchers (Berwick, 1998; Van Matre, 1992). Quality function deployment has been
6 used to focus on customer requirements in healthcare (Chaplin and Terninko, 2000).
7 Increasingly, an integrated patient safety team is used in hospitals for solving patient
8 safety problems (Gandhi et al., 2003). Six Sigma has been extended to healthcare (Barry
9 et al., 2005; Carey, 2003; Chassin, 1998) in order to improve mortality and morbidity in
30 hospital-based healthcare. CQI also includes statistical quality and process control as well
1 as the other quantitative tools such as checksheets, histograms, Pareto analysis, cause and
2 effect diagrams, flow charts etc. (Bell and Krivich, 2000). Benchmarking healthcare
3 facilities for best practices has emerged as the most common process improvement
4 approach (Dolan, 2003). Healthcare organisations have also recognised the impact of
5 effective SCM (Tucker, 2004) and exploited it for quality improvement (Bendoly et al.,
6 2004). According to Gowen and Tallon (2005) effective management of quality strongly
7 depends on SCM.
8 Although various quality improvement programmes contribute towards improved
9 performance, their effectiveness depends on how efficiently they can be integrated with
40 the organisational strategies and project management practices (Dey and Hariharan, 2006).
1 Moreover, many of the contemporary practices are general guidelines and do not
2 specifically address the unique problems of specific services in the hospital-based
3 healthcare system. Additionally, planning, implementing and evaluating the improvement
4 projects are equally challenging tasks, which were not discussed by any of the above
5 studies. In the hospital-based healthcare practices, there are uniform and global
6 approaches towards identifying deficiencies of specific service and planning strategies to
711 mitigate those deficiencies in order to achieve superior performance (Lurie et al., 2002).
8
Is this
shortened Managing healthcare quality 3
running header
OK? If not,
please provide Most healthcare units use a peer-review process to identify issues and concerns of
copy that will
fit this space. improved performance (Snelson, 1992). The Joint Commission on Accrediting Health
Thanks.
Care Organizations proposed a ‘10-step monitoring and evaluation process’ for improving
111
quality of healthcare services (Evan and Lindsay, 2002). Although this identifies problems
2
and concerns, it does not provide a framework of strategies for corrections and
3
improvement. Chen et al. (2004) reported issues of implementing total quality
4
management projects in healthcare service in Taiwan.
5
In view of the above, there is need of an integrated model, which provides all the
6
aspects of quality improvement from concept to implementation for superior performance.
7
Organisations require fostering a quality culture, which would motivate the process
8 owners to identify issues/problems in the system dynamically, suggest solutions to those
9 issues and develop a framework for implementation of those solutions. Relating
1011 improvement measures of each service with the strategies of the entire organisation are
1 another challenge to healthcare services providers. The objective of this study is to
2 develop an integrated quality management model for hospital-based healthcare services.
3
4
5 2 Methodology
6
7 This study adopts a case study approach with the involvement of the concerned
8 stakeholders (clinical professional) using focus group discussions. The proposed quality
9 improvement framework has been applied to the intensive care unit (ICU) of Queen
2011 Elizabeth Hospital in Barbados in order to demonstrate its effectiveness to improve quality
1 of specific healthcare unit.
2 Several focus group discussions were undertaken with the involvement of the
3 anaesthetists and senior intensive care nurses to analyse the internal and external
4 environments of the system, identifying and prioritising quality improvement projects.
5 The organisation of the paper is as follows: Section 3 introduces the proposed quality
6 improvement model, Section 4 demonstrates the application of the model in a specific
7 healthcare organisation, Section 5 discusses the utility of the proposed model in order to
8 improve organisational performance, and Section 6 concludes the study with the
9 illustration of specific findings.
30
1 3 The proposed quality improvement model
2
3 The proposed framework has the following steps:
4

step 1: identifying a system for quality improvement and its environment
5
6
step 2: deriving strengths, weaknesses, opportunities and threats (SWOT) of the
7 system under study
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step 3: formulating SWOT matrix with various strategies
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step 4: deriving projects from strategies
1

step 5: identifying criteria for project prioritising
2
3
step 6: developing hierarchical framework for project prioritising
4

