Clinical Governance & MI:
An Introduction
Mark Cheeseman
Education & Training and
Secondary Care Support Medicines
Information Pharmacist
East Anglia Medicines Information Service
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
Session
 Background
 Methods
 Key tools for MI
 Available support
 Summary
What does Clinical
Governance mean to you?
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.”
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
How did this affect Pharmacy?

RPSGB published ‘Achieving excellence in
pharmacy through practice’ (1999)
1.
2.
3.
4.
Clear lines of responsibility
Quality improvement activities
Risk Management
Poor Performance
What has MI done?
 UKMi Clinical Governance
Working Group
 “Clinical Governance – a
briefing paper for
Medicines Information
Services”
 Focus:
– Framework
– Tools
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
Does anyone have all these?
How can we achieve quality?
Defining
standards
Ensuring delivery
of standards
Quality
Checking delivery
of standards
What tools can we use to
ensure quality?
Tools for Quality
 Standards
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Audit programmes
User satisfaction surveys
Benchmarking schemes
Evidence-based practice
CPD
Training programmes
Tools for Quality
 Standards
 UKMi Standards
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Audit programmes
User satisfaction surveys
Benchmarking schemes
Evidence-based practice
CPD
Training programmes
QA Visits
MI User Survey
Workload Survey
Enquiry Answering!
Personal CPD
NMITC, Advanced MI
Training, NMITTC
Tools for Quality
 Risk Assessment/
Management Schemes
 Appraisal schemes
 Incident/near miss
reporting schemes
 Dialogue with principal
stakeholders
 Involvement with
commissioning
specialist services
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?
How can we achieve quality?
UKMi Standards & Clinical
Governance Working Group
National
standards
Resources, CPD, Job description,
E&T, SLA’s, KSF, Service commissioning
Competency Framework
Defining
standards
Ensuring delivery
of standards
Quality
Checking delivery of
standards
Audit, Peer review / bench marking, Outcomes /
indicators, Near-miss / incidents reports
So what does the UKMi Clinical
Governance Working Group do?
Conduct research
Monitor and continuously
update national standards
for MI Services
Advise
UKMi Exec
Liaise with UKMi Exec
& NPSA
UKMi
CGWG
Maintain IRMIS
Co-ordinate
audit/surveys
Respond to UKMi Exec
relating to Clinical Governance.
Collate data
from QA
programmes
Develop QA
programmes
& documentation
Monitor implementation
of QA programmes
What should you be aware of?
 UKMi Standards
 QA Visits
 MI User Survey
 Peer Review
 Risk Management
Policy
 IRMIS
Standards
 Enquiry Answering Process
 Education & Training
 Publications
 Clinical Governance
 Risk Management
Quiz
Quiz (1)
1. How quickly should the MI phone be answered
within?
A) 10 seconds
B) 30 seconds
C) 60 seconds
2. The pharmacist supervising trainees in MI does
not need to have attended the National MI
training course?
True or False
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
Quiz (3)
5. Non-MI pharmacists should have MI training as
part of their induction.
True or False
6. When receiving an enquiry via email, it should be
acknowledged within
A) 1 hour
B) 4 hours
C) 30 minutes
Quiz (4)
7. What is the ‘National Standard’ for an enquiry ‘answer’?
A) 100%
B) 95%
C) 90%
8. How long should pre-registration pharmacists spend in MI?
A) 4 weeks
B) 6 weeks
C) 8 weeks
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
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
Quiz (7)
11. Which of the following should be kept by a MI centre:
A) A dated record of all pharmacists offered training and those who
accept it.
B) A dated record of all pharmacists who borrow a book/journal from
the centre.
C) 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
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
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
QA Visits
 Regional centre -> Regional centre
 Regional centre -> Local centre
 Audit centre against national standards AND
peer review sample of enquiries
 National template
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
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
What do you think is important
to users of the service?
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
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
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
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
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
Peer Review
 UKMi provide:
– Definition for ranking enquiries
– Summary of criteria for grading answers to
enquiries using documented evidence
– Enquiry assessment form
Peer Review
 Documentation
 Analysis
 Coverage
 Answer
Peer Review
 Internal
– Sample enquiries (manager led)
– Sample enquiries (team led)
– Sample enquiries (user feedback)
– Group discussion
 External
– Peer Review visits
– Regional network meeting
Peer Review
Workshop
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?
Risk Management Policy
 Environment
 Equipment & Information Resources
 Outputs
 People
Risk Management Policy
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
IRMIS - what information is
recorded?
 Title
 Enquirer status
 Summary of enquiry and incident
 Enquiry Category
IRMIS - what information is
recorded?
 Near miss or error
 Checked by?
 Date
 Answer given by?
 Type
 Cause of incident
 When did it occur?
 Potential Risk
 Detected by?
 Actual Outcome
 Enquiry received by?
 Action (s) for prevention
 Processed by?
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
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***
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
What about wider clinical
governance issues?
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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
Where can you access Clinical
Governance information for MI?
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
Questions
Tel No. 01473 704431
[email protected]