TOTAL QUALITY MANAGEMENT

The department was later renamed in consonance with global best practices as the Department of Total Quality Management. This was approved during the UCH Board of Management meeting held on the 18th of March, 2011. This directive was enacted by Professor Temitope Alonge, the Chief Medical Director, UCH, on the 4thof April, 2011. The department at this time comprised of three (3) Units namely:

• Quality Assurance Unit
• Quality Control Unit
• Quality Assessment Unit

The SERVICOM Unit which was initially under the purview of the department of Hospital Services was subsequently moved to the department of Total Quality Management on the 7th of April, 2011. The Management’s realization of the need to have Statisticians in the department who would be saddled with the task of data management, led to the recruitment of this category of staff who were incorporated into the department in March 2014. The Statisticians collect data from the various departments for analysis. The outcomes of such analysis are later used to facilitate evidence based decisions as well as data guided policy implementation by the Hospital Management.

The achievements that have thus far been recorded by the Department can be phased into different time periods all of which have been spearheaded by the head of the department at the time under consideration. These time periods are indicated below:

• 2011-2012
• 2012-2015

• 2015-2020

• 2020-2023

2011-2012

• Execution of the Management’s mandate in introducing Total Quality Management to all Departments in the Hospital with an overwhelmingly positive feedback.
• Institution of ‘feedback mechanisms’ to improve services in the Hospital by ensuring that when complaints are addressed, patients are updated about the outcomes.
• Selection of Mrs. O. A. Olusegun as the Quality Improvement Focal Officer following the Chairman Medical Advisory Committee’s approval (and the nomination of the Head of Department). She co-ordinated the quality groups for quality control assessment in the various departments of the Hospital
• Population of the workforce of the department by putting forward a position on the need to increase the staff strength which eventuated in the deployment of some capable hands to the department. These newly deployed personnel which included Administrators and Legal Officers, worked in the capacities of SERVICOM officers, Service Development Officers and the Legal Officer.
• Preparation and submission of the 2012 Strategic Plan for the Department.
• Presentation of a comprehensive report of all reactions, comments and suggestions for further improvement on service delivery to the management for the year 2012.
• Participated in the orientation programme for the newly engaged companies (outsourced services), newly converted Ward Assistants, Porters, House officers/interns and newly employed members of staff of the hospital for 2012.
• Establishing an interaction process with an expert in Total Quality who was appointed as a visiting Consultant to the Department, in the person of Professor. Ope. O. Adekunle of the Department of Surgery, University College Hospital to best address quality issues within UCH.
• Collaboration with the VESTA Healthcare Partners, United Kingdom, and presentation of a paper titled ‘Improving quality and efficiency through better clinical Governance’ by the Managing Partner in the maiden interaction.

2012-2015

• Coordination of the setting of Performance Standard Reviews for 16 Departments in the Hospital.
• Inauguration of the Quality Management Committee to function in an advisory capacity to the Department of Total Quality management with regards to policy formulation and providing technical resource for policy implementation.
• Organized Quality Assurance Workshop Module I&II for Hospital Departments.
• Creation of the Death Report Format in conjunction with the Morbidity and Mortality Committee, UCH.
• Development of the Employee Handbook.
• Review of some Hospital Panel Reports as a statutory function of the Department.
• Conduct of survey of the patients’ waiting time in the MOP & SOP clinics.
• Handling School of Nursing Certificates by Mrs. F. A. Ogunde.

2015-2020

• Creation of SERVICOM Working Tools. These include forms to capture:
  – Management/Logistics/Complaints
  – Relationship complaints,
  – Clinical complaints
• Creation of SERVICOM Help Desks.
• Designed SERVICOM Officers’ Uniforms.
• Provided CUG phones and lines to SERVICOM Officers to aid communication and report across service areas.
• Reorganized Units in Total Quality Management Department:
  – SERVICOM Unit
  – Statistics Unit
  – Quality Management Unit – Comprising of the Quality Assurance, Control and Assessment sections.
• Trained SERVICOM officers on:
  – How to capture complaints using the patients’ complaints capture forms and awarding of certificates of training.
  – Standard greeting protocol.
  – Institution of Departmental feedback to deal with complaints highlighted in the month.
• Creation of Monitoring officers in-charge of the Ward Clerks
• Creation of Monitoring officers in-charge of SERVICOM Officers manning Help Desks in the Clinics, Service Areas and on the Wards.
• Collaboration with Epidemiology Statistics Department to engage clinical heads of the department on forming quality indicators to impact quality of care.
• Monthly Departmental Statistical Presentations.
  Monthly Departmental Administrators meeting.
• ‘One Stop-Shop’ where patients could purchase drugs, dressing packs, and store appliances in the Pharmacy outlets.
• Survey on patients’ waiting time at EYE Clinic.
• Printing of Standard Operating Procedure for safe blood transfusion in the University College Hospital, Ibadan.

2020-2023

• Collection and analysis of necessary data for policy formulation and implementation towards accomplishing the organizational goal of enhancing service delivery at an internationally competitive standard. Some of the data collected include:
  • Generation of data on patients that leave the Hospital against Medical Advice (DAMA)
    – Generation of data on the number of beds in the Hospital to reveal the capacity of the Hospital on the number of patients it can hold.
    – Generation of data on the ‘Discharge Process Time’ of patients on the wards. This enables the Management to know when beds open up for patients to use. Keeping a low discharge process time, means that beds open up faster.
    – Initiated the Operating Room Turnaround time. Although this is still ongoing, the initiative would help to calculate the time it takes to clean and prepare the operating room before procedures are carried out. Saving some time in this process, has an impact on the number of procedures that would be scheduled.
    – Initiated the generation of data on the media presence of the organization through the tracking of the number of press releases and media mentions. This is however an ongoing process
• Initiated activities to boost employee motivation while analyzing the employee satisfaction levels, staff reward systems in the Hospital as well as the effectiveness of existing standard operating procedures within the Hospital.
• Commenced the yearly checks of fire extinguishers in the Hospital. Also, muster points were designated in the Hospital in addition to the initiation of a yearly fire drill in the Hospital.
• Development of process flow for patient journey across service areas in the hospital.
• The department organised and conducted data capturing tool training for SERVICOM officers
• Organization of soft skill training for some categories of health professionals (Health information officers, billers, cashiers, laboratory staff at haematology)
• Implemented safety monitoring across Wards and Clinics
• Successful monitoring and evaluation of processes such as VTE, discharge process time, CSSD, account slips, bed linen, raw food, Bio-medic department and so on.
• Successful evaluation of in-patient discharge satisfaction and clinicians’ quality of care (doctors, nurses, pharmacists)