step 7: prioritising projects for implementation using analytic hierarchy process.
5
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111 4 Application
2
3 One of the most important areas of a hospital is the ICU, which provides support for
4 critically ill patients. ICU consumes a large share (about 10%) of budgetary allocations of
5 a hospital. Until recently, the performance of ICU was measured by prognostic scoring
6 systems such as the ‘Acute Physiology and Chronic Health Evaluation’ (APACHE); the
7 Simplified Acute Physiology Score (SAPS) or the ‘Mortality Prediction Model’ (MPM)
8 (Zimmerman, 2002). All of these systems consider binomial patient outcome namely
9 ‘survival’ or ‘death’ as the indicators of measurement. These systems incorporate logistic
1011 regression equations to predict the mortality for a case-mix in a particular ICU. The ratio
1 of the predicted mortality to the observed mortality (Standardised Mortality Ratio – SMR)
2 is used to compare the performance of different ICUs (Becker and Zimmerman, 1996).
3 Although used by many studies, there are many inherent problems with these models: a
4 study which has used all three models to compare ICUs from 32 hospitals (Project
5 IMPACT) reported only a fair-to-moderate agreement in the identification of quality
6 measures (Glance et al., 2002). Other studies have reported poor goodness of fit for these
7 scoring systems, implying that the prognostic models do not perform consistently in all
8 ICUs (Katsaragakis et al., 2000; Marik and Varon, 1999; Markgraf et al., 2000). Although
9 patient outcome should always be the primary goal of any ICU, there are many other
2011 contributory factors that also have to be considered which are omitted from these scoring
1 systems. Attempts have been made to resolve these omissions using such methods as Data
2 Envelopment Analysis (DEA) which have helped to improve structural measures
3 (Dlugacz et al., 2002; Field and Emrouznejad, 2003).
4 Changes in individual ICU outcome factors such as an increase in ‘mortality rate’ could
5 be interpreted as a reduction in the level of overall performance. However, it is imperative
6 that before any conclusions are finalised all possible causes must be considered.
7 Many of the outcome-based models do not incorporate root cause analysis of the
8 problems, which may be the causative factors for the reduced performance. They do not
9 suggest enablers for correcting the problems once they are identified and do not provide a
30 framework for strategies for correction and improvement. The managers of the units
1 design their own methods from the performance appraisal level to the implementation
2 strategy level. With the presently available models of performance measurement, most of
3 the units qualify with honours and it is difficult to distinguish whether they genuinely
4 perform well or it is grade inflation (Green et al., 1997; Popovich, 2002). Therefore, there
5 is a need of new models, which provide all these aspects of quality improvement as a
6 package for the manager and link them with the organisational strategies. The proposed
7 quality improvement framework has been applied to the ICU of a hospital in Barbados in
8 order to demonstrate its effectiveness in improving quality of specific healthcare unit.
9
40 4.1 Hospital and ICU setting
1
2 Barbados is an island of the Eastern Caribbean, with a population of 268,000. It is an
3 English-speaking country of the British Commonwealth with a high quality-of-life index.
4 The Queen Elizabeth hospital is a 650-bed tertiary care centre, affiliated to the University
5 of the West Indies and a referral centre for several Caribbean countries. The
6 multidisciplinary ICU in the Queen Elizabeth hospital is a six-bed open unit, admitting
711 patients from all specialties.
8
 Managing healthcare quality 5

111 4.1.1 Step 1: identifying a system for quality improvement and its environment
2 An organisation may select a specific system for performance improvement on the basis
3 of either the criticality of its operations in terms of customer satisfaction and business
4 success or unsatisfactory current performance. In this study, the ICU of the hospital had
5 been chosen on the basis of the criticality of its operations for overall patient satisfaction.
6 Figure 1 shows the ICU system for the case under study and its environment.
7
8 4.1.2 Step 2: deriving strengths, weaknesses, opportunities and threats
9 After identifying the system for the study, the next step of the model was to identify the
1011 strengths, weaknesses, opportunities and threats of the ICU. Strengths and weaknesses
1 refer to those within the organisation of the ICU. Opportunities and threats are those forces
2 arising from developments or changes often outside the ICU. The clinicians involved in
3 the day-to-day management of the ICU were interviewed and the existing problems of the
4 ICU were identified by discussions and brainstorming sessions.
5 The participants identified appropriate ICU setting for 14-bed occupancy, availability
6 of state-of-the-art monitoring equipment, aggressive therapeutic intervention, competent
7 clinical professionals, the presence of a high dependency unit close to ICU, availability of
8 adequate research facilities, link with academia and good working environment, as
9 strengths of the ICU in Queen Elizabeth Hospital. They also identified a critical shortage
2011 of nurses and support staff, weak patient administration, weak human resource
1 management practices, a poor information and communication technology framework,
2 and slow adoption of newer recommendations and technology as the weaknesses.
3 Additionally, advancement in healthcare technology as well as information technology,
4 government support in healthcare, rapid development in healthcare management research
5 and globalisation, were identified as the opportunities, and increasing awareness,
6 competition from other hospitals, increasing legal complication and poor functioning of
7 other units of hospital were identified as the threats to the ICU under study.
8
9 4.1.3 Step 3: formulating SWOT matrix with various strategies
30 The next step was to construct the SWOT matrix using information from the previous step.
1 Figure 2 shows the SWOT matrix for the ICU under study. It revealed various strategies
2 of the ICU under study. The strategies, which had been formulated by capitalising the
3 organisation’s strengths and environmental opportunities are developing a supply chain
4 management framework in order to develop long-term relationship with technology
5 providers, equipment, drug and disposable suppliers; retaining of competent consultants
6 and doctors; encouraging the clinical professionals to get involved in healthcare
7 management research; and developing the information and communication technology
8 framework. Recruiting of competent clinicians and developing human resources
9 management policy for ICU management were derived as WO–strategies. The participants
40 derived continuous performance improvement, integrating medical practices with the legal
1 framework, and developing the communication framework with other units of hospital as
2 ST-strategies. Organising both technical and management training for clinical
3 professionals and putting emphasis on changing hospital policy for customer-focused
4 patient care using standardised processes were WT-strategies, as derived by the
5 participants of the ICU under study.
6
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 6 P.K. Dey and S. Hariharan

