QUALITY MANAGMENTArea of Concern G

Margaret LincyMHA,PGD(QM&AHO) & SIX SIGMA Green Belt

Consultant (QA)

QUALITY.....ever you think of it????

PLAN stage involves analyzing the current situation, gathering data, and developing ways to make improvements DO stage involves testing alternatives experimentally in a laboratory establishing a pilot process, or trying it out with small

number of customers. CHECK stage requires determining whether the trial or process is working as intended, whether any revisions are needed, or

whether is should be scrapped.ACT stage focuses on implementing the process within the organization or with its customers and suppliers.

Once all this stages are completed to the fullest satisfaction, the improvement is standardized .

With the changing circumstances or new techniques this standardized work, process, product or service is again subjected to further improvement thus repeating the Deming Cycle again and again.

Deming’s PDCA Cycle • The Improvement Cycle

•

Standards for Quality Management • Standard G1: Facility has established quality

Assurance Programme as per state/National guidelines.• Standard G2 : Facility has established system

for Patients and employees satisfaction.• Standard G3: Facility has established,

documented &implemented standard operating procedure system for its all key processes.

QUALITY ASSURANCE PROGRAMME...in Short ,

• Constituting Quality Team in Institutions • Formation of committee• Quality Policy and Objectives• SMART criteria• Periodical review of Quality objectives.

Quality Team • Benefits;• Shared Responsibility• Reduced stress• Coordination of patient care

process• Feeling of unity• Easy implementation of activities• Increased communication• Problem solving....etc etc.

Quality Team in UPHCsBe a part of........QA Team.

TEAM MMBERS/COMMITTEE MEMBERS

• Mo i/c• Staff Nurse• Lab Technician• Pharmacist• JPHNDistrict level (Special Invitee)• District Coordinator• LHV

Frequency of meeting : Once in Every Month.

Team/Commitee Responsibilities • Defining the road map for Quality assurance for the facility.• Defining quality policy and objectives and periodic monitoring

on them• Dissemination and orientation for Quality Standards &

Standard Operating Procedures (SOP) among the facility staff.• Assuring that services being provided to defined quality

standards and clinical protocols.• Performing baseline as well as subsequent periodic quality

assessment against defined standards with support from district quality assurance committee.

• Measurement, reporting and review of the key performance indicators

• Providing hands on training and guidance to facility staff for meeting quality standards

• Facilitating change ideas and focus interventions for Quality Improvement.

How to document ???Name of Meeting with date

Venue & Time (Conference hall @ 12.30pm)

Agenda:1.Review of action taken report2. Other agenda

Participants Name Designation Signature

Dr. ABC MO i/c

Meeting Decisions

Sl. No

Discussion Action taken Responsible person

Target date

1.

2.

House keeping monitoring checklist not available

Decided to implement house keeping checklist in wards/OPD/departments..etc

SNDUHC

20.10.16

Prepared ByName &Sign

Hospital Seal Approved ByName & Sign

Quality Policy and Objectives • Quality Policy needs to be framed by the facility in

consultation the staff and other stakeholders.• Quality policy is a broad statement that describes

what & how the facility intends to improve the quality of its services. Quality policy should always acknowledge user satisfaction as key component of its policy.

• It should be formulated in local language and displayed at critical places for better understanding.

Look some examples;;;;;

• UPHC ……...... aims at providing highest level of Preventive, Promotive, and Curative Healthcare services to the catchment community with sustained efforts to ensure that it is Equitable, Affordable, Accountable and responsive to the people’s need.

• We are committed to satisfy and delight our clients by efficient services delivery with an aim of improving areas like Sanitation and hygiene and safe drinking water, reducing waiting time, respecting patient’s rights and encouraging community participation.

• We are committed to delight the end users of our services by efficient service delivery

SMART way to perform....

A Quality Objective is a quality oriented goal or something you aim to achieve

• S- Specific • M – Measurable• A -Attainable• R- Reviewable• T – Time bound

Answerable ....Is it???

• Is Quality Measurable ?• How could You measure quality ??• How would you check your

service ???• How you evaluate your service ????

Let us frame our quality Objectives,,,

Quality Objectives ...Departmen

t Policy Objective Specific Measurable Attainable Reviewable Time bound

OPD

Increase the OP service from

current 60% to 70% in 3 months Y Y Y Y Y

Laboratory

Reduce the re dos in laboratory

from current 40% to 30% two months Y Y Y Y Y

Pharmacy

Reduce the stock out of drugs from current 15% to 10% in 3 months Y Y Y Y Y

Dressing room and

Injection room

Reduce the injection abscess reported from current 10%to 7% in one month Y Y Y Y Y

Out reach session

Increase the house hold visit of ANM to 80% from current 70% in one month Y Y Y Y Y

SOP/Work Instructions

• A standard operating procedure, or SOP, is a set of step-by-step instructions compiled by an organisation to help workers carry out routine operations.

