IMPLEMENTATION OF ISO 9001:2008 QUALITY MANAGEMENT SYSTEM AT MOI TEACHING AND REFERRAL HOSPITAL

The Moi Teaching and Referral Hospital (MTRH), recognizing the importance of its customers and other stakeholders undertook to achieve ISO 9001:2008 standard which is a Quality Management System (QMS) awarded by Kenya Bureau of Standards Certification Body (KEBS CB). In the year 2006, the Hospital Board signed a contract with the Ministry of Medical Services to ensure that this standard is attained by the Hospital. This international standard specifies requirements for a quality management system where an organization:

• Needs to demonstrate the ability to consistently provide a product /service that meets customer and applicable regulatory requirements and
• Aims to enhance customer satisfaction through the effective application of the system, including processes for continual improvement of the system and the assurance of conformity to customer and applicable regulatory requirements.

As a healthcare institution, we embarked on this process to ensure among others, that we provide consistent quality services to our customers.

Moi Teaching And Referral Hospital (MTRH) Experience
The following milestones were accomplished in our journey to full ISO 9001:2008 certification:

• Awareness training for Top Management.

• Training of mid-level management staff and consequently creation of awareness throughout the Hospital.

• Development of the Hospital Quality Policy & Quality Objectives, Quality Manual and Departmental Quality Work Procedures/Work Instructions.

• Awareness training for Top Management.

• Training of mid-level management staff and consequently creation of awareness throughout the Hospital.

• Development of the Hospital Quality Policy & Quality Objectives, Quality Manual and Departmental Quality Work Procedures/Work Instructions.

• Implementation of Quality Work Procedures/Work Instructions.

• Training of Internal Quality Auditors who have so far carried out three Internal Quality Audits.

• Management Review Meetings.

• Pre- Certification/Stage 1 audit.

• Certification Audit/ Stage 2 audit.

• Follow up/Clear out Audit.

The journey towards ISO 9001:2008 certification has taken 3 years of intense trainings, documentation, implementation and internal auditing of our Quality Management System (QMS).

A Quality Policy, Quality Objectives and Quality Manual were written and circulated to all Moi Teaching and Referral Hospital staff. Initial employee uncertainty regarding the import of implementing a quality management system was addressed by having several meetings with respective Divisions/Departments/ Units in order to describe the ISO concept and clarify importance of staff involvement in establishing the system. Hospital staff were actively engaged in designing the MTRH Quality Management System and in many cases were asked to describe their job responsibilities as Quality Work Procedures/Work Instructions were formulated. This staff involvement was key as they learned that the quality management system was not a threat but a supporting framework to be used in improving their clinical and business processes.

A controlled document system was developed during the second year (2007) using alpha-numeric numbering system to manage all documents within MTRH. Documentation and establishing this numbering system was actually considered to be a milestone in our journey to ISO certification given the diversity and complexity of MTRH processes.

The 307 quality work procedures/work instructions were reviewed, revised and put into a common format.

Management review meetings were instituted during the second and third year in accordance with the requirements of the ISO 9001:2008 standard. These meetings are held after every audit and are designed to discuss:

• Results of internal audits.
• Customer feedback.
• Process performance and product conformity.
• Status of preventive and corrective actions.
• Follow-up actions from previous Management Review meetings.
• Changes that could affect the Quality Management System.
• Recommendations for continuous improvement.

Both internal and external quality audits are requirements of ISO 9001:2008 standard. Our internal quality auditing requires staff involvement in both maintaining and improving the quality management system and has been well received and supported by our staff. Internal quality audits are conducted quarterly based on high risk and high volume activities and previous audits and findings of non- conformance.

The sustained implementation of a Quality Management System at MTRH has ensured that there is positive staff attitude, fewer mistakes at the workplace, organizational development/change management and the resultant increase in overall customer satisfaction levels.

Preventive and Corrective action plans are required procedures within the Quality Management System. These are important to prevent, deter and address any non-conformities which might arise in the Quality Management System (QMS).

The challenge now is to ensure maintenance and sustainability of the implemented Quality Management System. The MTRH staff guided by the Quality Management Representative and the ISO Secretariat are fully committed to ensure that not only do we meet and exceed our Customer/Regulatory Requirements But That We Delight/Amaze All Our Customers At All Times.

Dr. Wilson K. Aruasa
Quality Management Representative