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 Managing healthcare quality 7

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 8 P.K. Dey and S. Hariharan

111 4.1.4 Step 4: deriving projects from strategies

2 The participants then identified three projects from the above strategies after thorough
3 brainstorming. The projects were implementing supply chain management (SCM) in an
4 information and communication technology framework; improving ICU infrastructure;
5 and recruiting and training of clinical professionals. The brief descriptions of the projects
6 are as follows.
7
8 Project 1: managing supply chain in information and communication technology (ICT)
9 framework. The project would improve intra and inter unit communication and materials
1011 flow from external sources. Additionally, communication with concerned stakeholders
1 (clinical professionals, management, patients, government, consultants, technology
2 suppliers, drug and disposables suppliers, and contractors) would also improve. The
3 project would also improve treatment protocol covering therapeutic intervention,
4 antibiotic protocol, infection control, monitoring, daily rounds, case reviews, and
5 admission and discharge protocol and improve healthcare management processes with
6 customer focus. The scope of works includes installation of hardware, software,
7 networking and security systems; recruiting ICT professionals; and training of clinical
8 professionals for effective SCM using ICT, establishing long-term contract/partnership
9 among suppliers, contractors, consultants and technology suppliers and establishing
2011 integrated clinical and management processes.
1 Project 2: improving ICU infrastructure. This project would improve the physical
2 infrastructure of the ICU under study along with procuring state-of-the-art technology
3 equipment.
4
5 Project 3: recruiting and training of clinical professionals. Recruitment and training
6 would ensure an increased number of competent clinical professionals. The project
7 would consist of recruiting clinical professionals and administrative personnel after
8 thorough human resource requirement analysis, identifying their training needs along
9 with the needs of current employees and managing the entire process.
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4.1.5 Step 5: identifying criteria for project prioritising
1
2 It was planned to implement the above projects on the basis of their priority in relation to
3 the organisation’s competitive strategy. The participants identified the overall cost of the
4 projects, likely benefits, customer satisfaction and project characteristics, as the criteria for
5 project prioritisation.
6 Both the capital and operating costs of the project are important factors for project
7 selection. Project benefits can be measured by morbidity, mortality, advanced patient
8 occurrences and patient throughput (Hariharan et al., 2005). Hence, they are important in
9 order to prioritise projects. Various stakeholders are involved in healthcare services. Their
40 satisfaction is important in order to improve patient satisfaction. Various improvement
1 projects would bring varied levels of satisfaction to the customer. The analysis of
2 customer satisfaction with respect to patients, clinical professionals (doctors, nurses, and
3 support staff) are important for project prioritisation. Each project has its own
4 characteristics (work contents), which determine its technical complexity, schedule, risk,
5 faster implementation and user friendliness during operations. Project prioritising would
6 depend on those characteristics of projects.
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 Managing healthcare quality 9

