QESTRAIN –project
Personnel training model for integrated quality-environment-safety managements
system in hospitals and public health services
1st Internal Report
Lohja Hospital Area and Lohja Health CentreSykli Environmental School of Finland
QESTRAIN -project The main targets of Lohja Health Centre
Basis:– Holistic approach (quality-safety-environment)– Practical tools– Work towards learning organization
Main targets :– Commitment of management– Holistic view of quality– International and local cooperation
The main targets of Lohja Health Centre…
• Management commitment:– Economy, process, staff & client perspective– Strategies of the Health Centre and the Hospital Area– Practical working instruments– Management education
• Holistic view of quality– Safety, quality, environment = Quality Policy– Unite existing quality projects: common procedures, common target
and criteria– Continued quality control– Practical quality methods
• International & local cooperation– Sharing & making use of knowledge– Examples
• Safety plan “How to encounter an aggressive client / patient”• Long term patients excretion function• Implementation of guidelines for treatment / caring
– Common work, common world
QESTRAIN -project The main targets of Lohja Hospital Area
• To have a good continuation to the successfully started quality work to continue with quality
• To combine quality, environmental and safety activities (QES) together (= holistic approach) by having QUALITY of operations as the viewpoint
• To highlight the quality view in the managemetn of operations
• The continuous development and training of QES
• Cooperation with Lohja Health Centre with the QES issues and activities
Task 1.1 – Evaluationof needs and existing problems
Objective:
to identify the areas as related to the development of quality-environmental-safety issues at Lohja Hospital Area and Lohja Health Centre for the basis of the development of the training model
– strenghts, best practices
– develomental areas and issues
– problematic areas and issues
Task 1.1 - Evaluation02 – 05 / 2003
• Survey of work done and existing material 02 –05 / 2003– including interviews and discussions
• Management review & meeting 27.03. 2003 / 03.04.2003 – project info, basic concepts and managements views
• Personnel informations 4.4.2003 / 06.05.2003– project info & basic concepts
• Questionnaires 23.04. – 09.05.2003– specified personnel groups, working groups and departments
• Work shops (2 – 3 hours) spring and autumn 2003– specified personnel groups, working groups and departments
• Management system audit at Health Centre – physiotheraphy and clinical laboratory, 13. & 14.05.2003
resp.
Survey of work done and existing material
02 – 05 / 2003
• Organization and operational surroundings• Environmental review and programme• Quality work
– EQFM approach /hospital area– ITE –method / health centre
• Occupational safety and security• Including interviews and discussions with key
persons reports 06/2003
Management review and meeting
• general information of the project– the objectives of the project– the objectives and targets of pilot
organizations– schedule and resources
• review of total quality (QES) and management systems & processes
• management interview• managements view of the most important
areas
Personnel information
• general information of the project– the objectives of the project– the objectives and targets of pilot
organizations• personnel´s role, schedule and resources• review of total quality (QES) and
management systems & processes• managements view of the most important
areas
Questionnaire23.04. – 09.05.2003
• Target groups at the hospital area:– multiprofessional quality group– nursing quality group– environmental group and ”agents” of the departments– occupational health and safety organization– security group– management group
• Target groups at the health centre:– Health & family counselling / as group answer– Hospital wards / in connection with the work shops, group answers– Technical service (partly) / in connection with the work shop– Doctors
• Questionnaire possibly used in connection with the work shops at autumn?
reports 06/2003
Work shops
• 2 – 3 hours per group• Facilitator (subcontractor) used• At health centre:
– hospital wards – excretion function problem• 07.05. ja 20.05.2003 • continuation at autumn – process model
– technical service (part) 22.05.2003 - questionnaire– dental care at autumn 2003 – process model– health and family counselling at autumn 2003 – process
model
• At hospital area:– Dates only agreed for autumn
Management system audits
• Based on standards ISO 9001, ISO 14001 and OHSAS 18001
• Lohja Health Centre – Physiotheraphy– Clinical laboratory– several years experience on ITE –method
(based on main elements of ISO 9001)– one day audits
Task 3 – Testing of the training model
02 –08 / 2004
Objective:
to test the personnel training models developed together for the implementation of quality – environmental – safety issues– On the basis of the needs of pilot
organizations
raportti 09 / 2004
Task 1.1. – Results of the evaluation
• Management reviews and meetings– Management´s objectives & key areas for the project and for
the training– Linkage with other programmes and projects
• Balanced Scorecard / both organizations• Human Resource Strategy / City of Lohja, Health Centre• Organizational groups / Lohja Hospital Area• EFQM Approach / Lohja Hospital Area• ITE –method / Lohja Health Centre, departments• Environmental Programme / both organizations• Security/safety programme / both organizations
– Management´s commitment– Resources for the project– Training for the modelling and charting of processes!!
Task 1.1. – Results of the evaluation…
• Personnel information– One hour sessions for all personnel– Project leaflets– No discussion generated– Use of Intranet instead?– For smaller groups instead?
