1. Clinical Governance & MI: An Introduction
Mark Cheeseman
Education & Training and
Secondary Care Support Medicines Information Pharmacist
East Anglia Medicines Information Service

2. Aims & Objectives By the end of this session you should:
Understand the principles of clinical governance, risk management and quality assurance
Be able to describe the main tools used to ensure quality assurance
Be able to apply these principles and tools in your own workplace

3. Session
Background
Methods
Key tools for MI
Available support
Summary

4. What does Clinical Governance mean to you?

5. Definition “a framework through which NHS
organisations are accountable for
continuously improving the quality of the
services and safeguarding high standards of
care by creating an environment in which
excellence in clinical care will flourish.”

6. History WHO. Principles of quality assurance; 1983.
DH. A First Class Service: Quality in the new NHS; 1998.
CMO/CNO. Supporting implementation of clinical governance. NHS Exec; 1999

7. How did this affect Pharmacy?
RPSGB published ‘Achieving excellence in pharmacy through practice’ (1999)
Clear lines of responsibility
Quality improvement activities
Risk Management
Poor Performance
Clear lines of responsibility and accountability for overall quality of clinical care
A comprehensive programme of quality of improvement activities (e.g. audit, CPD, R&D)
Clear policies aimed at managing risks
Procedures for identification of poor performance

8. What has MI done? UKMi Clinical Governance Working Group
“Clinical Governance – a briefing paper for Medicines Information Services”
Focus:
Framework
Tools

9. Framework Right climate = acceptance and implementation Features:
Good ideas and practice shared
Education and research valued
Blame only used in exceptional circumstances
Collaboration rather than competition

10. Does anyone have all these?

11. How can we achieve quality?
Defining standards
Ensuring delivery of standards
Quality
Checking delivery of standards

12. What tools can we use to ensure quality?

13. Tools for Quality Standards Audit programmes User satisfaction surveys
Benchmarking schemes
Evidence-based practice
CPD
Training programmes

14. Tools for Quality Standards Audit programmes User satisfaction surveys
Benchmarking schemes
Evidence-based practice
CPD
Training programmes
UKMi Standards
QA Visits
MI User Survey
Workload Survey
Enquiry Answering!
Personal CPD
NMITC, Advanced MI Training, NMITTC

15. Tools for Quality Risk Assessment/ Management Schemes
Appraisal schemes
Incident/near miss reporting schemes
Dialogue with principal stakeholders
Involvement with commissioning specialist services

16. Tools for Quality Risk Assessment/ Management Schemes
Appraisal schemes
Incident/near miss reporting schemes
Dialogue with principal stakeholders
Involvement with commissioning specialist services
Risk Management Policy
Peer Review
IRMIS
Who are yours?
Who commissions your service?

17. How can we achieve quality?
UKMi Standards & Clinical Governance Working Group
Resources, CPD, Job description,
E&T, SLA’s, KSF, Service commissioning
Competency Framework
Quality
Defining standards
Ensuring delivery of standards
Checking delivery of standards
National
standards
Audit, Peer review / bench marking, Outcomes / indicators, Near-miss / incidents reports

18. So what does the UKMi Clinical Governance Working Group do?

20. What should you be aware of?
UKMi Standards
QA Visits
MI User Survey
Peer Review
Risk Management Policy
IRMIS

21. Standards Enquiry Answering Process Education & Training Publications
Clinical Governance
Risk Management

22. Quiz

23. Quiz (1) How quickly should the MI phone be answered within?
A) 10 seconds
B) 30 seconds
C) 60 seconds
The pharmacist supervising trainees in MI does not need to have attended the National MI training course? True or False

24. Quiz (2) 3. How long should enquiries be kept for? A) 8 years
B) 25 years
C) A and b
4. A pharmacist should be available to take a call
A) Straightaway
B) Within 2 minutes
C) Within 5 minutes

25. Quiz (3)
5. Non-MI pharmacists should have MI training as part of their induction.
True or False
6. When receiving an enquiry via , it should be acknowledged within
A) 1 hour
B) 4 hours
C) 30 minutes

26. Quiz (4) 7. What is the ‘National Standard’ for an enquiry ‘answer’?
B) 95%
C) 90%
8. How long should pre-registration pharmacists spend in MI?
A) 4 weeks
B) 6 weeks
C) 8 weeks

27. Quiz (5)
9. How often should the MI centre’s risk management policy be reviewed?
A) Every year
B) Every 2 years
C) Every 3 years

28. Quiz (6)
10. How soon after a MI Pharmacist has started in their role should they attend the National MI training course?
A) Within 6 months
B) Within 12 months
C) Within 24 months

