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The QCS guide to quality assurance

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Introduction

The CQC’s guide ‘Essential Standards of Quality and Safety’ is intended to enable us to determine how good care standards are. In an ideal world, each achievement measured against the Outcomes would provide the best result for the service user every time. Care would be exacting, consistent and repeatable from one service user to the next.

Unfortunately serious cases of poor care now seem to emerge with greater frequency and the whole process of regulation and the upholding of care standards remains highly contentious. In the wake of the Francis Report there are several changes to the regulatory regime in the pipeline. One of the key changes is a ‘star’ rating system.

This may provide an opportunity for some light relief in the shape of comparing some care services with The Ritz and others with Fawlty Towers. However, joking aside, many believe the serious business of grading care providers in such a manner equates to little more than a ‘dumbing down’, like the much criticised ‘league tables’ in education.

If we put arguments about ratings systems to one side, the central objective on which everyone agrees is that we need to improve care standards. In this guide we discuss how the QCS compliance management system enables care providers to continually improve care standards, against an assessment system governed by quality assurance.

A potted history of quality assurance

The post-WWII reconstruction effort in Japan was lead by the US and helped the nation back to its feet. As part of the effort to revive the economy the Americans trained the Japanese in the principles and practicalities of mass production and manufacturing.

In 1950, W. Edwards Deming trained hundreds of Japanese engineers, managers and scholars in statistical process control (SPC) and concepts of quality. The Deming cycle of PDCA (plan-do-check-act) was central to the knowledge that was transferred.

Although the lessons were widely adopted in Japanese industry, it was Toyota that refined and distilled this learning into the principle of kaizen, a philosophy for continuous improvement. Brief interpretations identify kaizen as a method for increasing productivity, but this is far from the whole story. We find that better productivity is actually a side-effect of the intended purpose of kaizen, which is to improve quality while reducing cost.

Correctly implemented, kaizen is a process that humanises the workplace, eliminates overly hard work, and teaches people how to perform experiments on their work and identify and eliminate waste in business processes.

Theory into practice

On the production line, kaizen empowers each worker to take responsibility for quality control. This applies not only to the product being manufactured, but also to the process by which the product is manufactured. In simple terms the system promotes the idea that if there is a better way to do something, we do it.

Notable aspects of kaizen include:

  • From the very top down, people at all levels of an organization participate in kaizen, and if appropriate, external stakeholders
  • Kaizen can be structured as a suggestion system, around an individual, or a small or large group
  • Toyota usually implements it to so that a small group is involved in improving its work environment and productivity and is often guided by a line supervisor
  • On a broad cross-departmental scale, kaizen generates Total Quality Management (TQM), the management philosophy for continuously improving processes, products and services
  • The net effect is to free human efforts through improving productivity using machines and computing power

From kaizen to Total Quality Management

Since the late 1980’s the benefits of kaizen have been refined and disseminated to the wider organisational community as Total Quality Management (TQM), the management philosophy for continuously improving processes, products and services.

Quality Management Systems (QMS) are now established as essential in governing the design, development and delivery of products and services. For many, quality management is most recognisable as the internationally accepted range of ISO 9000 certifications administered by the British Standards Institute in the UK.

The evolution of the regulators

Despite the emergence of organisational systems for quality assurance some ten years before, there was no national policy covering all aspects of safety and quality of health care when the White Paper, ‘The new NHS, modern, dependable’ was published in 1997.

In the intervening period between then and now, a series of moves has restructured, refined and condensed the regulatory function across the UK, and the chief responsibility now resides with four main bodies: The Care Quality Commission (CQC) in England; the Regulation and Quality Improvement Authority (RQIA) in Northern Ireland; Social Care and Social Work Improvement Scotland (SCSWIS) and the Care and Social Services Inspectorate Wales (CSSIW).

To a greater or lesser extent, quality assurance is now a key element in the design of the regulatory frameworks that are employed to determine the quality of health and social care that is provided in the UK.

Implementation today

Established in 2009, The Care Quality Commission published its keynote guide to compliance ‘Essential Standards of Quality and Safety’ in March 2010.

This provides seven Outcomes (15 through 21) that are concerned with quality and management. ‘Outcome 16: Assessing and monitoring the quality of service provision’ spells out how quality management is applied to protect service users and others against the risks of unsafe care and treatment.

