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Unit 3 Manage quality systems | International Board for Quality in Healthcare IBQH

Unit 3 Manage quality systems



Unit Code - H/602/2330
Level - 7
Credit Value - 10

Learning Outcome - The learner will: Assessment Criteria - The learner can:
1. Understand and evaluate quality management systems and standards in own organisation.

1.1 Critically evaluate a range of quality management systems
1.2 Critically evaluate quality management systems in own organisation.
1.3 Explain legal and regulatory requirements.
1.4 Evaluate the quality expectations of the stakeholders.
1.5 Identify specialists and consult if necessary.

2. Be able to evaluate systems in own organisation.

2.1 Develop a strategy to evaluate quality standards and systems.
2.2 Identify and prioritise key success criteria.

3. Be able to establish responsibilities for meeting organisational quality standards with key stakeholders.

3.1 Communicate organisational quality standards.
3.2 Define roles and responsibilities in meeting quality standards.

4. Be able to implement a quality management system in own organisation.

4.1 Develop risk assessment procedures.
4.2 Identify resource requirements to support quality management system.
4.3 Produce a strategic plan for implementation in own organisation.

5. Be able to monitor and evaluate quality performance for continuous improvement within own organisation.

5.1 Monitor product and/or service quality against quality management standards.
5.2 Evaluate data and feedback against key success criteria.
5.3 Take corrective action if required.
5.4 Communicate with key stakeholders on quality performance.


Learning outcome 1


1. Understand and evaluate quality management systems and standards in own organisation

1.1 Critically evaluate a range of quality management systems

The candidates should have evaluated a range of quality management systems

Evidence: Critical evaluations and referenced research in their portfolios

Further information and guidance:
The candidate might select the range of quality management systems that might be appropriate to the organisation but the main requirement is to investigate and compare at least 3 systems. These should be researched and referenced drawing out strengths and weaknesses taking account of the particular circumstances in which they operate.

1.2 Critically evaluate quality management systems in own organisation
The candidates should be able to identify and evaluate specific aspects of quality management within an organisation drawing conclusions and stating clear judgments based on the evidence gathered.

Evidence: Critical reports on researched quality systems

Further information and guidance:
The candidate should evaluate the current quality management systems in the organisation and determine whether there are improvements possible. This might be identifying risk, improvements to cost-benefit or overall provision. If aspects are confidential, candidates should consider only writing in general terms in their e-portfolio and keeping anything confidential in a separate file that can be e-mailed to their assessor.

1.3 Explain legal and regulatory requirements
The candidate should be able to explain legal and regulatory requirements with quality and management system in their locality.

Evidence: Descriptions, explanation and referenced research in their portfolio

Further information and guidance:
The candidates should be able to identify and explain the legal and regulatory considerations within the sector or their area of the responsibility. This could be an essay type exercise reviewing the available literature and explaining its relevant to their particular organisation and/or job role.

1.4 Evaluate the quality expectations of the stakeholders

The candidate should be able to evaluate the quality expectations of the stakeholders

Evidence: Outcomes of a small scale research project documented in their portfolio.

Further information and guidance:
The candidate should carry out a small scale research project to determine the quality expectations of stakeholders, including peers within the organisation and end-users of the services provided by the organisation.

1.5 Identify specialists and consult if necessary

The candidate should be able to identify specialists in particular aspects of quality management and decide the cost-benefit of using them.

Evidence: Case studies in their portfolio

Further information and guidance:
The candidate should carry out a case study on at least one consulting company that specialises in quality management systems. They should identify particular strengths and areas where the provision can be shown to have been cost-effective. They should also identify weaknesses or examples where they judge the provision not to be cost-beneficial if these are uncovered.

Learning outcome 2

2. Be able to evaluate systems in own organisation

2.1 Develop a strategy to evaluate quality standards and systems
The candidate should be able to develop a plan for conducting an audit or survey of the quality standards or systems for quality assurance in their organisation.

Evidence: Documented plan in their portfolio

Further information and guidance:
Logically this will come before 1.2 above. The units are presented purely for convenience and there is no need to stick to any order or separation of criteria or learning outcomes. A single project can contribute evidence against criteria in different learning outcomes or units.
Plans should focus on the key aspects likely to have the biggest impact.