111 4.1.6 Step 6: developing hierarchical framework for project prioritising using
2 analytic hierarchy process
3
4 Steps 4 and 5 demonstrate the characteristics of the projects and the factors for their
5 prioritising. These reveal that factors are both objective as well as subjective. Additionally,
6 they are conflicting in nature, i.e. if a specific factor prioritises a project, other factors
7 prioritise another project. These call for using multi-attribute decision-making techniques
8 for prioritising projects for quality improvement. The participants decided to use the
9 analytic hierarchy process (AHP), a multi-attribute decision-making technique (Saaty,
1011 1980) in order to prioritise quality improvement projects for the ICU under study.
1 Figure 3 shows the hierarchical project selection framework for ICU using AHP.
2
3 4.1.7 Step 7: prioritising projects for implementation using AHP
4
5 The AHP developed by Saaty (1980) provides a flexible and easily understood way of
6 analysing complicated problems. It is a multiple criteria decision-making technique that
7 allows subjective as well as objective factors to be considered in decision-making
8 processes. The AHP allows the active participation of decision makers in reaching an
9 agreement, and gives managers a rational basis on which to make decisions. AHP is based
2011 on the following three principles: decomposition, comparative judgement, and synthesis
1 of priorities. The AHP is a theory of measurement for dealing with quantifiable and
2 intangible criteria that has been applied to numerous areas, such as decision theory and
3 conflict resolution (Vargas, 1990). AHP is a problem-solving framework and a systematic
4 procedure for representing the elements of any problem (Saaty, 1983).
5 Formulating the decision problem in the form of a hierarchical structure is the first step
6 of AHP. In a typical hierarchy, the top level reflects the overall objective (focus) of the
7 decision problem. The elements affecting the decision are represented in intermediate
8 levels. The lowest level comprises the decision options. Once a hierarchy is constructed,
9 the decision-maker begins a prioritisation procedure to determine the relative importance
30 of the elements in each level of the hierarchy. The elements in each level are compared as
1 pairs with respect to their importance in making the decision under consideration. A verbal
2 scale is used in AHP that enables the decision maker to incorporate subjectivity,
3 experience, and knowledge in an intuitive and natural way. After comparison matrices are
4 created, relative weights are derived for the various elements. The relative weights of the
5 elements of each level with respect to an element in the adjacent upper level are computed
6 as the components of the normalised Eigenvector associated with the largest Eigen value
7 of their comparison matrix. Composite weights are then determined by aggregating the
8 weights through the hierarchy. This is done by following a path from the top of the
9 hierarchy to each alternative at the lowest level, and multiplying the weights along each
40 segment of the path. The outcome of this aggregation is a normalised vector of the overall
1 weights of the options. The mathematical basis for determining the weights was
2 established by Saaty (1980).
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 10 P.K. Dey and S. Hariharan

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 Managing healthcare quality 11

111 Project selection is usually a team effort, and the AHP is one available method for forming
2 a systematic framework for group interaction and group decision making (Saaty, 1982).
3 Dyer and Forman (1992) describe the advantages of AHP in a group setting as follows:
4

both tangibles and intangibles, individual values and shared values can be included
5
in an AHP-based group decision process
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the discussion can be structured so that every factor relevant to the discussion is
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1011 considered in turn
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in a structured analysis, the discussion continues until all relevant information from
2 each individual member in a group has been considered and a consensus choice of
3 the decision alternative is achieved.
4
5 A detailed discussion on conducting AHP-based group decision-making sessions,
6 including suggestions for assembling the group, constructing the hierarchy, getting the
7 group to agree, inequalities of power, concealed or distorted preferences, and
8 implementing the results, can be found in Saaty (1982) and Golden et al. (1989). For
9 problems with using AHP in group decision making, see Islei et al. (1991).
2011 The participants derived through extensive brainstorming the importance of each
1 factor and the sub-factors by pair-wise comparison using a nine-point numerical scale
2 (Table 1). Table 2 shows the pair-wise comparison in factor level and Table 3 shows the
3 normalised matrix with weights of each factor. Similarly, relative importance of each
4 subfactor was also derived. Subsequently, the alternatives are pair-wise compared with
5 respect to each sub factor in order to develop priorities of each alternative. Then the results
6 were synthesised across the hierarchy to derive the overall priority of the projects. The
7 results are shown in Table 4. The study used Expertchoice™ software and consistencies
8 of all the matrices were checked along with overall consistency, which were within 10%.
9
30 Table 1 Nine point scale for pair-wise comparison
1
2 Intensity of pair-wise Importance
3 comparison
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1 Equal importance, two activities contribute equally to the object
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6 3 Moderate importance, slightly favours one over another
7 5 Essential or strong importance, strongly favours one over another
8 7 Demonstrated importance, dominance of the demonstrated importance in
9 practice
40 9 Extreme importance, evidence favouring one over another of highest
1 possible order of affirmation
2 2, 4, 6, 8 Intermediate values, when compromise is needed
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4 Source: Saaty (1980).
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 12 P.K. Dey and S. Hariharan

