EMPLOYEE QUALITY AWARENESS Page 1 of 11

OCTOBER 1998 Issue 3

______

EMPLOYEE

QUALITY AWARENESS TRAINING

Presented By:

TABLE OF CONTENTS

1.0Purpose......

2.0Scope......

3.0References......

VISION......

MISSION......

QUALITY POLICY......

4.0Definitions......

5.0Procedure......

5.1Responsibility- General......

5.1.1Employee

5.1.2Manager And Supervisor

5.2System Documentation......

5.2.1The Quality Manual

5.2.2Quality Procedures

5.2.3Regional Procedures

5.2.4Standard Procedures

5.2.5Forms and Records

5.2.6New Documentation

5.2.7Changes To Documentation

5.2.8External Documents

5.2.9Position Descriptions

5.2.10Agreement Register Manual

5.3Internal Quality Audit Programme......

5.4Incident Reports......

5.4.1Nonconformance Reporting

5.4.2Corrective And Preventive Action

6.0Records......

6.1 What Every Employee Needs To Know......

6.2Dealing With Quality Auditors......

6.3How Do Quality Procedures Apply To Me......

1.0Purpose

The purpose of this document is to provide employees of the Company X Victoria - North Western Region and Western Region with a basic understanding of the Quality Management System and its application in the work place.

ASV has a mission to develop and provide services and products for a broad range of customers. We want these services and products to be consistently of high quality, and we expect them to meet the full needs and expectations of our customers.

To meet this mission, we must all ensure that documentation, materials, products and services delivered to satisfy our customers, are in accordance with our mission and the supporting management policies.

The three initial objectives of the Quality Management System are:

  • to achieve and sustain the quality of services and products provided so as to meet continually the customer’s stated or implied needs
  • to provide confidence to ASV management that the intended quality is being achieved and sustained
  • to provide confidence to the customer that the intended quality is being achieved in the services and products provided

2.0Scope

The “Scope” of the Quality Management System defines the boundaries, within which the system applies. The Scope statement is:

The provision of ambulance based clinical services including emergency telephone calltaking, emergency ambulance dispatch and co-ordination, relay of emergency information to health facilities, paramedic acute health care, acute health transport, inter-hospital patient transfers and specialised medical transport. The provision of first aid courses to the public, corporate first aid training, customized first aid training and scenario based training.

This scope statement is followed by the locations of Stations where the scope statement applies. “Casual Stations” are scheduled for inclusion in this scope in 1999.

3.0References

VISION

Company X Victoria

will be the world’s best

Company X

MISSION

Company X Victoria provides high quality cost effective ambulance based medical care as a critical link in the health care chain.

QUALITY POLICY

Company X Victoria, through its staff, is committed to providing the best possible patient outcomes by continually improving the quality of service and being receptive to customer needs.

4.0Definitions

Quality:Meeting the customers' requirements (stated or implied).

Quality Management System (QMS): The determination and implementation of quality policy and objectives using the organizational structure, procedures, processes and resources.

Total Quality Management(TQM): The management philosophy that seeks control and continual improvement in the processes, goods and services of an organization.

Product:The result of activities or processes.

The Standard: AS/NZS ISO 9002:1994 Quality systems-Model for quality assurance in production, installation and servicing. Referred to as ISO 9002.

System Element:Each of the 19 sub-clauses found under clause 4 “Quality System Requirements” of ISO 9002.

ISO 9002 CERTIFICATION FLOW CHART

5.0Procedure

5.1Responsibility- General

5.1.1Employee

All employees are responsible for the quality of work they carry out, and for ensuring:

  • that the need for additional procedures, instructions or training is identified and brought to the attention of their supervisor or manager;
  • that when assigned to a task, they confirm that they are qualified and experienced in their technical discipline and can perform their assigned duties in a satisfactory and safe manner;
  • that they are familiar with Quality Procedures, Regional Procedures and Standard Procedures applying to their tasks;
  • adherence to occupational health and safety procedures required by statutory regulations and ASV Policy, and
  • that they strive for excellence in their tasking and participate willingly in ASV's continuous quality improvement programmes.

Personnel under training, including new employees, must work under direct supervision until their supervisor or manager is satisfied that the required skill and competency level is attained.

