Managing quality

This article, based on a presentation delivered to the
Scottish RCN OH Nurses Forum Conference in April, describes how Salus
Occupational Health & Safety implemented a quality management system, by Tom

Salus Occupational Health & Safety is a multi-disciplinary provider of
occupational health and health and safety services to the NHS and other public
and private sector organisations.

It is based within NHS Lanarkshire and has more than 100 staff, including
occupational health physicians, occupational health nurses, health and safety
specialists, occupational hygienists, fire safety advisers, clinical
psychologists, moving and handling advisers, health promotion specialists, and
administrative and support staff.

Salus has contracts throughout the UK, has established bases throughout
central Scotland and north-west England, and has provided services from the
Shetlands to the Isle of Wight. It currently generates surplus income from
these extended services for the benefit of the NHS.

As the service developed from a handful of staff to the much larger, growing
organisation it is now, Salus recognised the need for more formal management
processes. This has ultimately led to registration with an
internationally-recognised quality management system.

NHS Scotland context

As part of NHS Scotland, quality management for Salus takes place within a
much wider context. In particular, Towards a Safer Healthier Workplace, the
Scottish Executive strategy for the provision of occupational health and safety
for NHS Scotland, which proposed a national framework of shared standards with
a system of peer reviews.1

These standards were launched for consultation in June 2003.

Following a series of pilot peer reviews, it is expected that the first set
of standards will be issued for implementation across NHS Scotland by the end
of 2003.

What is quality management?

The Salus approach to quality management was to keep it simple to make it
work. There are a variety of models for managing quality, but most reduce
essentially to plan, do, monitor and review. In communicating this message,
Salus describes this as ‘say what you do, do what you say, prove it and review
it’.2 Each step is equally important in ensuring an effective system.

STEP 1: Say what you do

This stage involves making a clear statement about the organisation’s
planned activities. This can be in the form of documented plans or requirements
agreed with customers or other stakeholders.

In a large and complex organisation, it can be particularly helpful if this
stage includes written policies, procedures and processes. This helps clarify
explicitly the accepted standards of practice or behaviour for the

We already had a range of documented procedures for many activities, but
what was required was to ensure that all significant processes were covered in
the system and that these were consistent.

To help ensure staff felt a degree of ownership of the system, everyone had
the opportunity to contribute to the discussion about which processes to
include. These included clinical, technical and administrative processes. Once
agreed, volunteers were sought to develop the written procedures for each
process. Where possible, authors were allocated on the basis of regular
involvement or special interest in the topic.

Authors were encouraged to take notice of research and evidence-based
practice in developing the procedures. An agreed format was used for each
process to ensure consistency.

This also makes the system more user-friendly, since similar information is
found in a similar place in each procedure. Existing procedures were updated
and modified to ensure they matched with the new format.

STEP 2: Do what you say

The next stage is to actually apply the agreed planned activities. The
documented procedures developed are now applied in practice by staff across the

The procedures developed by Salus were planned to assist in the consistent
delivery of services. This includes a core set of standard documentation to
record interactions with clients, records of activities, reports generated and
the evaluation of some aspects of services. Staff are introduced to the content
of the system at induction and are expected to familiarise themselves with the
areas that relate to their practice.

In a recent anonymised survey of Salus staff, there was clear support for
the benefits obtained from this approach.

In addition, staff new to the organisation have commented favourably on how
this approach assists them to quickly learn what is accepted practice. It is
also useful as a reminder of the current process for staff who have not
performed a procedure for some time.

However, it is important to ensure the system does not enforce unnecessary
rigidity, which stifles the ability to respond to individual client

During the development of the procedures, all staff had the opportunity to
comment on them, which ensured they reflected the needs of all parts of the

During the early part of the implementation of the system, many developments
and improvements in the procedures occurred. Some flexibility is written into
the procedures themselves to allow for the adaptation to the specific
requirements of clients.

This includes recognising the need to adapt the standard documentation at
times, to meet with client needs.

While this is accepted, adaptations are expected to be made only where there
is good reason and, where possible, the main content is retained. It is also
recognised that some clients will insist on using their own documentation. Such
variation is controlled throughout the service by a department recording the
local changes they have made, along with the reasons for the change.