111 Table 2 Pair-wise comparison in factor level to derive factor importance

2
Cost Benefit Customer satisfaction Project characteristics
3
4 Cost 1.00 0.50 1.00 2.00
5 Benefit 2.00 1.00 2.00 3.00
6 Customer satisfaction 1.00 0.50 1.00 2.00
7 Project characteristics 0.50 0.33 0.50 1.00
8 Column sum 4.50 2.33 4.50 8.00
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1011 Table 3 Normalised matrix
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2 Cost Benefit Customer Project Weights
3 satisfaction characteristics
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Cost 0.22 0.21 0.22 0.25 0.23
5 Benefit 0.44 0.43 0.44 0.38 0.42
6 Customer satisfaction 0.22 0.21 0.22 0.25 0.23
7 Project characteristics 0.11 0.14 0.11 0.13 0.12
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In a common objectives context where all members of the group have the same objectives,
2011
there are four ways that could be used for setting the priorities:
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geometric mean of the individuals’ judgments
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separate models or players (Dyer and Forman, 1992).
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In the present study, all pair-wise comparisons were made using group consensus.
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The participants gave highest priority to the ‘managing supply chain in ICT framework’
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project. They ranked ‘improving ICU infrastructure’ and ‘recruiting and training clinical
30
professionals’, second and third respectively. The participants came to consensus on
1
‘benefit’ as the most important criteria for quality improvement project prioritisation. Lower
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capital cost, benefit to ICU processes, patient satisfaction and project risk were considered
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as the most important sub criteria for improvement project prioritisation.
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Currently, the ‘managing supply chain in ICT framework’ project has been implemented
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using a process-reengineering framework (Dey, 2001). In the reengineered processes
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changes were made as follows. A therapeutic intervention scoring system (TISS) was
7
adopted to assess the intensity of therapeutic interventions received by the patients admitted
8
to the ICU. This scoring system was applied on a daily basis from the day of admission to
9
the day of discharge of every patient. The overall result showed that the therapeutic intensity
40
of the ICU under study is comparable with international standards. Regular teaching
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sessions for the junior medical officers and the critical care nurses were organised in order
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to prevent iatrogenic complications. Additionally, a database was set up to record the
3
illness severity of the patients admitted to the ICU. The Simplified Acute Physiology
4
Score – version II (SAPS II) and the Pediatric Index of Mortality – version 2 (PIM2) were
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adopted regularly for adult and paediatric patients respectively, in order to assess the
6
severity of illness of the case mix admitted to the ICU and follow up their outcome.
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Criteria Weights Sub-criteria Weights Project 1: Managing Project 2: Improving Project 3: Recruitment and
supply chain infrastructure training

LP GP LP GP LP GP LP GP

Cost 0.23 Capital cost 0.600 0.138 0.380 0.052 0.210 0.029 0.410 0.057
Operating cost 0.400 0.092 0.370 0.034 0.380 0.035 0.250 0.023
Benefit 0.42 Morbidity 0.280 0.118 0.380 0.045 0.350 0.041 0.270 0.032
Mortality 0.300 0.126 0.360 0.045 0.420 0.053 0.220 0.028
Advanced patient 0.300 0.126 0.350 0.044 0.450 0.057 0.200 0.025
Managing healthcare quality

occurrences
Patient throughput 0.120 0.050 0.370 0.019 0.250 0.013 0.380 0.019
Customer 0.23 Patient 0.480 0.110 0.380 0.042 0.370 0.041 0.250 0.028
satisfaction Clinical 0.270 0.062 0.350 0.022 0.200 0.012 0.450 0.028
professionals
Management 0.250 0.058 0.340 0.020 0.350 0.020 0.310 0.018
Table 4 Prioritising projects using an analytic hierarchy process

Project 0.12 Risk 0.330 0.040 0.180 0.007 0.340 0.013 0.480 0.019
characteristics Faster 0.120 0.014 0.280 0.004 0.280 0.004 0.440 0.006
implementation
Complexity 0.230 0.028 0.190 0.005 0.390 0.011 0.420 0.012
Schedule 0.170 0.020 0.350 0.007 0.250 0.005 0.400 0.008
User friendly 0.150 0.018 0.420 0.008 0.360 0.006 0.220 0.004
0.354 0.341 0.306

Notes: LP: local percentage, GP: global percentage.