• SOPs aim to achieve efficiency, quality output and

uniformity of performance, reducing miscommunication and failure to comply to organizational regulations.

Standard G3; Facility has established, documented & implemented standard operating proceduresystem for its all key processes

Contents in an SOP

• SOP Number & SOP Title • Purpose• Introduction• Scope• Definition• Process Owner• Specific Procedures• References • Records

Formation of an SOP SOP for SAMPLE DISCARDING IN LABORATORY

SOP Number : UPHC/NT/LAB/SOP- SD/01/A

SOP Title : SOP for Sample Discarding in Laboratory Purpose: The SOP is prepared as per the fulfilment of requirement of Compliance to State Guidelines & National Quality

Assurance Standards. The principal purpose is disposing of samples is to avoid contamination with infectious waste agents known to

be infectious to humans Introduction Biomedical laboratories are special and unique work environments that may pose identifiable infectious disease

risks to persons in or near them. Correct discarding of samples is therefore necessary to reduce or eliminate exposure to laboratory staff, other persons and the outside environment to potentially hazardous materials: such as blood or other body fluids, which might be contaminated with agents known to be infectious to humans.

ScopeLaboratory Definitions Medical laboratory:Biological hazards:Biomedical waste...etc etcProcess Owner The person responsible for review the process is Laboratory technicianThe person responsible to amend the process is Laboratory technicianThe person responsible for the approval of the process is Medical Officer

SOP- Continuation.............Specific Procedures- Disposal of Specimens ; We have a documented procedure for discarding the unused samples. The laboratory assistant in presents of

laboratory technician is responsible for discarding the unused samples as per the rules of biomedical waste management system.

ProcedureThe samples are to be dealt with in the following manner after the test is conducted.SOP 1.1: Serology:- After the test completed and results gets ready he serum sample is store till ....pm . SOP 1.1.1: Discard the samples after ...pm the samples as per the bio medical waste management rules. Sop1.1.2: Treat with bleaching powder/ hypochlorite solution and flushed to drain and the vials are discarded in red

bucket as per biomedical waste management rules. SOP1.2: All urine samples –Discard on the same day after the results gets ready, SOP 1.2.1: Treat the samples with bleaching powder/hypochlorite solution and flushed into drainSOP1.2.2: Put the vials in red colour bucket as per the biomedical waste management procedure. SOP1.3 : Biochemistry/Hematology samples – Discard everyday at .......pm. SOP1.3.1: Treat with hypochlorite solution/bleaching powder solution and flushed into drain. SOP1.3.2: The vials are put in red colour bucket as per the biomedical waste management procedure. References(This section is used to list all references, used within the text of the SOP, sufficient for the user to find the source

document(s). 1eg:Handbook of laboratory MethodsRecords1. Sample Discarding Register

Patient and Employee satisfaction

• Patient satisfaction surveys are conducted at periodic intervals (At least 30/month)

• The facility analyse patient feed back and “root cause analysis “

• The facility prepares the action plans for the areas, contributing to low satisfaction of patients

• Employee satisfaction – Yearly once.

Root cause analysis ..Methods

• Brain storming• ISHIKAWA Diagram• Y-Y Analysis

Root cause analysis

Internal &External Quality Assurance programmes

• ME G 3.1The facility has established internal quality assuranceprogramme in key departments• ME G 3.2The facility has established external assurance

programmes at relevant departments• ME G 3.3The facility has established system for use of check listsin different departments and services

Internal Quality Assurance Programmes • Internal assessment of departments using the

checklist.

