arabic canadian medical center quality management policies ... management policies.pdf · arabic...

ARABIC CANADIAN MEDICAL CENTER QUALITY MANAGEMENT POLICIES AND PROCEDURES

1 Approved by ACMC CEO

CONTENTS

Section Title

2 Performance Measurement and Management

3 Clinical Audit

4 Person Served Safety

5 Risk Management

6 Culture of Quality and Person Served Safety

7 Person Centered Care

8 Interdisciplinary Person served Education

9 Complaint Management

10 Incident Reporting



2. Performance Measurement and Management.

2.1. Policy.

2.1.1. The Organization must constantly assess and monitor its performance against a

series of performance indicators and targets.

2.1.2. The Organization determines the degree it is achieving the desired service and

business outcome by setting specific and measurable goals.

2.1.3. The quality performance indicators data collection process must ensure evidence

based, reliability, validity, completeness and accuracy of the information.

2.1.4. Purpose of each performance indicator must be well defined and understood.

2.1.5. The data collection system shall be in continuous basis from a variety of internal

and external sources. Data collected must be traceable from the sourced and is

signed off by the owner.

2.1.6. The Organization measures both its business function and service delivery

performance indicators.

2.1.7. An analysis of performance measurement must be conducted at least annually in

relation to the performance targets.

2.1.8. An action plan must be formulated to address the improvements needed to reach

established or revised performance targets.

2.1.9. The Organization will use its present technology available which is manual

submission of data through excel sheet to generate electronic reliable reports.

2.1.10. The IT department is responsible for backing up and protecting the integrity of all

data collected.

2.1.11. The Organization should communicate its performance information to its persons

served, personnel and other stakeholders for transparency.

2.2. Procedures.

2.2.1. The data collected from internal and external sources will be consolidated in the

Quality and Compliance Department.

2.2.2. Departments involved in the Organization‟s data collection process are provided

a unique template to be used for data gathering purposes.

2.2.3. Departments involved shall submit their collected data in quarterly basis to the

Quality and Compliance Office.

2.2.4. All data will be consolidated and tabulated at the Quality and Compliance Office

for performance measurement against the Organization established or revised

target.

DOCUMENT TITLE: PERFORMANCE MEASUREMENT AND MANGEMENT

REFERENCE NUMBER: HR-002

VERSION: 2.0

EFFECTIVE DATE: 01 DEC 2016 REVIEWED: 01 DEC 2017



2.2.5. Results of performance measurement are subject for analysis by the responsible

person designated by the Quality and Compliance Office.

2.2.6. Performance measurement, analysis, and action plan will be done quarterly and

annually by the Quality and Compliance Department and its designees which

includes both the business functions and service delivery.

2.2.7. Ongoing performance issue that enormously impacts the organization business

functions and service deliveries will be address urgently.

2.2.8. An annual performance meeting (November of each year, headed by the Quality

and Compliance Team, communicates performance information to the

administration and personnel.

2.2.9. A summary copy of the performance information may also be available upon

Chairman‟s approval and can be access on the organization website for its

persons served and other stakeholders.

2.3. Appendices.

2.3.1. Rate of Emergency Attendance.

2.3.2. Rate of Unplanned Hospital Admission.

2.3.3. Rate of DVT.

2.3.4. Rate of Newly Acquired or Worsening Pressure Ulcers.

2.3.5. Percentage of Denials, Ineligibility, and Interrupted Service.

2.3.6. Percentage of Accessibility Barriers Resolved.

2.3.7. Rate of Health Care Acquired Infection.

2.3.8. Personnel Retention Rate.

2.3.9. Personnel Turnover Rate.

2.3.10. Rate of Reportable Occupational Related Incident.

2.3.11. Percentage Personnel Satisfaction.

2.3.12. Percentage of Risk Identified Resolved.

2.3.13. Percentage of Accomplished Technology Improvement Plans.

2.3.14. Personnel Overtime Variance.

2.3.15. Persons Served Satisfaction Rating.

2.3.16. Percentage of Persons Served Complaint Resolution.

2.3.17. HAAD Audit Compliance Rating.

2.3.18. TASNEEF Audit Compliance Rating.



3. Clinical Audit.

3.1. Policy.

3.1.1. The Organization must develop, maintain and support a culture of best practice

in the management and delivery of clinical audit.

3.1.2. The Organization must use the findings from clinical and other audits reviews to

drive actions that will improve the quality of care delivered and, if any unsafe

clinical practice is identified during audit, to ensure that a risk assessment is

undertaken, and measures put in place and monitored effectively in order to

deliver safe care.

3.1.3. The Organization shall assess how closely its clinical practice resembles the

recommended practice.

3.2. Procedures.

3.2.1. The Director for Quality and Compliance is the accountable officer of the

Organization and as such has overall accountability and responsibility for

ensuring it meets its statutory and legal requirements and adheres to guidance

issued by the Health Authority Abu Dhabi.