29. Quiz (7) 11. Which of the following should be kept by a MI centre:
A dated record of all pharmacists offered training and those who accept it.
A dated record of all pharmacists who borrow a book/journal from the centre.
None of the above
12. Which of the following are MI services expected to provide:
A) A paper and electronic guide to basic MI resources for all on-call pharmacists
B) An electronic guide to basic MI resources for all ward pharmacists
C) Both of the above

30. Quiz (8)
13. If a MI centre is producing a publication which of the following is necessary:
A) Protocol checklist
B) Author of material is identifiable
C) Both of the above

31. Quiz (9)
14. MI technicians should undertake the UKMi Accredited MI Technician Training scheme within:
A) Within 6 months
B) Within 12 months
C) Within 24 months

32. QA Visits Regional centre -> Regional centre
Regional centre -> Local centre
Audit centre against national standards AND peer review sample of enquiries
National template

33. National Template
Summary of the MI service, recommendations from last visit and this visit
Performance Review
Enquiry Answering
Education and Training
Publications
Clinical Governance
Risk Management

34. MI User Survey
Developed to provide statistically robust questionnaire.
Eleven questions linked to provide validity
Three categories measuring different aspects of user satisfaction:
Answer satisfaction
General Helpfulness/Time Satisfaction
Ease of Contact Satisfaction

35. What do you think is important to users of the service?

36. Questions Initially I was able to contact the service easily
I was informed when I could expect an answer
The answer provided was sufficiently detailed for my needs
In general I found the service to be helpful
I had to contact the MI centre more than once before I received a response
I received the answer to my enquiry too late for it to be useful

37. Questions The information was received when requested
I did not receive the information that I required
I received the answer to my enquiry within the time requested
I was happy with the answer to my question
My question was answered in full

38. MI User Survey Conducted at least once per annum
Minimum of 40 questionnaires should be sent out to generate a minimum of 20 responses.
Consider 10% of enquiries each month

39. Peer Review Monitor standard of enquiry answering
All centres expected to undertake peer review
Encourage sharing of:
Experience
Knowledge
Expertise
Should be non-judgmental
Provide professional support

40. Peer Review Peer review allows:
Regular objective feedback on performance
Feedback and suggestions on improving the quality of the service
Sharing of ideas and learning from colleagues
Development of own practice and service
Identification of learning needs

41. Peer Review UKMi provide: Definition for ranking enquiries
Summary of criteria for grading answers to enquiries using documented evidence
Enquiry assessment form

42. Peer Review
Documentation
Analysis
Coverage
Answer

43. Peer Review Internal External Sample enquiries (manager led)
Sample enquiries (team led)
Sample enquiries (user feedback)
Group discussion
External
Peer Review visits
Regional network meeting

44. Peer Review
Workshop

45. Workshop Group work Peer Review enquiry Use national documentation
Present findings to the group
What did you like about doing this?
What did you not like?

46. Risk Management Policy
Environment
Equipment & Information Resources
Outputs
People

47. Risk Management Policy

48. IRMIS Incident Reporting in Medicines Information System
Secure web-based database (NHSnet)
Complement existing NHS reporting systems – NOT a replacement
Incidents – local and IRMIS
Anonymous data

49. IRMIS - what information is recorded?
Title
Enquirer status
Summary of enquiry and incident
Enquiry Category

50. IRMIS - what information is recorded?
Near miss or error
Date
Type
When did it occur?
Detected by?
Enquiry received by?
Processed by?
Checked by?
Answer given by?
Cause of incident
Potential Risk
Actual Outcome
Action (s) for prevention

51. IRMIS- What happens to the data?
Serious incidents
Notified to IRMIS monitor (electronic)
Reporter consent
Learning points circulated to Regional Directors
Data used to compile quarterly report.
Routine Incidents
Dataset used to compile quarterly report

52. IRMIS- What happens to the data?
Incident Number
Title
Date of incident
Potential Risk
Actual Outcome
Action (s) for prevention
***Enquiry and hospital number removed***

53. IRMIS- What happens to the data?
IRMIS monitor ensure report is completely anonymous
Learning points highlighted
Report presented to UKMi Exec
Paper copy -> regional MI managers for discussion at local meetings
Summary posted on UKMi site

54. What about wider clinical governance issues?
Hospital clinical pharmacy services
Formularies
Medicines management programmes
Prescribing advice
MMC/Area Prescribing Committees
Local guideline writing/protocols
Dissemination of good practice
Input into audit programmes and quality initiatives
Training and CPD programmes
Shared care support

55. Where can you access Clinical Governance information for MI?

59. Summary You should now:
Understand the principles of clinical governance, risk management and quality assurance
Be able to describe the main tools used to ensure quality assurance
Be able to apply these principles and tools in your own workplace

60. Tel No. 01473 704431 mark.cheeseman@ipswichhospital.nhs.uk
Questions
Tel No