Level 1

At level one there is no quality control except for significant event auditing (SEA). Important as SEA process is, it can, take place far from where the error has occurred. This is especially true for teams such as care navigators/ receptionists. Corrective plans/ action to prevent repeats of same errors are therefore less likely to succeed.

• Build a practice wide attitude to the next stage of the process. To be aware that errors when completing or passing over work will have implications for the patient. Even if it the error is small there is a recognition that a culmination of small errors can lead to significant events.
• Never send on a work without ensuring all the required information or sending information knowing it could be incorrect.
• When errors are found they are ALL reported to the member of staff who made the error. It is important to also ensure there is support of the member of staff who is making the mistakes. If training is needed then it is provided. If they are having other difficulties, e.g problems at home, then they are given as much support as practically possible. It should be clear that feedback to staff is to improve quality and not seen to harassment. Hence care should be taken when implementing this key.

Level 2

At level 2 staff complete their own checks. However this cannot be forced, which makes this difficult.

• Training must be provided to ensure that staff are able to assess their work fairly.
• Staff set themselves tasks/ actions to prevent recurrence. This must go beyond “I got careless”
• Supervisors must provide support by:
  • Providing a clear set of standards or criteria
  • Create examples of errors and successful tasks for judgement inspections. i.e inspections of self inspections.
  • The coupling teams key provides insight into the criteria and opposite is true through amendments to coupling points found in QA.

Once the above is provided to an adequate level then staff can perform self checks as well QA inspectors or supervisors.

Level 3

At level 3, not only are self checks in full swing but also root causes of errors are established. This is as a direct result of the root cause analysis happening so near to the faults. When normal QA checks, such as hospital letter audits, they are often reported to management. It is hard to relay the results to those who need to take corrective action. The root cause analysis requires staff to discuss the outcomes of self checks. This requires the culture of a practice to at a level where this does not cause discord.

• Staff are happy to share self checks
• Create a mechanism where root cause analysis can add or amend the standards set for self checks.
• Staff work together to create corrective plans.

To move to level four, the seven tools of quality control must be fully taken advantage of. These tools maximise the reduction of mistakes.

Level 4

At level four a 2 point inspections system is introduced. This comprises of the self check and an immediate second check. The second check is an instant feedback loop where errors found instantly sent back to the person responsible for the fault. One example of this is were all tasks created by care navigators are sent to the care coordinators. If no errors are found they are sent on to the most appropriate person to complete the task. This is introduced at level 4 because if the incidents of errors are too high this makes the system unworkable.

This is an example of poka-yoke, in essence:

• Stopping when mistakes are found
• Use of Warning Methods

In addition, Management, SGA’s and Improvement events refine inspections so they are efficient as well as effective.

Level 5

• Poka-yoke is active at all levels of the practice.
• Key 9 is fully implemented and prevents breakdowns in systems introducing faults.
• Quality of supplementary materials is assured – Key 12
• A practice at level 5 should have all but eliminated any patient complaints that are the result of processing errors.