STEP 3: Prove it

The third step in the process is to monitor this activity by measuring
practice against the agreed procedures. This is where auditing enters the
system and the actual results and outcomes of service delivery are recorded.
Some objectivity is required to ensure the results recorded are representative,
as bias could creep in if the auditor is too close to the subject being

For Salus, the most important part of this stage is the internal audit of
practice by the service itself. As a reasonably large organisation, Salus has
the resources to allow it to monitor its own activity with reasonable

The frequency of audits reflects the importance of the process to the
organisation. All Salus staff are trained in the internal auditing process to
allow them an understanding of how it works and how important it is to the
system overall. All are offered the opportunity to take part in internal

To maintain impartiality as far as possible, audit teams are planned to
ensure that no-one audits the activities they are directly involved in.
However, it emerged early in the development of the system that it was often
useful if one of the team understood the process under review. This meant they
could penetrate any technical aspects and/or jargon and focus on the main

This internal audit activity could be more difficult in a smaller
organisation. However, with some careful planning, it should be possible to
organise such audits to maintain impartiality, by ensuring that auditors were
as removed as possible from the activity being audited.

Alternatively, to allow impartial reviews of practice against standards, a
reciprocal arrangement could be made with another organisation.

It might be useful if the organisations were in similar areas of practice.
This would allow understanding of technical aspects, while protecting against

As part of the requirements for registration to quality standard ISO 9000,
the internationally-recognised standard which provides a framework for quality
management systems, based on clear documented processes, external assessments
are also required. Twice a year, a client manager from BSI visits and assesses
a significant part of the organisation and the services it provides.6

In 1999, Salus successfully underwent initial assessment and achieved
registration to ISO 9002:1994.7

Salus has since been successfully assessed and recommended for transition to
the updated ISO 9001:2000.8 This standard has developed the principles of
quality management further with less reliance on documented processes and more
emphasis on identifying and meeting the needs of customers.

STEP 4: Review it

The first three stages provide a useful basis for practice, with clear
agreed standards, practice based on these standards and measurement of practice
against the standards. However, in themselves, these stages do little to
improve quality. If the standards are set low then they will encourage
consistent, but poor, service provision.

To drive up the quality of practice, a further stage is required, that of
reviewing the results and taking action based on them. It is important that the
results are delivered to appropriate staff, with the authority to act to make
changes when necessary.

This is where the Salus quality management system comes to life. The results
of internal audits and external assessments are fed back into the system to
allow it to develop and improve to the benefit of the organisation, its staff
and its clients.

Where practice does or does not match to agreed plans, there is a need for
change, which could be in practice (what we do) or in the procedures (what we
say we do). Either can be a valid response to identified discrepancies.

Particularly in the early days of the system, many changes were required to
match procedures to the needs of the various operating environments. It is
important that due consideration is given to understanding the causes of the
discrepancy before taking corrective action.

The author of the audited procedure considers all the issues identified and
determines if changes are required. Significant findings must be reported to
relevant groups, such as clinical staff, health and safety staff or
administrative staff. This allows for changes in practice to be discussed,
agreed and communicated where necessary.

The organisation has a system for dealing with suggestions, complaints and
comments from staff and clients, and for considering the results of formal
audits. This means the system does not rely on waiting for a discrepancy to be
identified at audit, and that any staff member, service user or purchaser can
initiate a change at any time.

Salus also formally reviews summarised results at least twice a year. This
allows for a clear overview of the effectiveness of the system and to spot any
emerging trends. Each procedure is formally reviewed by its author to ensure it
continues to reflect best practice.

What are the benefits of audit and evaluation?

The system described above clearly requires considerable commitment and
effort to implement, operate and maintain. So, why should an organisation
expend all this effort?

– A system such as this allows the organisation to verify that the results
of its activities meet with agreed plans. This allows it to clearly assess
whether it has achieved what it set out to do. If the plans were agreed with
clients or were the basis of an agreement with clients, this allows it to
determine the effectiveness of the organisation in meeting client needs. This
means it can determine not only if it does things right, but whether it is
doing the right things

– The system allows the organisation to use this information to identify opportunities
for improvement. It is critical that issues identified are not treated as
weaknesses or deficiencies, but are treated as a chance to make things better
for all concerned. There is a positive advantage to be gained for all if the
system is seen to objectively allow improvement

– There are advantages beyond those to current stakeholders. An explicit
quality management system, particularly one that incorporates external
assessment, assists the organisation to be recognised by others. This can be
useful when promoting services to potential clients. It can also be a
reassurance to new and existing clients that the services provided meet an
agreed, approved standard

– All of these mechanisms are good management practice. Management processes
that involve clear objective setting and regular review of processes with
documented actions and follow-up are likely to result in improved
organisational effectiveness.

Delivering quality

There are many different types of organisation, delivering a variety of OH
services to a variety of clients. These can be large or small, in the public or
private sectors. All are intent on delivering high-quality services to their
clients. So, what aspects should they concentrate on?