2.2 Identify and prioritise key success criteria
The candidate should be able to Identify and prioritise key success criteria according to strategic planning and their impact on the customers

Evidence: Key success criteria are identified in plans, explanations and evaluations

Further information and guidance:
The candidate should be able to Identify and prioritise key success criteria according to strategic planning goals, objectives and feedback from customers and key stakeholders. These should be incorporated in the evidence they provide for other aspects of the assessment that require documented planning and evaluation. When using the TLM tracker system the candidate can simply link these criteria to the evidence they submit.

Learning outcome 3

3. Be able to establish responsibilities for meeting organisational quality standards with key stakeholders.

3.1 Communicate organisational quality standards
The candidate should be able to communicate the core of quality standards to all relevant stakeholders making lines of accountability clear.

Evidence: Descriptions, explanation and referenced research in their portfolio.

Further information and guidance:
There are two dimensions to this criterion. The first is to establish single points of accountability for ensuring quality standards are met and the second is that all those affected by the standard are fully informed and understand any implications for them in their job role. The former are covered in more detail in 3.2 below, and this criterion is more about communicating the need and the procedures that support quality.

3.2 Define roles and responsibilities in meeting quality standards
The candidate should be able to determine the role and responsibilities of for each employee in the organisation such that quality standards are implemented effectively.

Evidence: Model job/role descriptions, policies and procedures related to quality

Further information and guidance:
The candidate should be able to identify the teams and individuals who have responsibility for the processes and development of job descriptions that incorporate quality standards. This might mean collaborative work with specialists charged with the task of writing specific job descriptions of which quality is one aspect. Lines of accountability and levels of expectation should be clear.

Learning outcome 4

4. Be able to implement a quality management system in own organisation

4.1 Develop risk assessment procedures
The candidate should be able to conduct a risk assessment and use appropriate tools such as FMEA to identify the external and internal risk factors.

Evidence: Practical risk assessment in their portfolio

Further information and guidance:
Risk assessment should priortise the highest risk and incorporate a feedback mechanism to inform the person responsible for judging risk which risk is most significant. Empirical evidence from the field might be difficult to attain but some evidence is usually better than none. The tools developed should lend themselves to regular review and evidence gathering.

4.2 Identify resource requirements to support a quality management system

The candidate should be able to identify the resources needed to support quality management systems.

Evidence: Descriptions, explanation and referenced research in their portfolio

Further information and guidance:
The candidate should be able to identify and cost resource requirements needed to support quality management systems including, qualified employees, training programs, computers, time for meeting and commitment from top management.

4.3 Produce a strategic plan for implementation in own organisation
The candidate should be able to develop a strategic plan for implementation of quality management system in their organisation

Evidence: Model strategic plan in their portfolio

Further information and guidance:
The candidate should be able to develop a strategic plan for implementation of quality management system in their organisation which draws on their learning in other aspects of the Diploma. This plan should be clearly and comprehensively referenced to demonstrate the learning that underpins it.

Learning outcome 5

5. Be able to monitor and evaluate quality performance for continuous improvement within own organisation

5.1 Monitor product and/or service quality against quality management standards
The candidate should provide evidence of systematic monitoring of a product and/or service over a period of time using specified quality management standards.

Evidence: Documentation of monitoring including recorded data.

Further information and guidance:
The candidates should know the importance of regularly monitoring progress towards key performance indicators and demonstrate that they can do it using measuring and monitoring tools such as indicators, checklists and Gantt chart, etc.

5.2 Evaluate data and feedback against key success criteria
The candidate should be able to collect date and analysis it evaluating the quality of performance using key success criteria.

Evidence: Evaluation report including empirical data and references as appropriate.

Further information and guidance:
This criterion is a component of the requirements for 5.1 above.

5.3 Take corrective action if required
The candidate should identify and classify shortcomings resulting from the monitoring process and take appropriate corrective action.

Evidence: Descriptions, explanation and referenced research in their portfolio

Further information and guidance:
Corrective action implies something has gone wrong but it can also include improvements to functioning systems if these can provide a quality benefit.

5.4 Communicate with key stakeholders on quality performance
The candidate should be able to provide feedback on quality performance as a means to improving overall quality of performance.

Evidence: Descriptions, explanation and referenced research in their portfolio

Further information and guidance:
Feedback to stakeholders will need sensitive handling in some cases, especially where shortcomings related to individuals reduces quality below the agreed levels. The dialogue with regard to quality should inform not only changes to policies, systems and procedures but also priorities for staff development.