Pharmacy:

• Physical verification of Inventory• Periodic and random sampling of drugs• Prescription audit

Physical Verification Date Name of

itemStock as on date

Physically checked and found correct

Verified by Signature

23.09.16 Tab .calpol 550 550 Pharmacist

Laboratory- Quality Management• IQC system• Control charts- Corrective action taken on the identified outliers

• Cross validation of lab test and corrective action on abnormal value

• Laboratory assessment using checklist

Quality Management- OUT REACH• ASHA and ANM are represented in Quality Team• ASHA and ANM are aware of Quality Policy of the UPHC• Specific Quality Objectives are set for Outreach services• Quality of outreach services are reviewed during Monthly quality team meeting• Internal Assessment Conducted for Outreach services• Feedback is taken during outreach• Employee Satisfaction survey includes ASHA and ANM serving under UPHC area

Further requirements QM• UPHC performance and Quality indicators are reviewed in meeting• Quality team review that all the services mentioned in RMNCHA &

National Health Program.• Quality team report regularly to DQAC about Key Performance Indicators

and Quality Scores• There is a system of Daily round of MO to all department of UPHC &

Records shall be available.• SOP shall prepared/ available in all work areas• All staff should be trained in Work areas• Work instructions shall be displayed.

Support Services Area of Concern - D

Why it is important,,??

• Backbone of Hospital Operations• Usually most neglected area in public hospitals• Directly & Indirectly leads to poor quality of

services – Poor Upkeep of facility , long down time of equipment

• Little efforts in process improvement may give high & visible results as much more tangible to Clinical Care

Standard D1 The facility has established facility management programme for maintenance& upkeep of equipment & infrastructure to provide safe & secure environmentto staff & users

Standards

MD1.1 The facility has system for maintenance of critical Equipment

MD1.2 The facility ensures comfortable environment for patients and service providers

MD1.3 Patient care areas are clean and hygienic

MD1.4 Facility infrastructure is adequately maintained

MD1.5 Facility has policy of removal of condemned junk material

MD1.6 Facility maintains both the internal and open area of the facility.

MD1.7 The facility provides adequate illumination level at patient care areas

MD1.8 The facility provides Clean and adequate linen as per requirement

MD1.9 The facility has adequate arrangement for storage and supply of potable water in all functional areas

MD1.10 The facility ensures adequate power backup

MAINTANANCE OF CRITICAL EQUIPMENT

• Ask staff if all critical equipments are in working condition• Whether equipment are covered under annual maintenance contract (AMC)• Does preventive maintenance is done at least one in a year• What is the system of corrective maintenance if in condition of Equipment breakdown. How much

time it takes• Is there any practice of daily/routine cleaning, maintenance by the user. Who does it. Review Maintenance records • To verify that equipment's are covered in AMC• Preventive Maintenance is done timely• How much time it took for repair (log Book) Observe• Any equipment is lying idle since long time in need of repair• In areas like Lab out of order/defective equipment are labelled and kept apart• Equipments are numbered

The facility has established facility management programme for maintenance & upkeep of equipment & infrastructure to provide safe & secure environment to staff & users

• Floors, walls, roof , sinks patient care and corridors are Clean • Surface of furniture and fixtures are clean• Trolley & cupboard etc are painted & in intact condition• Cold Storage equipments are under AMC and temperature log book • Temparature control at Pharmacy & medical store• Drug Storage area and Pharmacy Counter are clean • No junk, condemned, unused articles in the pharmacy• Power backup arrangement for cold chain equipmentsLABORATORY:There is system of timely corrective break down maintenance of the equipmentsAdequate ventilation in Laboratory Floors, walls, roof , sinks in patient care area are Clean Surface of furniture i.e work benches are clean Fixtures and Furniture are intact and maintained No condemned/Junk material in the Laboratory Adequate illumination at work station & Collection area

ME D1.5 Facility has policy of removal of condemned junk material

• Follow state guideline.• Junk material in patient care areas/ Corridor• Demarcated space for keeping condemned junk material

Recommended Illumination level in HospitalArea Recommended Min. Illumination

(in LUX)1. Bathroom 100-1502. Entrance – hall 2003 Consultation room 1004. Corridor , General 3005. Ward 150-3006. Diagnostic x ray , Work Place 3007. Doctors office 3008. Enquiry Office 5009. Nursing Station (Day) 30010. Nursing Station (Night) 30-10011. Laboratory , Pathology 300-50012.. Toilets 100-15013. Store 10014. Pharmacy 300

Standard D2 :Facility has defined procedure for storage, Inventory Management &dispensing of drugs in Pharmacy ∞

STANDARDS

MD2.1 The facility has established procedures for estimation, indenting and procurement of drugs and consumables

MD2.2 The facility ensures proper storage of drugs and consumables

MD2.3 The facility ensures management of expiry and near expiry drugs

MD2.4 The facility has established procedure for inventory management techniques

MD2.5 There is process for storage of vaccines and other drugs, requiring controlled temperature & storage environment