5.1.2Manager And Supervisor

All managers and supervisors are responsible for the quality of work carried out by personnel within their respective areas of responsibility and for ensuring that:

  • all their employees have ready access to and familiarity with the relevant Quality Procedures, Standard Procedures, and other workmanship standards;
  • personnel assigned to a task are qualified and experienced in their technical discipline and have the tools and materials necessary to perform the duties of their position in a satisfactory and safe manner;
  • the administration of quality control activities as apply to their area of responsibility;
  • the implementation of Continuous Quality Improvement (CQI) Programmes, and
  • for ensuring adherence to occupational health and safety procedures in accordance with statutory regulations and ASV Policy.

5.2System Documentation

The system documentation provides a clear picture of the breakdown of the sources and information that collectively describe what the system is intended to achieve, how it works, what is to be produced, by whom and when.

This system consists of five tiers of documentation.

  • The Quality Manual
  • Quality Procedures
  • Regional Procedures
  • Standard Procedures
  • Forms and Records

5.2.1The Quality Manual (Contained in Quality System Manual)

The Quality Manual defines WHAT is to be achieved. It translates the 19 QMS elements of ISO 9002 in terms of ASVs operations. It references the Quality Procedures that have been established for each of the elements.

5.2.2Quality Procedures (Contained in Quality System Manual)

The quality procedures establish broadly HOW intended arrangements are to be achieved across Company X Victoria. Procedures are numbered to provide traceability to the matching element of the Quality Manual.

5.2.3Regional Procedures (Contained in Regional Quality Manual)

Regional Procedures serve two functions. Firstly to fill any gaps that exist in the generic quality procedures that cover all of ASV, relating more accurate information about QMS activities in the North Western Region. Secondly to provide the standardized methodology of work practices across the Region.

Regional Procedures are segregated into categories and are individually numbered. Current and planned categories include:

GeneralRP:3001:NWR to 3999

OH&SRP:4001:NWR to 4999

OperationalRP:5001:NWR to 5999

Clinical TrainingRP:6001:NWR to 6999

Public EducationRP:7001:NWR to 7999

AdministrationRP:8001:NWR to 8999

Fleet MaintenanceRP:9001:NWR to 9999

At this time Administration and Fleet Maintenance procedures are yet to be developed, but are not within the current scope of the system.

5.2.4Standard Procedures (SP) (Contained in Regional Quality Manual)

Standard Procedures apply to a singular station only, and provide operational information that is specific and unique to that station.

Identification and numbering of Standard Procedures is defined in RP:3003:NWR. They are identified with the prefix SP, are numbered from 0001 for each station, and have a suffix that corresponds to the station code used on PCRs. (e.g. BO = Bendigo)

5.2.5Forms and Records (Forms Contained in Regional Quality Manual)

Forms are a means to record data, and records provide the objective evidence needed to prove that we did what the procedure/instruction/etc prescribed the process to be. Normally only those forms listed in the Forms Register Manual (RM:0002) are to be used within the NWR. To assess the validity and status of forms you are using, refer to the flow chart below.

FORM STATUS ASSESSMENT FLOW CHART

5.2.6New Documentation (QP:0501)

During implementation of the QMS, procedures and instructions need to be developed, reviewed, approved, registered, distributed and controlled.

Proposal for new documents must be submitted to the Quality Manager for these processes to take place.

5.2.7Changes To Documentation (QP:0501)

Any document that forms part of the QMS can be altered by lodging a DOCUMENT CHANGE NOTICE with the Quality Manager. All QMS documents are controlled, and must only be altered after formal documented review and approval.

5.2.8External Documents (List Contained in Regional Quality Manual)

All external documents used as guidance for the performance of clinical and educational services (Acts, Regulations, AOTC Manuals, Australian Standards, etc.) must be registered to ensure that the current information is available in all work areas where it is required.

Maintaining the current issue status and the list of controlled holders of external documents is the role of the “Responsible Controller” who is identified in the External Document Register.

5.2.9Position Descriptions (Contained in Regional Quality Manual)

Position Descriptions (PDs) have been approved by management for all positions that are covered by the “Scope” discussed earlier. They describe the responsibilities, authorities, objectives and activities of a position.

Relevant PDs are issued to each registered holder of a Regional Quality Manual. Every Station has at least one copy of the Regional Quality Manual, so you can have access to the PD that applies to you.

