Quality ManagersWhat are they good for?

Pat BeardPathology Quality Manager

New Cross Hospital Wolverhampton

Governance

o Compliance with Trust Governance Strategyo Minutes

o Record evidence for NHSLA Scheme

o Incident Reporting o Completion of cycle, timeliness, Categorisation of incidentso Trend analysis

o Risk Registero Review and escalationo Controls Assurance

o Action Plans – Responsibilities, Resources, Target Times

CONTRIBUTION

Corrective Actions

User Satisfaction

Turnaround Times

Document Control

PathologyNewsletter

User Guide

ImprovementTools

Request Rejection

Quality Improvement

VALUEOutputs

TIME

Waste

QUALITY

Variation

COST

STRATEGY

Quality Management Systems

Quality

Improvement

Quality

Procedures

Quality

(Learning)

Culture

1st STEP 2nd STEP 3rd STEP

Culture

Actualisation/ Esteem

Belonging

Safety

Physiological

Maslow’s Hierarchy of Needs

o Number one reason for employees leaving an employer is the (poor) relationship they have with their line managers.

o Dissatisfaction is the single best predictor of absenteeism

o Estimates that between 70 – 80 % of absenteeism is stress related.

Stress

Per capita

Homeless, unemployed

1 2

Blue collar workers

3

White collar /Managerial

4

White collar /Managerial

5

White collar /Managerial

6

Independently wealthy

Who experiences stress: Black Report (1989)

Socio – economic groups

A different way of thinking

o Creation of a Quality Culture

o Management commitment

o respect, o recognition, o personal development, o understanding and support

o Strategic planning for quality

Improvement infrastructureo Leadership

o Systemisationo Anything the organisation does should be systemised – set

down in procedureo Tracking improvements – updating procedures

o Roles and Responsibilities

o Processo Methodical approach to quality improvement

for example – DMAIC systematic approach used in six sigmao Defineo Measureo Analyseo Implemento Control

Improvement People

o Good Management

o Training for all grades

o Involving all grades of staff

‘Quality at the end of the day is human

commitment’

W.E.Deming

Thank You

Document Control

o Evidence – Good Governanceo Document Control and review

o Procedures

o Minutes

o Action Plans

o Reports

Knowledge Managemento Tacit knowledge that exists in someone’s head

o Explicit knowledge that has been documented in some way, allowing others to share it

o Pathology Policieso Departmental Procedures

o Notices and Instructions

Improvement Tools

o Root Cause Analysis

o Process Flow Charts

o Option Appraisal

On Call BMS

DOStock Take

of Blood

UPDATEfrom

Accident & Emergency Department

Have other staff

arrived?

Major Incident 'Declared'

Immediately

No

CONTACTSenior BMS

CONTACTOther Haematology

Staff

Haematology Consultant

INFORMBlood Transfusion

Service of

possible usage

Obtain predicted blood usage from

the Accident & Emergency Department

If unable to contact Senior BMS

contact next BMS in priority

Subsequently

Yes

DE-RESERVEnon essential cross-matches

Set UpO Negative

Flyers

Set UpEmergency

Blood Box(es)

Process samples

PrioritiseWork

Continue with Routine work if

appropriate

Option Appraisal

Option 1 Option 2 Option 3

Weighting Factor

ScoreWeighted

ScoreScore

Weighted Score

ScoreWeighted

Score

Objective 1:5 8 40 3 15 10 50

Objective 2:2 5 10 10 20 7 14

Objective 3: 2 5 10 3 6 4 8

Objective 4:1 10 10 10 10 5 5

TOTALS 10 26 70 26 51 26 77

Corrective and Preventative Actions

o Sourceso Complaintso Internal Auditso External Auditso Other external inspectiono Risk Identificationo Error logging

o Corrective actionso Completion of cycleo Preventative Actions

o Project Management - Objectives- Responsibilities - Action Plans - Monitoring and Review - Target dates

Rejected Microbiology Requests

0.00%

0.10%

0.20%

0.30%

0.40%

0.50%

0.60%

0.70%U

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2003

2004

2005

Year 2003 2004 2005

Rejected Samples 1762 1804 1857

Total Requests 169578 171303 187301

% Rejected 1.04% 1.05% 0.99%

Question Score? Comments

Department Poor OK Good faults/compliments/ suggestions:

0 2 4 6 8 10

1 Your overall estimated quality rating for these Pathology service (s):

Clinical Chemistry

Haematology

Blood Bank

Immunology

Histopathology

Cytology

Microbiology

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Pathology Service User Perception vs. Location

Contour Map

Microbiology Best Endeavour Times in hours

Test Inpatient Out/GP Urgent

  Expected Tested Expected Tested Expected Tested

Urines 24/48 27:05:02 24/48 26:34:41 24 NA

Faeces Culture 48/72 53:09:28 48/72 54:24:22 48 NA

Faeces Microscopy 48 48:09:45 48 49:12:16 4 NA

             

Genital GUM     48/72 64:49:03 48 NA

Genital non-GUM 48/72 58:46:15 48/72 54:41:47 48 NA

             

MRSA screens 48 47:28:15 48 47:37:20 48 NA

             

Mycology - Micro 48 > 4 Days 48 > 4 Days 24 NA

             

Pus/Swabs 48/72 48:10:54 48/72 47:45:42 48 NA

             

Respiratory (TB) Microscopy 24 17:10:25 24 44:00:21 4 NA

             

Serology Chlamydia ELISA 48 40:52:29 48 37:46:49 24 NA

             

Serology Hepatitis C 24 05:19:44 24 05:47:35 4 NA

Serology Hepatitis Bs Ag/core 24 05:36:32 24 06:11:45 4 NA

Serology HIV 24 08:29:04 24 08:06:05 4 NA

Serology Rubella IgG 24 27:05:16 24 25:40:37 4 NA

Serology Syphilis 24 26:45:13 24 29:36:17 24 NA