Building of a Quality Management System

Today, most hospitals are going in for systems of Quality management, such as ISO, NABH (National Accreditation Board for Hospitals & Healthcare Providers), Joint Commission International (JCI) etc. Quality Management System (QMS) is the backbone of effective running of any hospital.. QMS is broadly defined as “all the procedures explicitly designed to monitor, assess and improve the quality of care. “ Accreditation is a form of self-evaluation and peer review, against explicit standards, and is aimed to enhance quality improvement.

The QMS is the backbone or framework, on which a system of accreditation can be built up. It consists of documents, processes , training plans, Quality Indicators, Committee structure, Incident Reporting System, Audit plan etc. All of these add up and integrate into a common QMS, on which the system of accreditation can be built up.

The essential qualities of a QMS are that the parameters must be

-          Simple

-          Measurable

-          Achievable

-          Reasonable

-          Timeline –bound

-           

i.e. S.M.A.R.T.

The usual components of a QMS, are:

1.       Manuals

-          Quality Manual

-          Quality Policies Manual

-          Infection Control Manual

-          Safety  & Security Manual

-          Laboratory Quality & Safety Manual

-          Radiology Quality & Safety Manual

2.       Departmental  SOPs

3.       Quality  indicators

-          Structural  indicators

-          Process indicators

-          Outcome indicators

4.       Incident Reporting  System

5.       Emergency and disaster management system

6.       Committees

-          Quality Steering Committee

-          Infection Control Committee

-          Facility  Management & Safety Committee

-          Pharmaceutical & Therapeutics Committee

-          Medical Audit Committee

-          Mortality & Morbidity Audit Committee

7.       Annual  training and retraining plan

8.       Internal Audit System

The steps of setting up a QMS, are as follows:

1.       Management and stakeholder adoption of Quality requirements, and Mission & Vision statement

2.       Documentation of Policies, Procedures, SOPs, Manuals

3.       Training of staff

4.       Internal audit and Reaudit

5.       Improvement of the system

Through this process, the QMS can set up and sustained.

The focus of a modern –day QMS should be on Continuous Quality Improvement and Patient Safety. Essential elements of patient safety, including a Patient Safety Plan, must be built into the QMS System.

A QMS focuses on both Clinical and Non-clinical quality. These include Patient assessments, Radiology investigations, Laboratory investigations, Medication management, Infection control, Continuous Quality Improvement, Facility Management, Human Resource Management, Information Management Systems etc.

European countries have taken up Quality management at a national level, aided by a broad policy framework. In Finland, the recommendations for building up the QMS have been outlined as under:

Ø  Customer participation in QMS

Ø  Leadership for the steering of quality;

Ø  Personnel as a prerequisite for high quality;

Ø  QMS for preventive as well other activities;

Ø  Management of processes as a basis for QM;

Ø  Information as a basis for the continuous enhancement of quality;

Ø  Systematization of QM;

Ø  Detailed recommendations and quality criteria support quality management.

In our country, the development of QMS in hospitals has mainly been aided by the growth in demand for ISO, NABH & JCI accreditation. Based on this, QMS systems have been developed, and sustained. It is expected that with the further growth of accreditation in our country, Quality Systems will continue to evolve and flourish, and lead to an exponential improvement in Quality Improvement and Patient Safety.