WHAT IS QUALITY?
– Doing the right thing right the first time, and doing it better every time .
– Incremental improvement ( Dr A Al Assaf ).
– The degree to which health services for individual and population increase the likelihood of desired health outcome and are consistent with current professional knowledge ( WHO )
What is your role as a leader in quality ? – Being the highest authority in their departments, each department Head will lead the Quality Improvement Initiatives in his/her department.
– Developing and implementing policies and procedures that guide and support the provision of services.
– Identifying the Performance Indicators and leading his department in all data collection and analysis activities. He will, in general, lead all initiatives regarding improving department quality work performance. Integrating services into primary functions compatible with the mission and vision of the hospital
What do we mean by accreditation?
– A comprehensive peer review process to measure compliance with a set standards by surveyors from an authorized organization
– CBAHI survey team: 7 surveyors.
Accreditation……. Why? – Standardized Care ( How ? ) Clinical Practice Guidelines, Policies and procedures
– Safe Care
– Better Resource Utilization
– Good Reputation
What does “cbahi” stand for?
– C : Central
– B : Board for
– A : Accreditation of
– H : Healthcare
– I : Institutions.
What are System components?
What is juran triangle?
– Quality Assurance.
– Quality Control
– Quality Improvement
How do organizations assure quality care. Measure , and improve performance? – QA : Implement Standards.
– QC : measure structure, process, outcomes indicators.
– QI : Performance improvement projects
What are the quality dimensions ?
– S : SAFETY
– T : TIMELINESS.
– E : EFFECTIVENESS
– E : EFFICIENCY
– E : EQUITY
– P : PATIENT CENTERDNESS
Why ,IN YOUR OPINION, organizations should stress on measuring?
– Know that there is an opportunity for improvement,
– Know the magnitude of the problem
– Identify trends over time
– Identify special cause and common cause variations,
– Know the success or failure of the pilot intervention,
– Monitor progress
– Learn about Patient/Client Satisfaction ,
– Learn about Employee satisfaction ,
– Monitor Staff productivity
– Ensure that Performance Improvement is sustained
Why data collection is important?
– Decision Making,
– Planning ,
– Performance Improvement ,
– To monitor progress
– To measure the effects of change
Could you mention some of data collection methods?
– Data Sheet or Work Sheet,
– Check sheet ,
– Interviews ,
– Focus Group,
– Automated retrieval from a computerized data source.
What is the tool for performance measurement?
Could you mention some of the indicators your hospital is measuring? – Structure: out of stock medications.
– Process : TAT for STAT lab results
– Outcomes: mortality rate, post operative infection rate, Patient falls.
WHAT SHOULD YOU CONSIDER BEFORE DATA COLLECTION?
– WHAT exactly are we collecting?
– WHY are we collecting this data?
– From WHERE are we going to collect it?
– WHEN are we going to collect data, how frequent, and for how long?
– WHO is going to collect it?
– HOW will it be collected ,displayed, and analyzed?
How did the hospital develop its strategic plan?
– Leadership responsibility
– Identify customers
– SWOT analysis
– Strategic Intent : Mission, Vision, and Values
– Set goals
– Set objectives
– Operational plan
– Monitor achievements
What is your role as a leader in the strategic planning process?
– Allocate Required Resources,
– Empower staff & Assign and Delegate responsibilities,
– Monitor activities and achievements,
– Celebrate success,
– Decide contingency plans, and
What does the Mission Statement reflect?
– It describes the scope and functions of an organization/service/department/unit , and should answer questions like:
Who we are?
Why we exist?
What our main purpose as an organization is?
What are the services provided by the organization?
Whom we are serving?
What their needs and expectations are?
How to meet those needs and expectations?
What is meant by the Vision statement ?
– Organizational aspiration in the future.
– Answers the question of what the organization strives to be in the future (3,5, or 10 yrs)
hospital mission ,vision & values Mission- To provide the highest quality of health care and safety for Al Hassa community, and to create appropriate conditions to cover as much as possible of their medical needs.
Vision- To achieve the highest level of excellence and quality in the provision of health services for all members of society
Patient Rights first
Safety and preventing of errors
Being efficient in our services
Job improvement and respect
High adherence to Islamic regulation and social values
Can you elaborate on your role in achieving the hospital mission
To achieve the hospital mission, we have strategic plan that includes the hospital’s goals and objectives : such as …
What does A scope of service tell us?