13
 14 P.K. Dey and S. Hariharan

111 Information from the microbiology laboratories was assimilated to reveal the spectrum of
2 microbial infections in the ICU and their sensitivity to various antibiotics. This culminated
3 in formulating an antibiotic protocol. The clinical director of the ICU had arranged
4 conferences with the various departments who admit their patients in the ICU, which
5 improved interdepartmental communication. The Ministry of Health had recently
6 formulated a National Policy for admission and discharge to ICUs, which had also been
7 implemented in the institution.
8 Long-term partnership was developed with drug and disposable suppliers, equipment
9 and instrument manufacturers and suppliers, and infrastructure maintenance contractors.
1011 Dynamic monitoring of customers’ satisfaction and effective communication with
1 government was done through IT infrastructure.
2
3
4 5 Discussion
5
6 Quality in healthcare is usually assessed by three parameters namely structure, process and
7 outcome of healthcare (Donabedian, 1988). Quality improvement measures should always
8 include all the three parameters, which are remarkably missing in the current models. The
9 structure of the hospitals is assessed by the human and material resources available in each
2011 hospital. Processes of hospital operations has been difficult to measure by specific metrics
1 (US News & World Report, 1990). Some authors have recommended process measures,
2 but this may require large databases, which may not be consistently available (Palmer
3 1997). Researchers used various performance measurement methods using data envelop
4 analysis (DEA), fuzzy theory, balanced score card, analytic hierarchy process etc. in order
5 to identify quality improvement projects in healthcare systems (Hariharan et al., 2005).
6 However, they suffer from not having sufficient link with the organisational strategies
7 (Hariharan et al., 2004, 2006). The proposed model incorporates all the three parameters
8 (structure, process and outcome) of healthcare evaluation along with the consideration of
9 organisational strategies.
30 As mentioned earlier, most of the performance appraisal methods of healthcare units
1 have a fragmented approach. Some institutions have peer review committees to audit the
2 morbidity and mortality of patients (Snelson, 1992). Peer review is invariably done
3 retrospectively and analyses the deficiency in patient care, which could have contributed
4 to the adverse patient occurrences. Although effective as a quality improvement measure
5 with respect to patient care there are many inherent difficulties when this is considered as
6 the major or one and only approach (which is true in many institutions). The multifarious
7 schools of thought involved in patient care could justify the approach taken towards the
8 patient, unless it is an obvious deficiency in patient care. Peer review predominantly
9 approaches the technical aspect of patient care and most often may not give weight to the
40 other aspects, such as human and material resources, which could have possibly
1 contributed to the morbidity and mortality. Thus, this method does not appraise the
2 performance as a whole. Furthermore, it is too focused on the aspect of the deficiency of
3 patient care and may not approach the performance of the organisation from other factors
4 not involved with deficiency in patient care. Additionally, this method might only find the
5 deficiencies and may not be able to provide enablers to mitigate various factors involved
6 in a framework for the manager to implement.
711
8
 Managing healthcare quality 15

111 The present model addresses many of the aforementioned disadvantages of the
2 existing quality improvement methods:
3

it approaches the performance of the organisation from a holistic point of view by
4
incorporating every factor
5
6
it does not limit itself to the morbidity and mortality of patients
7

it reviews the various important aspects of the infrastructure of the healthcare unit
8
such as material and human resources
9
1011
it also provides the manager a project management framework in order to plan and
1 implement improvement projects
2

it is not necessary to wait for adverse patient occurrences to do a retrospective
3
analysis, but the model may be applied in continuum on an ongoing basis for
4
continuous quality improvement
5
6
it also facilitates the prioritisation of implementation measures objectively to quickly
7 improve the performance of the unit
8