3.2.2. The Medical Director has executive accountability for clinical effectiveness and is

responsible for providing assurance to the CEO and Chairman on the

implementation of this policy.

3.2.3. Involving Persons Served.

3.2.3.1. The Organization promotes a commitment to the principle of involving

persons served and family/support system in the clinical audit process

either indirectly through the use of persons served surveys/questionnaires

or directly through the participation of identified individuals on project

steering groups, or forums.

3.2.4. Multi-Disciplinary and Multi-Professional Audit, and Partnership Working

with Other Organizations.

3.2.4.1. The Organization encourages clinical audit undertaken jointly across

professions and across organizational boundaries. Partnership working with

other local and international organizations will be encouraged where

improvements to the persons served journey may be identified through

shared clinical audit activity.

3.2.5. Working with Health Authority Abu Dhabi.

3.2.5.1. As a provider organization, clinical audit activity should reflect HAAD‟s

requirements and aspirations. The findings of any audit must be made

DOCUMENT TITLE: CLINICAL AUDIT

REFERENCE NUMBER: QM-003

VERSION: 2.0




available to the HAAD on request and the HAAD can appoint an auditor to

audit quality and outcomes and the recording and coding of clinical activity.

3.2.6. Annual Clinical Audit.

3.2.6.1. On an annual basis, the Organization will conduct planned program of

clinical audit activity for quality improvement and quality assurance.

3.2.6.2. The annual clinical audit will be comprised of the following:

3.2.6.2.1. HAAD Audit;

3.2.6.2.2. TASNEEF Audit;

3.2.6.2.3. OSHAD Audit;

3.2.6.2.4. CARF Audit;

3.2.6.2.5. External Health and Safety Audit;

3.2.6.2.6. Internal Health and Safety Audit; and

3.2.6.2.7. PHD Laboratory Audit.

3.2.6.3. To facilitate the monitoring of audit listed above, an audit database is

maintained by the Quality and Compliance Office, identifying all audits

undertaken and their progress, which will support assurance of the

completion of the audit cycle, and identify any risks along with changes in

practice, if appropriate.

3.2.6.4. The Quality and Compliance Office monitor the completion of audit action

plans, to support the achievement of those action plans within the agreed

timescales.

3.2.7. Action Plans.

3.2.7.1. Details of completed audits will be presented at audit meetings where the

findings will be reviewed, risks identified and discussed.

3.2.7.2. Action plans will then be developed with a commitment to re-audit made if

required.

3.2.7.3. Action plans should be specific, measurable and achievable/realistic. They

should have clear implementation timescales with identified leads for each

action.

3.2.7.4. Action plans should be approved by the Director for Quality and

Compliance included in the Audit Report.

3.2.7.5. Not all clinical audits will require an action plan e.g. where an audit shows

that standards are being met or guidance followed. For such audits there

should be an explicit statement saying „no further action required‟ in the

audit report and a reason given for no re-audit.

3.2.8. Re-Audit.

3.2.8.1. Re-audit is necessary to determine whether agreed actions have been

implemented according to the action plan, where audits have demonstrated

a need for change in practice it is expected that a timescale for

implementation of the actions will include a planned re-audit and findings of

the re-audit will be submitted to the audit meeting and to Quality and

Compliance Office. This provides assurance that the audit cycle has been

completed.



3.2.9. Reports.

3.2.9.1. Once data has been collected, analyzed and an agreement reached as to

any actions required, it is the responsibility of the designee undertaking the

audit to populate the clinical audit report templates and when fully

completed, forward to Quality and Compliance Department.

3.2.9.2. Any clinical audit reports that are received with missing information (e.g.

author, action plan not completed) will be returned to the auditor for

completion and return. This will ensure that all evidence required to inform

changes in practice, or re-audit meets the Organization requirements.

3.2.10. Retention of Audit Records.

3.2.10.1. It is a fundamental requirement that all of the Organization‟s records are

retained for the correct period of time prior to secure destruction. In terms of

clinical Audits, records need to be retained for 5 years after completion of

the audits.

3.3. Appendices.

3.3.1. HAAD Audit Form.

3.3.2. TASNEEF Audit Report.

3.3.3. OSHAD Audit Report.

3.3.4. CARF Conformance Checklist.

3.3.5. External Health and Safety Audit Report.

3.3.6. Internal Health and Safety Audit Form.

3.3.7. PHD Laboratory Audit Report.



4. Persons Served Safety.

4.1. Policy.

4.1.1. The Organization commits on persons served safety goals that promotes

prevention of errors and adverse effects to persons served associated with

health care. The following safety goals are as follows:

4.1.1.1. Improve accuracy of person served identification.

4.1.1.2. Improve effectiveness of communication among care providers.

4.1.1.3. Improve the safety of using medications and medical devices.

4.1.1.4. Reduce the risk of healthcare associated infections.

4.1.1.5. Adherence to hand hygiene.

4.1.1.6. Reduce the risk of patient harm resulting from falls.

4.1.2. Person Served Identification:

4.1.2.1. Persons served identification is a fundamental part of the delivery of

healthcare in any discipline, and should be second nature to all care

providers.

