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Kevin Gibbs Clinical Pharmacy Manager
Quality Systems Kevin Gibbs Clinical Pharmacy Manager
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Aim: Introduce some approaches to quality systems
Objectives: At the end of the session the delegate will have a outline of - The quality systems: EFQM, ISO 9001, Toyota Production System The Donabedian quality of care framework The NHS Change model Lean waste reduction
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“Everyone in healthcare should have two jobs: To do the work and to improve how the work is done.”
Maureen Bisognano Chief Executive Officer Institute for Healthcare Improvement
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Don Berwick “Improvement requires a system of support”
The capability to measure and continually improve the quality of patient care needs to be taught and learned or it will not exist The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end. A promise to learn – a commitment to act: Improving the safety of patients in England. Aug Problem #6.
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Definitions Medical Quality Clinical Quality Improvement Medical quality is the degree to which health care systems, services and supplies for individuals and populations increase the likelihood for positive health outcomes and are consistent with current professional knowledge. Clinical quality improvement is an interdisciplinary process designed to raise the standards of the delivery of preventive, diagnostic, therapeutic, and rehabilitative measures in order to maintain, restore or improve health outcomes of individuals and populations. Institute of Medicine. Medicare: A Strategy for Quality Assurance. Vol.1. Washington, DC: National Academy Press, 1990
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Quality systems
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Quality Systems Healthcare and pharmacy teams provide quality healthcare services. The system that teams work within support them to provide quality services. A good system or a ‘quality system’ is a combination of sustainable structures, excellent leadership, right culture, good governance and processes, and a capable workforce all working together to enable continuous improvement and learning. PharmacyQS.com
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Improving the Quality of Healthcare
Providing services based on scientific knowledge to all those who could benefit Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity or socio-economic status Quality Effective Efficient Safe Timely Person centred Equitable Avoiding waste Providing care that is respectful of and responsive to individual patient preferences, needs & values and ensuring that patient values guide all clinical decisions The was the second IOM report following “To err is human” in the US giving a more detailed examination of ‘the immense divide between what we know to be good health care and the health care that people actually receive’ (IHI quote). Avoiding injuries to patients from the care that is intended to help them Crossing the Quality Chasm. Institute of Medicine 2001. NHS Scotland Quality Improvement Hub. Reducing waits and sometimes harmful delays for both those who receive and those who give care
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Donabedian - Quality of Care Framework
Structure Process Outcome buildings staff equipment Methods used to provide services Impact of the care on health status Patient reported outcome (PROM) Promoting Quality: The Health-Care Organization From a Management Perspective SW Glickman et.al. Int J Qual Health Care. 2007;19(6): <
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Example: Reduction in C. Diff infection
Reduction in antibiotic usage/DDD Cephalosporins Quinolones Co-amoxiclav Antibiotic governance Antibiotic Pharmacy team Microbiology Guideline App Comms Antibiotic reviews / audits C. Diff incidence Also reference to RPS hospital standards – services developed from patient experience etc Balancing measure: Infection rates
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ISO 9001 Quality Management System originally from the automotive industry Principles Leadership Strategic planning Customer and market focus Information management Agility Continual improvement Principles Innovation Document management Human resources management Process management Business results Levitt JM, Burney RG. Using ISO 9001 in Healthcare. ASQ Press: (Available Google Play Books)
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For a process to a system
Manage key processes Management review Controlled document system Audits Corrective / preventative action plans Measurement, data collection Inputs – Customer requirements Define key requirements Outputs – Customer satisfaction
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QMS: manage, improve, sustain improvements in key processes
Balanced scorecard Design, redesign Risk assessment Quality tools - Lean - Six sigma - PDSA - Process control Strategic planning Management review Controlled document system Audits Corrective / preventative action plans
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Performance Measurements
Process Quality Objectives Key Requirements Performance Measurements Physician staff Provider evaluation Patient care process Provider service delivery Clinical outcome Clinical process Customer satisfaction Functional outcomes Patient safety Recognition for quality care Development of clinical protocols Professionalism Peri-op antibiotic timing Surgical site infection rate Patient satisfaction survey Clinical staff Staff preparation Registration Care management plans Clinical outcomes Accuracy Compassion Efficiency Training / competency records Documentation Education Patient education Informed customers Health Promotion Promotion of public health Participation in events eg screening programmes This has direct applicability even to a pharmacy/medicines management processes
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European Foundation for Quality Management - EFQM Model