quality improvement measures are linked with the strategic intent of the organisation
9
2011
it involves the process owners in making decisions.
1 The major pitfall of the present model is that it has only been applied in an ICU setting of
2 a hospital. Additionally, both the SWOT matrix and project prioritising using AHP totally
3 rely on organisational effectiveness in making a right decision.
4
5
6 6 Conclusion
7
8 Quality improvement projects are not always linked to the strategic intents of the entire
9 organisation (e.g. specific departmental initiative to improve quality). A synergy between
30 the bottom-up and top-down approach for quality improvement improves organisational
1 effectiveness. An integrated approach to quality improvement by identifying quality
2 improvement projects using strategic management tools like SWOT and subsequently
3 prioritising those projects using the analytic hierarchy process with the involvement of the
4 concerned stakeholders ensures synergies between operational requirements and
5 organisations’ business strategies. Today’s healthcare services are extremely demanding
6 because of the constant variations in the customers’ needs, the intense competitive
7 environment and rapid technological advancement. Hence, a dynamic analysis of the
8 environment with the involvement of the stakeholders, deriving improvement measures
9 and fast implementation of those improvement projects are keys for success. The proposed
40 model has been successfully implemented in the ICU of a hospital in a developing country
1 and a subsequent stakeholder validation survey revealed that the model could be used
2 dynamically for evaluating the performance of any system along with other existing
3 performance measurement models in healthcare services.
4
5
6
711
8
 16 P.K. Dey and S. Hariharan
Please advise
issue numbers References
throughout if
known. Thanks
111 Barry, R. and Smith, A.C. (2005) The Manager’s Guide to Six Sigma in Healthcare, Milwaukee, WI:
2 ASQ Quality Press.
3 Barry, R., Murcko, A.C. and Brubaker, C.E. (2005) The Six Sigma Book For Healthcare, Chicago:
4 Health Administration Press.
5 Becker, R.B. and Zimmerman, J.E. (1996) ‘ICU scoring systems allow prediction of patient
6 outcomes or comparison of ICU performance’, Critical Care Clinic, Vol. 12, pp.503–514.
7 Bell, R. and Krivich, M. (2000) How to Use Patient Satisfaction Data To Improve Healthcare
8 Quality, Milwaukee: ASQ Press.
9 Bendoly, E., Soni, A. and Venkataramanan, M.A. (2004) ‘Value chain resource planning: adding
value with system beyond the enterprise’, Business Horizons, Vol. 47, No. 2, pp.79–86.
1011
1 Berwick, D.M. (1998) ‘Developing and testing changes in the delivery of care’, Annals of Internal
Medicine, Vol. 128, pp.651–656.
2
Carey, R.G. (2003) Improving Healthcare With Control Charts, Milwaukee, WI: ASQ Press.
3
4 Chaplin, E. and Terninko, J. (2000) Customer Driven Healthcare: QFD For Process Improvement
and Cost Reduction, Milwaukee: ASQ Press.
5
Chassin, M.R. (1998) ‘Is healthcare ready for six sigma quality?’, The Milbank Quarterly, Vol. 76,
6
No. 4, pp.565–591.
7
Chen, H.K., Chen, H.Y., Wu, H.H. and Lin, W.T. (2004) ‘TQM implementation in a healthcare and
8 pharmaceutical logistics organization: the case of zuellig Pharma in Taiwan’, Total Quality
9 Management, Vol. 15, Nos. 9/10, pp.1171–1178.
2011 Dey, P.K. (2001) ‘Reengineering materials management: a case study on Indian refinery’, Business
Reference Process Management Journal, Vol. 7 No. 5, pp.394–408.
highlighted in
blue is not Dey, P.K. and Hariharan, S. (2006) ‘Integrated approach to healthcare quality management: a case
cited in the study’, The TQM Magazine, Vol. 18, No. 6, pp.583–605.
main text.
Please insert Dey, P.K., Hariharan, S. and Clegg, B.T. (2006), ‘Measuring the operational performance of
relevant intensive care units using the analytic hierarchy process approach’, International journal of
citation or
delete this Operations and Production Management, Vol. 26, No. 8, pp.849–865.
entry. Thanks
Dlugacz, Y.D., Stier, L., Lustbader, D., Jacobs, M.C., Hussain, E. and Greenwood, A. (2002)
‘Expanding a performance improvement initiative in critical care from hospital to system’,
1
Jt Comm J Qual Improv, Vol. 28, pp.419–434.
2
Dolan, T. (2003) ‘Best practices in process improvement’, Quality Progress, Vol. 35, No. 8,
3 pp.23–28.
4
Donabedian, A. (1988) ‘The quality of care – how can it be assessed?’, Journal of American Medical
5 Association, Vol. 260, pp.1743–1748.
6 Dyer, R.F. and Forman, E.H. (1992) ‘Group decision support with the analytic hierarchy process’,
Reference Decision Support Systems, Vol. 8, pp.99–124.
highlighted in
blue is not Evan, J.R. and Lindsay, W.M. (2002) The Management and Control of Quality, 5th edn, USA:
cited in the Thompson Learning.
main text.
Please insert Feeney, A. and Zairi, M. (1996) ‘TQM in Healthcare’, Journal of General Management, Vol. 22,
relevant
citation or pp.35–47.
delete this Fernandes, C.M.B. and Christenson, J.M. (1995) ‘Use of continuous quality improvement to
entry. Thanks
facilitate patient flow through the triage and fast-track areas of an emergency department’,
7 Journal of Emergency Medicine, Vol. 13, pp.847–855.
8 Fernandes, C.M.B. and Christenson, J.M. (1996) ‘Continuous quality improvement reduces length
9 of stay for fast-track patients in an emergency department’, Academic Emergency Medicine,
Vol. 3, pp.258–263.
30
1
2
3
 Managing healthcare quality 17