– The main point is that they should focus on meeting customer needs. This
will involve needs assessment and analysis to identify priorities. Another
important aspect is to remember that we are all customers of each other. It is
equally important that internal relationships are treated in the same manner as
external ones

– From this assessment of needs, an agreed specification for services can be
reached. This forms the basis for service delivery in the form of contracts or
service-level agreements. The contract should specify responsibilities, services
to be delivered, standards to be achieved, monitoring mechanisms and any
necessary contacts

– Having agreed specifications, it is vital to manage all resources
associated with the service delivery. This should include all aspects,
including staff levels and competence, equipment required and any supplies
needed. One aspect to be considered is that, if the appropriate resources
cannot be arranged, then sometimes the optimal decision is not to agree to
provide the service. While this may not seem to be meeting customer need, it
can be better than creating false expectations, which are then not met

– To ensure that services agreed are delivered, it is important to monitor
performance. To do this, the organisation must decide what to measure and then do
it. This allows the organisation to determine if it is where it wants to be.
Allied to this is ensuring there is a mechanism to deal with client
suggestions, complaints and comments. This allows all stakeholders, including
users, purchasers and staff, to input to the process.

What should we measure?

Once the organisation has decided to implement a system that includes an
audit of its services, it is important it agrees what aspects it will attempt
to measure. If this aspect is planned in advance, it will ease the process of
measuring later on. The data to be recorded can be in the form of inputs,
processes or outcomes.

Input-based audits consider the requirements needed to do what the
organisation does. These can include having professional standards in place,
ensuring facilities meet a minimum standard, that the right equipment is
available, and that organisational structures provide suitable support for
service delivery or that staff have appropriate training and qualifications.
This effectively asks the question ‘Have we got the basics right?’.

Process-based audits consider how the organisation does what it does. An
important element is to ensure these standards reflect good practice and
involve the stakeholders. This asks the question ‘Do we follow agreed protocols
and best practice?’.

Outcome-based audits consider how well the organisation does what it does.
This can include, for example, coverage of surveillance or immunisation
programmes, response times or activity levels. Ultimately, measures such as
sickness absence rates or ill-health retirement rates may be a better measure
of outcomes in occupational health. However, there is a long time lag before
current activities can affect these rates. This asks the question ‘What did we
achieve?’ or ‘Are we doing the right thing?’.

Key challenges

Clearly, there are many benefits to be gained from implementing and
operating a quality management system. However, there are some challenges to
overcome in developing such a system.

– The first and most obvious of these is that it takes significant time, effort
and resources to achieve. If resources are not allocated to such a project, it
is unlikely to have any great impact on the organisation. While a speedier
result could be achieved by purchasing a ready-made system and paying for
others to audit and manage it, the experience of Salus is that, by doing it
itself, staff had a greater feeling of ownership and involvement.

This has led to a live and developing system, which staff regularly use. It
also contributes to its review. While this took time, effort and money, we
consider that this has paid off in terms of consistency, continuous quality
improvement, customer satisfaction and improved organisational effectiveness

– Data collection presents another challenge. If there is no adequate data
routinely available for monitor and review, it may be necessary to make sure
such data is made available.

This is made easier by planning data requirements in advance. Objective
evidence, which is documented at the time activities are undertaken, makes this
process easier and more effective

– The culture of the organisation can affect the ease of introduction of a
quality management system.

For the system to work, the organisation and its entire staff must accept
the positive aspects of its approach. In particular, defensive attitudes make
the requirement to open up practice to outside scrutiny difficult to accept.
Salus found that this could be changed from within the organisation by
constantly reinforcing the positive message of continuous improvement

– Dealing with identified discrepancies can be a major challenge to
overcome. The key to this is to ensure these are not treated as failures and
that they are always seen as opportunities for improvement. This can help to
overcome general negative attitudes.


When Salus started the process of movement towards quality management system
registration, it was stated that internal audit, evaluation and review is what
makes the system come alive and work for the organisation.

Several years down the line, Salus has come to recognise that this is indeed
the case. Overall, successful quality management is a state of mind, where all
staff are open to the opportunities it presents and contribute to its

Tom Gibb, RGN, BA, MBA, Diploma in Community Health Nursing(Occupational
Health) is operations manager and quality co-ordinator with Salus Occupational
Health and Safety.  E-mail:


1. Towards a Safer Healthier Workplace, Report of the Occupational Health and
Safety Service Short Life Working Group, The Scottish Executive, 1999

2. Auditors Questions – the process approach, Hoyle D, Thompson J, 2001, ISO

3. Understanding Organisation, Handy C, 1993, London; Penguin

4. Standard practice, Occupational Health, Feb 1999, Vol 51, no.2, Whitaker

5. Occupational Health Audit: a practical guide for occupational health
nurses, Royal College of Nursing, 1999, London

6. BSI website,

7. Quality Management System, ISO 9002:1994, International Organisation for

8. Quality Management System, ISO 9001:2000, International Organisation for

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