Vision Mission Values Communication Agents of change Strategy to implement your mission and vision Know your customers & stakeholders Involve Empower Reward Recognise Review/Appraise Key processes Performance indicators
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QUASER: Quality and Safety in European Union Hospitals
A guide - designed to help health care organisations “wherever they are on the ‘quality journey’, to reflect on, develop, and implement organisation- wide quality improvement strategies”. <
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NHS Change Model Designed by the NHS for the NHS
Used as a framework for change by NHS England A good model for analysing the strengths and weakness of your team in change management / improvement Note: Links to the NHS change model website in the document have expired
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Toyota Production System: 14 Toyota Way Principles
Base management decisions on ling term philosophy Create continuous process flow to bring problems to the surface Use “pull” systems to avoid overproduction Level out the workload Build a culture of stopping to fix problems to get quality right the first time Standardised tasks are the foundation for continuous improvement & employee empowerment The Toyota Way. McGraw-Hill. 2004
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Use visual control so no problems are hidden
Use only reliable thoroughly tested technology that serves your people and processes Grow leaders who thoroughly understand the work, live the philosophy, and teach it to others Develop exceptional people and teams who follow your company’s philosophy Respect your extended network of partners and suppliers by challenging them and helping them improve Go and see for yourself so thoroughly understand the situation Make decisions slowly by consensus, thoroughly considering all options; implement decisions rapidly Become a learning organisation through relentless reflection and continuous improvement
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Principles of Organisational Quality Management – Summarised:
Directional principles Focus on customers Focus on other stakeholders Focus on results Focus on agility (i.e. Flexibility) Focus on the future West JE, Cianfrani, CA. Unlocking the power of your QMS. ASQ Quality Press: 2005.
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Operational principles
Provide leadership, vision and purpose Establish and align objectives Manage a system of interrelated processes Manage with facts supported by credible data Innovate, learn and improve Develop and involve people Develop suppliers, partners and other stakeholders
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Six Sigma Define Measure Analyse Improve Control
Statistical methodology from Motorola to reduce cost / process variation / defects 6 standard deviations from perfection for a process ( % error free) Define Measure Analyse Improve Control Example from:
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Measurement
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Measurement for improvement
Measurement for Research Measurement for Learning and Process Improvement Purpose To discover new knowledge To bring new knowledge into daily practice Tests One large "blind" test Many sequential, observable tests Biases Control for as many biases as possible Stabilize the biases from test to test Data Gather as much data as possible, "just in case" Gather "just enough" data to learn and complete another cycle Duration Can take long periods of time to obtain results "Small tests of significant changes" accelerates the rate of improvement From: Institute for Healthcare Improvement <
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Summary and challenges
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Quality Health care is:
Doing the right thing at the right time in the right way for the right person and having the best possible results Agency for Healthcare Research and Quality. US Department of Health and Human Services. Your guide to choosing quality healthcare; a quick look at quality. Accessed Oct 2015
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Better value in the NHS Identified key opportunities to deliver better outcomes Variations in the UK in delivery of care Overuse, underuse and misuse of care exists Highlighted: Long term conditions, frail, complex needs & end of life patients Can build on existing improvement by clinical teams Interesting parallels with the 2001 Crossing the quality chasm report fro m the US eg variations in care Better value in the NHS. Kings Fund. July 2015.
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Models of Quality Improvement – A cascade
Quality assurance Event driven Compliant based Regulatory focus Retrospective Punitive Quality improvement System orientated Process orientated Organisation focus Prospective Imagine and Inspire Found and frame Ground and grow Continuous quality improvement Information driven Outcomes orientated Innovation Best practices Produce and sustain Quality improvement maturity Improved clinical and service outcomes Safety culture Exceed performance Aim higher Review and renew Models of Quality Improvement – A cascade Don Berwick believes that relying on inspection to improve does not work, that only produces fear Where is your organisation on this journey? From: Quality improvement training for health professionals. Health Foundation 2012 <
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Can you develop “The habits of an improver”?
<
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Further reading and resources
Click on the document to link to it
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Twitter @NHSIQ @TransformCare @HealthFdn @TheIHI
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Process mapping using Excel You Tube videos
You Tube videos Mayo Clinic Introduction to Quality Improvement Introduction to Lean Kaizen, DMAIC and Six Sigma NHS Improving Quality channel SlWxzA Driver diagrams ment_tools/quality_and_service_improvement_tools/driv er_diagrams.html ges/Activities/GoldmannDriver.aspx improvement-tools/driver-diagram.aspx
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Thank you for your time
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