111 Field, K. and Emrouznejad, A. (2003) ‘Measuring the performance of neonatal care units in
2 Scotland’, J Med Syst, Vol. 27, pp.315–324.
3 Gandhi, T.K., Graydon-Baker, E., Barnes, J.N., Neppl, C., Stapinski, C., Silverman, J., Churchill,
4 W., Johnson, P. and Gustafson, M. (2003) ‘Creating an integrated patient safety team’, Joint
Commission Journal on Quality and Safety, Vol. 29, No. 8, pp.383–390.
5
Glance, L.G., Osler, T.M. and Dick, A. (2002) ‘Rating the quality of intensive care units: is it a
6
function of the intensive care scoring system?’, Critical Care Medicine, Vol. 30,
7 pp.1976–1982.
8 Golden, B.L., Wasli, E.A. and Harker, P.T. (1989) The Analytic Hierarchy Process: Applications
9 and Studies, New York: Springer Verlag.
1011 Gowen III, C.R. and Tallon, W.J. (2003) ‘Enhancing supply chain management practices through
1 human resource management’, Journal of Management Development, Vol. 22, No. 1,
pp.32–44.
Please provide
publication Gowen III, C.R., McFadden, K.L., Hoobler, J.M. and Tallon, W.J. (2006) ‘Exploring the efficacy of
details if healthcare quality practices, employee commitment, and employee control’, Journal of
available. Operations Management, in press.
Thanks
2 Green, J., Wintfield, N., Krasner, M. and Wells, C. (1997) ‘In search of America’s best
hospitals – the promise and reality of quality assessment’, Journal of American Medical
3 Association, Vol. 277, pp.1152–1155.
4
Hariharan, S., Dey, P.K. and Chen, D.R. (2006) ‘Innovation management using logical framework
5 in hospital based healthcare units’, International Journal of Innovation and Learning, Vol. 3,
6 No. 3, pp.299–314.
7 Hariharan, S., Dey, P.K., Chen, D.R., Kumar, A.Y. and Moseley, H.S.L. (2005) ‘Analytic hierarchy
8 process for measuring and comparing the global performance of intensive care units’, Journal
9 of Critical Care, Vol. 20, pp.117–125.
2011 Hariharan, S., Dey, P.K., Moseley, H.S.L., Kumar, A.Y. and Gora, J (2004) ‘A new tool for the
1 process-based performance measurement of multi-specialty tertiary care hospitals’,
International Journal of Healthcare Quality Assurance, Vol. 17, No. 6, pp.302–312.
2
3 Islei, G., Lockett, G., Cox, B. and Stratford, M. (1991) ‘A decision support system using judgmental
modeling: a case of R&D in the pharmaceutical industry’, IEEE Transaction on Engineering
4 Management, Vol. 38, August, pp.202–209.
5 Katsaragakis, S., Papadimitropoulos, K. and Antonakis, P. (2000) ‘Comparison of Acute Physiology
6 and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiology Score II
7 (SAPS II) scoring systems in a single Greek intensive care unit’, Critical Care Medicine,
8 Vol. 28, pp.426–432.
9 Lurie, J.D., Merrens, E.J., Lee, J. and Splaine, M.E. (2002) ‘An approach to hospital quality
30 improvement’, Medical Clinics of North America, Vol. 86, pp.825–845.
1 Marik, P.E. and Varon, J. (1999) ‘Severity scoring and outcome assessment: computerized
2 predictive models and scoring systems’, Critical Care Clinic, Vol. 15, pp.633–646.
3 Markgraf, R., Deutschinoff, G., Pientka, L. and Scholten, T. (2000) ‘Comparison of acute
physiology and chronic health evaluations II and III and simplified acute physiology score II:
4
a prospective cohort study evaluating these methods to predict outcome in a German
5 interdisciplinary intensive care unit’, Critical Care Medicine, Vol. 28, pp.26–33.
6 Palmer, R.H. (1997) ‘Process-based measures of quality: the need for detailed clinical data in large
7 health care databases’, Annals of Internal Medicine, Vol. 127, pp.733–738.
8 Popovich, M.J. (2002) ‘If most intensive care units are graduating with honors, is it genuine quality
9 or grade inflation?’, Critical Care Medicine, Vol. 30, pp.2145–2146.
40 Re, R.N. and Krousel-Wood, M.A. (1991) ‘How to use continuous quality improvement theory and
1 statistical quality control tools in a multidisciplinary clinic’, QRB Quality Review Bulletin,
2 Vol. 16, pp.391–397.
3 Saaty, T.L. (1980) The Analytic Hierarchy Process, USA: McGraw-Hill.
4
5
 18 P.K. Dey and S. Hariharan

111 Saaty, T.L. (1982) Decision Making for Leaders, New York: Lifetime Learning.
2 Saaty, T.L. (1983) ‘Priority setting in complex problems’, IEEE Transaction on Engineering
3 Management, Vol. EM-30, August, pp.140–155.
4 Snelson, E. (1992) ‘Quality assurance implications of federal peer review laws: The Health Care
5 Quality Improvement Act and the National Practitioner Data Bank’, Journal of Quality
Assurance and Utilization Review, Vol. 7, pp.2–11.
6
7 Tucker, A.L. (2004) ‘The impact of operational failures on hospital nurses and their patients’,
Journal of Operations Management, Vol. 22, pp.151–169.
8
US News & World Report (1990) ‘America’s Best Hospitals’, April 30, pp.51–85.
9
1011 Van Matre, J.G. (1992) ‘The D*A*T approach to total quality management’ Journal of American
Health Information Management Association, Vol. 63, pp.38–44.
1
Vargas, L.G. (1990) ‘An overview of the analytic hierarchy process and its applications’, European
2 Journal of Operation Research, Vol. 48, No. 1, pp.2–8.
3
Weiler, G. (2004) ‘What do CEOs think about quality’, Quality Progress, Vol. 37, No. 5, pp.52–56.
4
Zimmerman, J.E. (2002) ‘Measuring intensive care performance: a way to move forward’, Critical
5 Care Medicine, Vol. 30, pp.2149–2150.
6
7
8
9
2011
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3
4
5
6
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