MD2.6 The facility has established procedure for dispensing of drugs

Pharmacy Procedures ..,• Forecasting and intending of medicines shall be done based on consumption only .• Consider stock out and wastage drugsStorage• Store in alphabetical order, medicines labelled• LASA Medicines should be listed and store separately (Colour coding system)• Procedure to identify near expiry drugs and avoid expiry of medicines• Expiry drugs if any shall be discarded in black bag• Physical verification of inventory• BIN CARD SYSTEM (Receipt/issues /balance/audit)/ FIFO/VED

Medicine storage

Expiry and Near Expiry of drugs

• Check for Expiry Date of the drug are written on emergency drug tray There are no expiry drug lying in drug tray or storageCheck for Expiry DrugsList of expiry dates is of drug available in the department is maintainedNear expiry drugs are marked and list is updated periodically

Pharmacy Procedures ..,DISPENSING• Store in labelled containers • Drugs dispensed in envelops (Medicine name/strength/dosage/

route/time of administration)• LASA should be displayed in dispensing counter• Drugs are not directly dispensed from drug storage area• Strip cutting is not done• Dispensing register is updated in real time

Laboratory Procedures• There is established system of timely indenting of consumables and

reagents • Reagents are labelled appropriately• No expired reagent found, Records for expiry and near expiry reagent are

maintained • Expenditure & stock register of consumables are available at laboratory• The facility provide monitoring and reporting service for Integrated

Disease Surveillance Programme, as per guidelines• Reporting format (Form L) are sent to District Surveillance Unit (DSU) as per guidelines)• Water Quality Checking (Form for Water Quality monitoring

Form W contain information on source of water sample,no. of sample tested from that source and their results )

Standard D3 - The facility has defined & established procedure for community participation for providing assured services

Compliance to standards..

Formation and functioning of • MAS( Mahila Arogya Samit)• Rogy Kalyan Samiti (RKS)• Community Participation (NGO)• Ensure participation of non official members in RKS• Functioning of ASHA- Supporting Mentoring and monitoring

by U- PHC

Functions of RKS• RKS is registered under societies registration act • RKS meeting are held at prescribed interval Minutes

of meeting are recorded Participation of community representatives/NGO/Local bodies is ensured

• RKS generates its own resources from donation/leasing of space

• Community based monitoring/ social audits are done at periodic intervals

Standard D3 Facility has defined & established procedure for Community Participation for providing assured services

• UPHC monitors the activities assigned to ASHAs • Incentives and TA/DA to ASHAs are paid on time • UPHC supports in skill development of ASHAs • There is system of taking feedback from ASHAs to improve the services • Mahila Arogya Samiti has been formed in all the slums served by UPHC• Accounts have been opened for MAS • MAS meets every month • Data base regarding functional MAS is available at UPHC

Reporting :• Reporting on Form S under IDSP• Reporting under Universal immunization program by ANM• Reporting for MCTS • Reporting for HMIS

Standard D4 -PHC has defined procedure for Governance & work management• The facility ensures the proper utilization of fund provided to it• There is established system for contract management for out-sourced services• The facility has established job description(Category wise) as per Govt guidelines (From Medical Officer to ASHA)• The facility has a established procedure for duty roster and deputation of staff

(Field visit plan for MO/ANM/LHV- Monitored and reviewed)• The facility ensures the adherence to dress code as mandated by the department. (ID Card and Name plate including ASHA)• The facility has requisite licenses and certificates, as required for operation of a

health facility.• Availability of authorization for handling Bio Medical waste from pollution control

board • Availability of NOC for Fire Safety • Availability of Licensee under Clinical Establishment Act

• The facility ensures its processes are in compliance with statutory and legal requirement

No Smoking sign is displayed at the prominent places in UPHC

• Staff is aware of requirements of medico legal cases

• Any positive report of notifiable disease is intimated to designated authorities

Protocol for issue of medical certificates.

Defined formats for issuing Medical Certificate is available

A copy of issued Medical Certificate is kept for records

Register is maintained for keeping details of Medical

Certificate issued

Identification marks and Patients address is mentioned in

medical certificate

Medical Certificate are issued on the day of request

Standard D5 Facility has procedure for collecting & Reporting of the health facility related information

• Facility Reports data for Mother and Child Tracking System as per Guidelines

• Facility reports data regarding Antenatal, Delivery and Postnatal care for availed services

• Facility reports data about child immunization in MCTS

• Facility utilizes MCTS data for action planning

• Facility utilizes MCTS data for tracing of missed out immunization and ANC cases

• HMIS data is reported on monthly basis

• All data elements of HMIS are reported

ALL THE BEST .....