Series: Understanding MSDS | Post 21 of 52
Standard 7 (QA-1) | Indicator 18 | Category: YELLOW (80% required)
The Drawer Nobody Opened
Dr. Mehwish Aslam ran a family practice near Kutchery Road in Sialkot. A printed quality assurance checklist hung behind the reception desk, and her manager filled it every Saturday without fail.
The PHC assessor turned the pages slowly. “Washroom tap leaking” appeared in the observation column in March. It appeared again in April, May and June. “Emergency tray, adrenaline ampoule missing” was written three weeks running.
“Your checklist is very honest,” the assessor said. “It tells me what was wrong. Where does it tell me what you did about it?”
Dr. Mehwish opened her desk drawer. Inside were forty patient satisfaction forms collected over six months. Several said the waiting time was too long. Two said no female staff was available during examination. She had read none of them.
Yet some things had improved. The tap had finally been replaced in July, and she had hired a female attendant in August. None of it was written anywhere.
The assessor could see the improvement with his own eyes, but not on paper. Indicator 18 was scored as partially met.
What Indicator 18 Requires
The indicator reads: A quality improvement system is in practice.
Indicator 17 asks the clinic to check itself. Indicator 18 asks what happened next. The manual requires the doctor, administrator or manager to demonstrate actions taken to improve the quality of services, based on the observations recorded during the periodic evaluations under Indicator 17.
The Quality Improvement Plan in the manual’s guidelines sets out how this should work:
- The in-charge of the clinic is personally responsible under a written order.
- The designated person is trained to ensure quality improvement of all processes involving clinical management.
- The MSDS self scoring matrix is used by all respective staff to ensure compliance.
- Complaints are investigated and their results are used to improve patient care, processes and systems.
- The activity is monitored by the in-charge through his or her own checklist.
- Patient feedback is used to improve the system.
The manual’s sample patient satisfaction form ends with a line that says a great deal: “Action by the person in charge with date.” A form without that line filled in is feedback, not improvement.
How It Is Scored
This is a YELLOW indicator with three possible outcomes.
Fully met: there is a written record of actions taken on the observations.
Partially met: there is no written record of actions taken, but quality improvement is demonstrated.
Not met: neither a record of actions taken nor any quality improvement is demonstrated.
The new tap and the female attendant earned Dr. Mehwish credit for improvement the assessor could see. The missing record held her below fully met.
Why It Matters
Quality assurance identifies gaps. Quality improvement closes them, and the written record proves that they were closed, by whom and when. An adrenaline ampoule noted missing three weeks running is a patient at risk for three weeks.
What Dr. Mehwish Changed
She began with a one line written order naming herself as in-charge of quality improvement, with her manager responsible for the weekly checklist.
A new column was added to the checklist: “Action taken, by whom, date.” No observation could stay blank in that column for more than one week.
The satisfaction forms now came out of the drawer every Saturday. She wrote her action and the date on each form, and treated complaints the same way. When three forms mentioned long waiting, she started a token system and wrote that decision in a small quality improvement register.
On the last Saturday of each month, she and her staff spent twenty minutes on the MSDS self scoring matrix and noted what had changed.
At reassessment, the assessor traced one observation from the checklist to the register to the repaired item. Indicator 18 was fully met.
“I had been collecting problems,” she said. “Now I close them.”
A Quick Self-Check
- Is there a written order naming the person responsible for quality improvement?
- Does every observation on your quality assurance checklist have a recorded action and date?
- Are patient satisfaction forms read, acted upon and signed with the action taken?
- Are complaint findings used to change a process, and is that change written down?
- Do your staff use the MSDS self scoring matrix at regular intervals?
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