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29 de ene. de 2013
Module 8 Decoding ISO 15189™ Conducting a Management ReviewA management review is a formal meeting of key members of senior management. The purpose is toreview the status and effectiveness of the quality management system. This meeting provides a venue formanagement to evaluate and analyze laboratory practices for the purpose of improvement. During thismeeting, a comprehensive look back at the organization’s quality management system takes place. Thisincludes a review of documented policies and a review of records. Following the meeting, a list of actionplans for improvement should be produced.The Agenda:A detailed, timed agenda should be prepared by the quality manager. With advance preparation, mostorganizations should be able to complete the meeting in a single day. However, it is critical that advanceplanning is done to allow the meeting to run smoothly.The management review agenda should include the following inputs for discussion: 1. Review of the quality policy 2. Progress towards goals and objectives 3. Results of audits from the past year, this includes internal audits and audits by external bodies 4. Customer feedback such as the results of satisfaction surveys and a summary of complaints 5. A summary of quality indicator data such a turn-around times or specimen rejection rates. 6. Review of proficiency testing performance 7. A review of nonconformites including the status of corrective actions 8. Status of the previous management review items 9. A review of resources taking into consideration any changes in the volume of work and type of work undertaken 10. An evaluation of suppliersFor your management review, all discussion inputs should be included on the agenda along with a targettimeframe for each discussion. A review of your quality policy and objectives from the past year shouldoccur at the onset of the meeting.Preparing for the Meeting:For each agenda item, consideration should be given to the desired outcomes. It would be advantageousto use standard templates for the preparation of briefing notes to establish continuity. In order to facilitatea smooth meeting, it is essential to be thorough in material preparation so that the volume of informationcan be managed in the time allotted. The meeting will be greatly enhanced by preparing graphicalsummaries of data such as the Pareto chart shown in Figure 1.Pareto charts and other summary tools will provide focus and direction to help pinpoint issues, monitorprogress and enable management to recognize trends. The champion—usually the quality manager—must determine which process records will support the identified areas of measurement (i.e., qualityindicators) and ensure that they effectively assess the status of the area to be reviewed. Themanagement team must analyze all information to determine if the target has been realized, the actionhas been adequate or if further improvement can be achieved. © Institute for Quality Management in Healthcare Page 1 of 2
Module 8 Decoding ISO 15189™Figure 1: Sample Pareto ChartDuring the Meeting:We suggest that as the meeting unfolds, the quality manager ensures that the management teamcommits to an action plan to address each input. Essentially, the outputs of the management review feeddirectly back into the strategic planning for the next year. The action plan should adequately identify theissue to be resolved, assign key responsibility for follow-up, indicate timelines for completion and define amechanism to evaluate effectiveness, i.e., mini audits. Timelines should be adequately assignedaccording to the urgency of the issue. Someone must be assigned to record the minutes of the meeting.This will provide a record of the management review. It is imperative that each action plan is completelydocumented.Page 2 of 2 © Institute for Quality Management in Healthcare