– Range of services provided ,
– Target population ( customers) : age group, types of diseases,
– What you provide the service with: (technology, diagnostics used) (Methods/equipment)
– When you provide the service :24 hours every day of the week, or ……., on weekdays, etc) (Working hours)
– Who provides the service? Physicians, nurses, technicians, etc. (Departments Staffing)
– Important diagnostic , therapeutic, and preventive activities.
How do you, as hospital leader, prioritize the PI projects?
– The Quality Management Committee identifies and prioritizes recommendations for quality improvement projects based on the organization’s prioritization criteria and the analysis of trends
– Prioritization criteria include:
What tools you are using in this issue?
– Voting : ( simple voting – multi voting – weighed voting)
– Selection matrix
How do you choose the PI team?
– Those involved in the process
– Those knowledgeable,
– Those who have the power to change,
– A facilitator from the TQMD.
What are some of the quality tools you know about ?
– Affinity Diagram
– Cause-and-effect Diagram
– Pareto Chart
– Action Planning
Mention a few of Statistical & Data Display Tools
– Bar Charts
– Pie charts
– Run charts
– Control Charts
– Gantt Charts
ELABORATE ON HOW LEADERS PROTECT Patient rights
– We adopt the MOH Patient bill of Rights and Responsibility statement, Posters are displayed
– The hospital has developed a policy on Patient Rights and Responsibilities.
– The hospital established a Patient Rights committee
– We frequently discuss aspects of patient rights in selected workshops and or meetings
– Patients are informed about their rights whenever arrive to the front desk.
– Consent and informed consent form
What do you mean by the informed consent?
– The informed consent is taken from patients, their relatives, or guardian; if minor whenever a patient is likely to undergo an invasive or high risk intervention.
– It contains the following items:
What is the procedure
What is the risk behind
What is the risk if not done
What is the alternative
Can you tell me about your role in patient and family education?
-Explain the necessary treatments, and procedures and provide pamphlets or diagrams if available
-Explain and teach the appropriate use of the medical equipment or appliances
-Any surgical procedure needed and its benefits and potential risks involved with the surgical procedure
How can you be sure of the effectiveness of education?
– Through return demonstration and actual asking the patient if they have understood the discussed matter ( health instructions)
How do you document education activities? We have establish a multidisciplinary form for patient education and we see to it that all pertinent details regarding the patient concerns are clearly communicated and documented in the form.
How do leaders foster Patient and family education?
– We do have a Patient education unit and the hospital has supplied it with adequate resources,
– The hospital has defined roles and responsibilities of all healthcare providers in patient and family education,
– There is a policy on patient and family education ,
– Educational activities are documented in a special form in the medical record,
– The quality department monitors compliance with this policy
What is the hospitals role in handling patient complaints?
– We have developed and implemented a policy on handling Patient complaints
– Patient relation is the unit for complaints management
– There is a committee that oversee the complaints process and the outcomes
– We are trending the reports of complaints and taking the necessary corrective actions
What is Safe patient care?
A system that avoids injuries and harm to patients from the care that intended to help them.
What do we mean by patient safety? – Freedom from accidental injury due to medical care, or medical errors.
– Prevention of healthcare errors, and the elimination or mitigation of patient injury caused by healthcare.
How can hospital leaders support patient safety?
– Development & Implementation of Quality Management and Patent Safety plan.
– Adopting the International Patient Safety goals.
– Establishing a multidisciplinary Patient Safety Committee.
– Assign a Patient Safety officer
– Establishing good reporting system (Incident report and Sentinel event policy).
– Fostering Safety Culture.
– Formation of RCA Team for sentinel event/near miss.
– Leadership Walk rounds
What are the patient safety goals?
– Goal 1 : Identify patients correctly
– Goal 2 : Improve effective communication
– Goal 3 : Improve the Safety of High- alert Medications
– Goal 4 : Eliminate wrong site, wrong patents, wrong procedures surgery
– Goal 5 : Reduce the risk of Healthcare-acquired infections
– Goal 6 : Reduce the risk of patient harm resulting from fall