Transcript West Midlands Health Protection Agency

Governance and quality
Ian Sharp
November 2006
Aims of the presentation
•To highlight the importance of quality management and
quality assurance in the governance of the
organisation
•To explore what governance means
•To explore how quality management and quality
assurance support governance
Top down commitment to quality?
• Everyone knows quality is only effective if we have
commitment from the top
• How do we ensure that we get that commitment?
• Firstly, we need to understand how we relate to
corporate activities and what we can and should do to
support them
• We then need to make sure senior management
understand how day to day quality activities helps
provide them with the assurance they need
Senior management
•Ultimately responsible for the quality of work
undertaken by the staff within the organisation
•They need to set up reporting mechanisms to provide
the assurance they need to meet their legal
responsibility
• Assurance needs to be evidence based
Governance
•Corporate governance
- the system by which organisations are directed and controlled
(Cadbury report 1992)
•Clinical governance
- the system through which NHS organisations are accountable for
continuously improving the quality of their services and
safeguarding high standards of care, by creating an environment in
which clinical excellence will flourish. (www.dh.gov.uk)
Corporate governance
• Corporate Governance supports the management
arrangements of the organisation.
• It helps to turn our strategic objectives into working
services by developing and implementing systems
and procedures.
• It’s the link between the high-level direction of the
organisation and the day to day function.
In the NHS, Clinical governance
is…
• Corporate accountability for clinical performance, i.e. quality
assurance in healthcare
• A framework through which NHS organisations are
accountable for continually improving the quality of their
services and safeguarding high standards of care by creating
an environment in which excellence in clinical care will
flourish (Scally and Donaldson, BMJ 1998:61-65)
• Good clinical and public health governance are essential
features of a learning organisation which will give assurance
of the quality of its outputs (test results and advice)
Quality management system
A Quality Management System is typically defined as:
"A set of co-ordinated activities to direct and control an
organisation in order to continually improve the
effectiveness and efficiency of its performance."
Quality management system
• A QMS enables an organisation to achieve the goals
and objectives set out in its policy and strategy.
• It provides consistency and satisfaction in terms of
methods, materials, equipment, etc, and interacts with
all activities of the organisation, beginning with the
identification of customer requirements and ending
with their satisfaction by delivering a product or
service which is fit for purpose.
Quality management activities
• Evidence-based practice
• (Adverse) incident reporting
• Standards, guidelines and SOPs
• Programme of internal quality audit
• Good record keeping and compliance with legal
requirements
• Assuring quality of individual practice via education and
training plans: CPD
• External scrutiny and accreditation [e.g. CPA, UKAS,
ISO 9000, Healthcare Commission, CE marking, IiP]
Quality assurance
•Assures that the product (test report and advice) is:
“fit for purpose”
•and that we
“do it right the first time”
Risk management
• Quality management = risk management
• Governance = risk management
• QM is relevant to clinical and corporate governance
• Must make sure senior management understand the
relevance of quality management to providing them
with the assurances they need
Risk management
• Risk Management means looking at what we want to
do, and putting things in place to help ensure success.
• This is done by identifying your processes and the
risks within them, taking preventive actions to
minimise potential risks, and by taking advantage of
opportunities for improvement.
• We also take corrective action when things go wrong,
i.e., we learn from problems when they occur.
Corporate committees
- Reporting structures
•Board
•Governance committee
•Health and safety committee
•Clinical governance committee
•Caldicott committee
•Risk management committee
•Quality committee
•Record management committee
Who in Pathology & the Trust is
responsible for key corporate activities?
• Corporate governance
• Risk management
• Clinical governance
• Health and Safety
• Environmental management
• Data protection (Caldicott policy)
• Quality
• Internal audit
• Who is ensuring that Healthcare standards are
implemented?
Adverse incident reporting
•Seen by senior management to be a very important
mechanism for organisational learning and risk
management
Logging and dealing with issues
•We have been doing this for a long time
-
Non-compliance notes
Nonconformance notes
Complaints forms
Caldicott breach forms
Error logging records
Deviation from specification notes
•Remedial and root cause corrective action
Link between local issues and
corporate ones
•Need to consider when a local issue should be raised
as an adverse incident
•At CfI, we have now linked quality forms to AIRs
- Reported as an AIR to the Head of Quality CfI: Yes
No
Reporting to senior management
•There is much more to governance than adverse
incident reporting
•Who want the information?
•What information do they need?
•What format do they want it in?
Reporting to senior management
•We need to identify how we report
•We need to ascertain what information we need to
report
•We need to decide the best way of presenting data
Management review meetings
•Quality Improvements
•Staff training
•Audits and noncompliances
•Caldicott issues
•Complaints
•Adverse Incidents
•Non-conformances/error logging
•Customer Survey Reports
•IQA Data
•Turn Around Times
•EQA Data
•Resources
•IQC Data
•Document control
- Staffing
- Equipment
- Environment
Management review meetings
•Present data quantitatively
•Trend analysis
•Objective setting
•Provide senior management with information
they need to understand the issues and gain
assurance, where appropriate
•Who do you invite to your management review
meetings?
•Who gets the minutes?
Influence upwards
• You need to let these people know who you are and
what you are doing to support their activities
• Provide them with a monthly quality report
–What audits have been done
–Any concerns that have been raised
–Highlight key concerns
–Highlight achievements
–Include any other quality related issues
• Copy in all senior staff in Pathology
• HPA Internal audit gain assurance from our activities
Governance and quality both require:
• Clear service outcomes/outputs
• Risk assessment of all key processes relating to outcomes/outputs
• Clear lines of responsibility and accountability for the overall quality
of services
• Management of risk
• Evidence-based/best practice systems
• A comprehensive programme for quality improvement
• Mechanisms to deliver quality assurance and audit
• System of staff education and training
• Evidence of staff competency
Healthcare Commission Standards for
Better Health
FIRST DOMAIN - SAFETY
Mapping Results/Comments
Core Standard C1 - Healthcare organisations
protect patients through systems that:
CPA
ISO 17025
ISO 9001
a) identify and learn from all patient safety
incidents and other reportable incidents, and
make improvements in practice based on local
and national experience and information
derived from the analysis of incidents
H6 Quality
improvement
4.10
Corrective
action
8.5
Improvement
b) ensure that patient safety notices, alerts
and other communications concerning patient
safety which require action are acted upon
within required timescales
H6 Quality
improvement
4.11
Preventive
action
4.10
Corrective
action
4.11
Preventive
action
8.5
Improvement
Conclusion
•Governance is all about gaining assurance that all risks
to the organisation are being managed effectively
•Senior management need to ensure that there are
effective reporting mechanisms to provide them with
the assurance they require
•Effective quality systems provide the evidence that
senior management require through:
–Following best practice (SOPs), evidence of staff competency
–Audits, corrective and preventive action mechanisms
–Complaints systems, error logging user surveys
–annual management reviews, etc…….