1. Kevin Gibbs Clinical Pharmacy Manager
Quality Systems
Kevin Gibbs
Clinical Pharmacy Manager

2. 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

3. “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

4. 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.

5. 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

6. Quality systems

7. 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

8. 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

9. 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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10. 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

11. 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)

12. 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

13. 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

14. 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

15. 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

16. 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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17. 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

18. 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

19. 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

20. 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.

21. 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

22. 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:

23. Measurement

24. 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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25. Summary and challenges

26. 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

27. 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.

28. 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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29. Can you develop “The habits of an improver”?
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30. Further reading and resources
Click on the document to link to it

31. Twitter
@NHSIQ
@TransformCare
@HealthFdn
@TheIHI

32. 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
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Driver diagrams
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33. Thank you for your time