4.1.2.2. Persons served identification must apply for all interactions to ensure the

correct their identity, particularly before any procedure or receive therapy.

4.1.2.3. Healthcare personnel shall use at least two identifiers to ensure the right

persons served get the right care. At least two identifiers will be used to the

following but not limited to administering medication, blood/blood

components, collecting samples, treatments and procedure.

4.1.3. Effective Communication among Care Providers.

4.1.3.1. Reporting Critical Results

4.1.3.1.1. The facility shall determine which tests performed by the affiliated

outside laboratory fulfill the criteria for critical values / critical

results and describes the processes for notification, read-back and

report documentation of those results.

4.1.3.2. Hand Over Process.

4.1.3.2.1. Person served information is communicated during transfers of

care from one provider to another to assure continuity of care.

4.1.3.2.2. The Hand-off Communication Forms will be used during the hand

off of care discussion for all service and care transfers within the

Organization.

4.1.3.2.3. The Hand-off Communication Form will be a permanent part of the

person served medical record.

4.1.3.3. Verbal Orders.

DOCUMENT TITLE: PERSON SERVED SAFETY


VERSION: 2.0




4.1.3.3.1. Verbal orders should be used in situations where any delay in

writing the order could cause harm or have a possible negative

outcome to the person served.

4.1.3.3.2. Verbal and telephone orders may be accepted by a licensed

healthcare staff when it is impossible or impractical for the

authorized prescriber to write them.

4.1.3.3.3. Generic drug names should be used when drug orders are given.

4.1.3.3.4. Abbreviations should be avoided in all possible circumstances to

ensure safety of the person served and avoid medication errors.

4.1.4. Safety use of Medications and Medical Devices.

4.1.4.1. For safety use of medication, refer to Medical Policies and Procedures.

4.1.4.2. For safety use of medical devices, refer to Facility and Medical Equipment

Management Policies and Procedures.

4.1.5. Reduce the Risk of Healthcare Associated Infections.

4.1.5.1. For reducing the risk of healthcare associated infections, refer to Infection

Control Policies and Procedures.

4.1.6. Adherence to Hand Hygiene.

4.1.6.1. For adherence to hand hygiene, refer to Infection Control Policies and

Procedures.

4.1.7. Reduce the Risk of Persons Served Harm Resulting from Fall.

4.1.7.1. Health care personnel are responsible for assessing all persons served for

risk of fall using the Modified Morse Fall Scale for Adults and Humpty

Dumpty Fall Scale for Pediatrics.

4.1.7.2. Fall assessment shall be completed upon person‟s served initial contact.

4.1.7.3. Fall reassessment of persons served shall be completed as follows:

4.1.7.3.1. Low risks shall be reassessed weekly.

4.1.7.3.2. Moderate or high risks shall be reassessed on every shift or daily.

4.1.7.3.3. Following any changes in person served condition related to fall

risk factors.

4.1.7.3.4. Following a fall.

4.1.7.3.5. Following procedural sedation.

4.1.7.3.6. Any medication effects (sedation/diuretics).

4.1.7.3.7. Narcotic administration.

4.1.7.3.8. Change in level of consciousness or mental status.

4.1.7.4. Fall prevention measures shall be implemented for persons served at risk

for fall.

4.1.7.5. Occurrence variance report shall be completed following patient fall.

4.1.7.5.1. None – no injury.

4.1.7.5.2. Minor - resulted in application of a dressing, ice, cleaning of a

wound, limb elevation, topical medication, bruise or abrasion.

4.1.7.5.3. Moderate – resulted in suturing, application of Steris trip/skin

glue, splinting or muscle joint strain.



4.1.7.5.4. Major – resulted in surgery, casting, traction, fracture or required

consultation for neurological or internal injury.

4.1.7.5.5. Death- person served died as a result of injuries sustained from

the fall.

4.2. Procedures.

4.2.1. Improving Accuracy of Persons Served Identification.

4.2.1.1. The following are the Organization approved identifiers for the persons

served:

4.2.1.1.1. Complete Name (Name, Middle and last Name);

4.2.1.1.2. Location or complete address;

4.2.1.1.3. Medical Record Number (MRN); and

4.2.1.1.4. Full date of birth (inclusive of day, month, and year).

4.2.1.2. When a person served has capacity and is assessed to be a reliable

informant, healthcare personnel can simply request verbal confirmation of

identity from him, asking him to confirm at least two of the above identifiers

and compare the information provided against the national ID and/or

insurance card located in the persons served medical records.