The “master” copies of all PDs are held by the Quality Manager. Uncontrolled copies of PDs are available upon request.

5.2.10Agreement Register Manual (Separate Red Folder – RM:0006:NWR)

This folder contains the agreements that exist between the employer and the employee’s representatives. This folder has now been brought under “control” to ensure that new agreements are distributed and available in the workplace.

5.3Internal Quality Audit Programme

To ensure the continued integrity and effectiveness of quality policy and the associated management system North Western Region has implementing an audit programme that measures and reports on the overall state of compliance of the Quality Management System.

When a company first sets up its QMS the initial work to be done is concentrated on the reduction of the “gap” between the current situation in-company and the requirements of the standard. Internal audits are the main source of documentation of these gaps, so that action can be taken to close the gap and avoid it re-opening in the future.

The on-going audit programme monitors activities to ensure that no gaps exist (compliance). All auditing activities are reviewed by management.

The three main reasons for gaps are:

  • the lack of maturity in the management of the system;
  • the tendency to act rather than document, and
  • the limited amount of available resources.

5.4Incident Reports

5.4.1Nonconformance Reporting (QP:1301 and RP:3007:NWR)

As part of the management system ASV is putting in to place a reporting system encouraging all employees to document those occasions when someone identifies the opportunity to:

  • improve the services provided
  • correct a service that does not meet procedural, protocol or skills requirements
  • identify the need for additional procedures to be documented to ensure that a recognized and acceptable standard of service is provided uniformly across the region
  • identify additional training requirements necessary to achieve quality service
  • provide innovative services to our customers

These opportunities should be documented on an Incident Report Form QF:1301.1

A hard copy is retained in the reporting book, with the original going to the responsible manager for investigation and action, and a copy going to the Quality Manager for tracking to ensure timely action and response.

5.4.2Corrective And Preventive Action (QP:1401)

After investigating the incident and documenting it on the form, the addressee documents the corrective action taken or intended to deal with the immediate case at hand.

Next the preventive action taken or planned is documented. This ensures that the system fault that allowed the original incident to occur is rectified to ensure it does not occur again.

All Incident Report forms will be reviewed for adequacy and effectiveness by the Quality Manager, who will advise the originator of the report of the outcomes.

Incident Report

REPORT TO:...... REPORT No.:00001

Responsible Manager

REPORT FROM:...... EMPLOYEE No: ......

originator

BRANCH/DEP’T: ...... SHIFT: ......

A:INCIDENTCompleted by originator

DATE:(Day) ...... (Date) ...... (Time) ...... hrs

LOCATION:......

DETAILS:(What happened, why, suggestions)Attach ALL supporting documentation where necessary.

......

6.0Records

6.1 What Every Employee Needs To Know

Every employee must know that the following exists, and where it is located:

  • Quality Policy
  • Quality Manual
  • Quality Procedures
  • Regional Procedures
  • Standard Procedures
  • External Documents
  • Position Description

6.2Dealing With Quality Auditors

Typically, auditors only really ask five questions:

  1. What do you do?
  2. How do you do it?
  3. Where does it tell you to do it that way?
  4. Where is the proof (record) that it was done?
  5. What gives you the authority to do it?

If you don’t know the answer to a question, then it should be found in one of the guidance documents above - then look in the index and then the document to find the answer.

If you still can’t find the answer, contact the Quality Manager who will either point you in the right direction or include the information in a new or existing procedure.

6.3How Do Quality Procedures Apply To Me.

Example – On Road Staff

Quality Procedure / Area Of Application
QP:0501 / Proposing new or changed controlled documents
QP:0601 / Purchase Requests
QP:0701 / Care of patient belongings and hospital equipment
QP:0703 / Confidentiality of personal information
QP:0801 / Documenting service on PCRs and CIS cards
QP:0901 / Rostering, time sheets and inventories
QP:0903 / General clinical process from dispatch to “clear”
QP:1001 / Inspect drug or pack for date or sterility prior to use (Oct 1998)
QP:1101 / Raise incident report for out-of-calibration equipment
QP:1301 / Raising incident reports
QP:1401 / Feedback of findings/actions
QP:1601 / Ensure records (e.g. PCR) is forwarded to correct person

______

C:\QUALITY TRAINING\QAT1098