If we read the full text of this Outcome there are two points to note. Firstly, the language used would not win any awards for plain English. Secondly, it is not explicit enough in stressing the importance of continually monitoring practice and the need to make, implement and review plans on quality, risk and improvement.

If we analyse Outcome 16, we see that it omits the key term ‘TQM’. It also fails to make the link to the ‘plan-do-check-act’ process of the Deming cycle, which is familiar to many care professionals. It hints at it, but ultimately it breaks up the concept, in effect diluting it.

As a general note on the evolution of the regulation, it can be observed that there is a shift from a prescriptive to a more descriptive approach.

Historically the approach has been to set out what is required and give service providers the processes and procedures required to meet compliance objectives. The CQC has pulled back from this position somewhat. It sets out a significant number of outcomes but leaves service providers to interpret how compliance objectives should be achieved.

Regulation tomorrow

Faced with such scandals as the Mid-Staffordshire NHS Trust and Winterbourne View, the regulatory regime is set to become more rigorous and robust.

The consultation document ‘A new start’ published on 17 June 2013 by the CQC set out a number of key changes to which it invited stakeholders to respond. These include:

  • A Chief Inspector of Social Care to lead an expert inspection team
  • The introduction of ratings for adult social care services in 2014-15
  • Increased corporate accountability to make individual first line managers and board members responsible for care quality

The CQC acknowledges the approach of schools regulator Ofsted, providing a clear indication of what is shaping its thinking. It has also signalled a pull back from the existing position of 28 regulations and 16 major outcomes. In future the Commission will be asking five simple key questions when conducting inspections. Is the service safe, effective, caring, well-led and responsive to people's needs?

This further shifts the regulatory approach from prescriptive to descriptive. Removing an unwieldy structure of regulations and outcomes and boiling regulation down to five simple questions, clarifies compliance at the top level.

However, this places the onus on service providers to clearly understand their service objectives, test the processes they have developed to meet them, and quickly and effectively change processes where they do not.

As the CQC strives to restructure regulation to eliminate the loopholes and grey areas, and as service providers are required to monitor and change processes, there can be little doubt about the increasing importance of quality assurance.

TQM is embedded within the QCS system

QCS is a compliance management system designed from the ground up to incorporate TQM.

Quality assurance is embedded throughout, interwoven within the framework of protocols, policies, procedures and audits. This means the system delivers on the key principles that define quality assurance - ‘Fit for purpose’ and ‘Right first time’.

QCS incorporates data collection as an integral part of the compliance process. The information recorded in different areas is fed into the system and properly analysed. The result is fed forward, to modify care or any other aspect of the service which influences care quality.

If we evaluate the QCS system against the benefits of kaizen, the PDCA cycle and the management practice of TQM, we can see that it remains true to Deming’s theories:

  • Better productivity

­      Better outcomes for service users by enabling the right care to be provided to every user in the right way

  • Improve quality

­      Raising the standards of care and making them consistent and repeatable so that each service user receives the best quality care

  • Reducing costs

­      Drives efficiency which lowers operational overheads

  • Humanises the workplace

­      Creates the conditions for a more compassionate care setting through the use of a fair and open HR policy set to influence how staff treat service users

  • Eliminates overly hard work

­      Allows manpower or ‘insufficient time allowed’ issues to be fed into the system, both major sources of stress

  • Encourages critical thinking

­      Staff evaluate what they are doing and the results they achieve

  • Efficient use of resources

Identifies and eliminates waste across the many different areas such as housekeeping, laundry, catering, maintenance and administration

About QCS

Quality Compliance Systems (QCS) offers a unique approach to CQC Compliance with an online based service specifically tailored to the individual needs of your organisation.

Whether you are an established Care Provider, Dental Practice , GP Surgery or a start-up organisation, our service is provided with the aim of ensuring that all aspects of compliance are being attended to.

Our industry experts continually update existing policies and procedures, whilst introducing new ones in response to the latest changes issued by the Care Quality Commission (England) and the SCSWIS(Scotland).

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Further reading and references

March 2010

Essential Standards of Quality and Safety Guide

The Care Quality Commission

June 2013

A new start - Consultation on changes to the way CQC regulates, inspects and monitors care

Wikipedia references

- Kaizen

- PDCA

- Total Quality Management

- W. Edwards Deming

URL: http://www.wikipedia.org

The Regulation of healthcare in England

The King’s Fund

URL: http://www.kingsfund.org.uk/topics/nhs-reform/nhs-white-paper/health-care-regulation

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