Task 1.1. – Results of the evaluation…
• Survey of the work done & existing material– Information for the review of the present state / 1st task
for the development of integrated) managements system
– Detailed information of the training needs, needs for improvement, good & best practices
– Further discussion with the management vs management review + departments / groups training needs categorized based on the importance of each item
Task 1.1. – Results of the evaluation…• Questionnaire
– Questions based on:• Management system elements / standards• Legal requirements / environmental, occupational safety,
hazardous chemicals legislation– Tailored for both organizations
• Specific programmes, plans, procedures, organizations / utilization of the results of the survey
– Answers
• Individually use of statistics vs answering percentages/personnel groups
• As groups by discussing no possibility for the use of statistics BUT as a tool for discussion
– Results / need for further information, training etc.• Further discussion with the management vs management
review + departments / groups training needs categorized based on the importance of each item
Task 1.1. – Results of the evaluation…
• Work shops:– 2 –3 hours per work shop– Facilitator & trainer as external agents– Delayed start, continued during autumn – Process approach!– Example: excretion function at Lohja Health Centre,
hospital wards• Real, long term problem intertwining quality, environmental
and safety aspects• Multiprofessional discussion needed work shop
participants from different personnel groups• Problem defining & problem solving • Process approach: patient´s day - as a concrete model • Continues on September process model / chart
Task 1.1. – Results of the evaluation…
• Management system audits– As system audits difficult
• At departmental level vs system elements• No top management commitment to system
elements & procedures– As a tool for
• training & discussion ok• As a tool for further development ok
– Results clear nonconformancies to requirements– Audit as a tool e.g. for
• Orientation programme for new employees
Orientation material
• The following material was used as orientation for total quality (QES), management systems and processes– at the management meetings– at personnel informations
• Linkage with Balanced Scorecard
• Linkage with EFQM
PlanReview of present state
Goals
DoAction programmeObjectives and targetsActivities
CheckAchievement of objectives
Level of operations
ActNew objectivesDevelopmental issues
DEMING CIRCLE AND CONTINUOUS IMPROVEMENT
Task of pilot organization
Values of parent organization
Customer needs
Legislation
Expectations of society and
interest groups
Needs of personnel
Vision
Strategy
Goals
OPERATIONS
Core processes
Support processes
Results
- customer feedback
- financial result- outputs
- personnel safisfaction
- etc.
Resources
- know how- technology- economy
- cooperational tahot
Control
- responsibilities, SOP´s, instructions, training
- measures- conrol of onconformancies- development of processes
Assessment
Development of operations
Ob
ject
ives
NE
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CORE PROCESSES
Services to the customers
core process
support process
management process
Nees of teams and personnel
Economical, quality, environmental and safety objectives
SUPPORT PROCESSESFinancial Man´ HR ManagementIT Managment Interest group coop´nHousekeeping Communication
Satisfaction of teams and personnel
Achievement of economica, quality, environmental and safety objectives
Eco
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safe
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bje
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Ach
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safety
ob
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PROCESS MODEL OF OPERATIONS
Management System
• Standards: • ISO 9001 (quality)
• ISO 14001 (environment)
• OHSAS 18001 (occupational health & safety)
Management and development of qualoity, environmental and safety issues:
- review of the present state
- identification & determination of important QES -aspects
- developmental objectives and activities
- responsibilities, procdures, instructions and control of operations
- training and communication
- assessment of operations, follow up and continuous improvement
MODEL OF INTEGRATED MANAGEMENT SYSTEM
SAFETY
QUALITY
Managed:• responsibilities• continuous follow up• nonconformancies• corrective & preventive actions
Managed:• responsibilities• continuous follow up• nonconformancies• corrective & preventive actions
Improved:• goals & objectives• actions• responsibilities & resources• schedule• follow up
Improved:• goals & objectives• actions• responsibilities & resources• schedule• follow up
instructonstraining
communication
contin
uous im
pro
vem
ent
Follow up and development• internal audit• management review• suggestions for improvement
Follow up and development• internal audit• management review• suggestions for improvement
TOIMINTAYMPÄRISTÖoperations
present state• remarkable environmental aspect• risk categories• important success factors
processes products
Policy
ENVIRONMENT
PRODUCTIVITY
BALANCED SCORECARD (BSC)
(Tasapainotettu tuloskortti)
• The implementation of strategy
• Measurements of operations and results Critical success factors
1. customer view
2. economical view
3. personnel view
4. effectivity / process view
• Objectives and measures for the different levels / units / processes of the organization
BSC and Management Systems together
• BSC and integrated Management System approaches can be applied simultaneously
• Problems: double work • Different elements can be taken for specified
purposes:
- setting up of goals and objectives & implementation of strategy -> BSC
- development and management of operations -> management system
- assessment and development -> BSC
Resources
INP
UT
S
OU
TP
UT
S
Control
BASIC PROCESS MODEL
Personnel: knowledge, skills,
attitudes
Surroundings, machines,
equipments, materials, etc
Economical resources
Instructions, responsibilities
Training
Control of nonconformancies,
improvement of processmeasures, follow up
patient taken in
patient taken in
Inspection and diagnosis
Inspection and diagnosis
treatment activities
treatment activities
Follow up and assessment
Follow up and assessment
• Actions in different phases of the process
• Critical factors (quality, environment, safety)
• Flow of information between the different phases of the process
• Issues to be documented
• Records to be created
Utilization of process descriptions in the planning of integrated management system
(example)
WHAT IS NEEDED:
• Identification of QES aspects and critical success factors together
• Review of processes as a whole
• Ideas and development
• Agreements of common procedures and principles
• Documentation of procedures and instructions
• Communication and training
• Assessment and follow up
• Integration of QRS issues to the planning and management of other operations
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