Transcript Quality Manager. What can they do for you

Quality Managers
What are they good for?
Pat Beard
Pathology Quality Manager
New Cross Hospital
Wolverhampton
Governance
o Compliance with Trust Governance Strategy
o Minutes
o Record evidence for NHSLA Scheme
o Incident Reporting
o Completion of cycle, timeliness, Categorisation of incidents
o Trend analysis
o Risk Register
o Review and escalation
o Controls Assurance
o Action Plans – Responsibilities, Resources, Target Times
Corrective
Actions
Turnaround
Times
User
Satisfaction
Request
Rejection
CONTRIBUTION
Document
Control
User
Guide
Pathology
Newsletter
Improvement
Tools
Quality Improvement
STRATEGY
TIME
Waste
QUALITY
VALUE
Outputs
COST
Variation
Quality Management Systems
1st STEP
2nd STEP
3rd STEP
Quality
Quality
Quality
Procedures
Improvement
(Learning)
Culture
Culture
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.
Actualisation/ Esteem
Maslow’s Hierarchy of
Needs
Belonging
Safety
Physiological
Stress
Homeless,
unemployed
Blue collar
workers
Independently
wealthy
White collar
/Managerial
Per
capita
White collar
/Managerial
White collar
/Managerial
1
2
3
4
5
Socio – economic groups
Who experiences stress: Black Report (1989)
6
A different way of thinking
o Creation of a Quality Culture
o Management commitment
o
o
o
o
respect,
recognition,
personal development,
understanding and support
o Strategic planning for quality
Improvement infrastructure
o Leadership
o Systemisation
o Anything the organisation does should be systemised –
set down in procedure
o Tracking improvements – updating procedures
o Roles and Responsibilities
o Process
o Methodical approach to quality improvement
for example – DMAIC systematic approach used in six
sigma
o Define
o Measure
o Analyse
o Implement
o 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 Governance
o
o
o
o
o
Document Control and review
Procedures
Minutes
Action Plans
Reports
Knowledge Management
o 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 Policies
o Departmental Procedures
o Notices and Instructions
Improvement Tools
o Root Cause Analysis
o Process Flow Charts
o Option Appraisal
Major Incident 'Declared'
CONTACT
Senior BMS
Immediately
CONTACT
Other Haematology
Staff
On Call
BMS
Subsequently
If unable to contact Senior
BMS
contact next BMS in priority
Haematology
Consultant
Have
other
staff
arrived?
No
Obtain predicted
blood usage from
the
Accident &
Emergency
Department
DE-RESERVE
non essential
cross-matches
Continue with
Routine work if
appropriate
INFORM
Blood Transfusion
Service
of
possible usage
Yes
Prioritise
Work
UPDATE
from
Accident & Emergency
Department
DO
Stock Take
of Blood
Process
samples
Set Up
Emergency
Blood Box(es)
Set Up
O Negative
Flyers
Option Appraisal
Option 1
Option 2
Option 3
Weighting
Factor
Score
Weighted
Score
Score
Weighted
Score
Score
Weighted
Score
5
8
40
3
15
10
50
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
Objective 1:
Objective 2:
Corrective and Preventative
Actions
o
Sources
o Complaints
o Internal Audits
o External Audits
o Other external inspection
o Risk Identification
o Error logging
o Corrective actions
o Completion of cycle
o Preventative Actions
o Project Management
- Objectives
- Responsibilities
- Action Plans
- Monitoring and Review
- Target dates
Year
2003
2004
2005
Rejected Samples
1762
1804
1857
Total Requests
169578
171303
187301
% Rejected
1.04%
1.05%
0.99%
Rejected Microbiology Requests
0.70%
2003
% of Total Requests
0.60%
2004
0.50%
2005
0.40%
0.30%
0.20%
Reasons for rejection
No Request
form
Information on
form
No sample
Collection
date
Inappropriate
Sample
Miscellaneous
Mismatch
Leaking
0.00%
Unlabelled
0.10%
User Satisfaction Survey
Question
Score?
Department
Poor
0
1
Your overall estimated quality
rating for these Pathology
service (s):
Clinical Chemistry
Haematology
Blood Bank
Immunology
Histopathology
Cytology
Microbiology
2
Comments
OK
4
Good
6
8
10
faults/compliments/ suggestions:
Cardiothoracic
Cardiothoracic
Cardiothoracic
Cardiothoracic
Cardiothoracic
Cardiothoracic
Cardiothoracic
Cardiothoracic
Cardiothoracic
Cardiothoracic
Cinical Sciences
Medicine
Medicine
Medicine
Medicine
Medicine
Medicine
Oncolgy
Oncology
Oncology
Oncology
Opthalmology
Opthalmology
Opthalmology
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Unknown
Unknown
Women's & Childrens
Women's & Childrens
Women's & Childrens
Women's & Childrens
Women's & Childrens
Women's & Childrens
Women's & Childrens
Women's & Childrens
Pathology Service
User Perception vs. Location
Contour Map
8-10
6-8
4-6
2-4
0-2
S7
S6
S5
S4
S3
S2
S1
Microbiology
Test
Best Endeavour Times in hours
Inpatient
Expected
Out/GP
Tested
Expected
Urgent
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
48
48:09:45
48
49:12:16
4
NA
48/72
64:49:03
48
NA
Faeces Microscopy
Genital GUM
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
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
Pus/Swabs