4.2.1.3. Staff should not read his details to them and allow them to passively agree

with you.

4.2.1.4. Instead staff should ask him to give his full details.

4.2.1.5. None of the following but not limited to administering medication,

blood/blood components, collecting samples, treatments and procedure

shall be performed to any person served until the identity of the person

served has been duly determined.

4.2.1.6. Identification for Minor Persons Served and/or are Disabled.

4.2.1.6.1. The capacity or reliability of some persons served can fluctuate

depending on age and disability.

4.2.1.6.2. If the person served does not have the capacity to identify himself

or otherwise does not have consistent reliability as an informant

the identification must initially be confirmed by another member of

staff who knows the patient, family member or other appropriate

person - if necessary accompanied by another member of staff

who knows the patient, family member or other appropriate

person.

4.2.1.7. Reporting Identification Errors.

4.2.1.7.1. If there is an error in administration of medication due to

misidentification the person served must be physically assessed

by a nurse or a doctor and any physical signs such as pulse rate

and blood pressure monitored as necessary. All this must be fully

documented.

4.2.1.7.2. Any error occurs must be reported immediately to the person in

charge of the service such as the department manager or



supervisor and an incident report must be completed. This must

include any error where an incident has

4.2.1.7.3. Refer to the Organization Incident Reporting Policy and

Procedures.

4.2.2. Improving Effectiveness of Communication among Care Providers.

4.2.2.1. Reporting Critical Results.

4.2.2.1.1. A critical value is defined as a value that represents a

pathophysiological state at such variance with normal (expected

values) as to be life-threatening unless something is done

promptly and for which some corrective action could be taken.

NOTE: The critical values do not necessarily correspond directly

with normal reference values, toxic ranges, or therapeutic ranges.

4.2.2.1.2. Notification.

4.2.2.1.2.1. The affiliated laboratory will notify the person served care

provider, normally the physician, when critical limits of

specified test results are exceeded and/or critical results

are obtained.

4.2.2.1.2.2. In addition to the usual normal results reporting process

(e.g. fax, computer interface). Affiliated Laboratory staff

telephone the ordering physician within 60 minutes

following laboratory release of the critical result(s)

according to their established procedures.

4.2.2.1.2.3. In the event that contact is not made within the 60-minute

period, the affiliated laboratory will continue to telephone

until the designated party is reached and the result is

conveyed.

4.2.2.1.2.4. Critical results obtained by Point of Care (POC) testing

are communicated to the treating healthcare provider.

4.2.2.1.3. Read-Back of Critical Value / Critical Results.

4.2.2.1.3.1. To verify the accuracy of information communicated via

the telephone, the physician or designee responsible for

person served care is required to read-back the name,

unique numeric identification, and the critical test

result(s) of the person served.

4.2.2.1.4. Documentation.

4.2.2.1.4.1. The critical high and low values are place in the person

served medical record. NOTE: Records of notification

and read back are documented in the progress notes.

4.2.2.2. Handover Procedures of the Persons Served.

4.2.2.2.1. Person-to-person contact is preferred when transferring care.

4.2.2.2.2. When this is not possible, it is acceptable to provide this

information via phone, allowing for appropriate feedback and

opportunity to ask questions, between and among care providers.



4.2.2.2.3. When possible and appropriate, include the person served and

family in the dialogue at the time of the transfer.

4.2.2.2.4. At a minimum, the transferring staff makes the person

served/family aware of the hand-off and provides the name and

the title of the person or agency that will be assuming

responsibility for their continued care.

4.2.2.2.5. SBAR communication tool will be used during the transfer of

professional responsibility and accountability as follows:

4.2.2.2.5.1. Transfer to other Organization units.

4.2.2.2.5.2. Transfer to other healthcare facilities.

4.2.2.2.5.3. Change of staff during home visits services (Home

Nursing and Home Supportive Therapy Services).

4.2.2.2.5.4. Initiation of new services.

4.2.2.2.5.5. Transfer of care from one physician to another.

4.2.2.2.6. The handover communication form (SBAR) will be used to

facilitate communication of the hand-off process between staff

and/or other receiver of care.

4.2.2.2.7. SBAR form will be placed on the person served medical record.

4.2.2.2.8. Separate form “Patient Daily Plan of Care” shall be used as

hands-off communication tool on the following services:

4.2.2.2.8.1. 12 hours Home Nursing Service; and

4.2.2.2.8.2. 24 hours Home Nursing Service.

4.2.2.2.9. Use of the SBAR Form. (See the appendix section for the

form).

4.2.2.2.9.1. Familiarize yourself with the person‟s served information

before initiating the communication.

4.2.2.2.9.2. Identify yourself, your position, the person‟s served

name, MRN number.

4.2.2.2.9.3. Review chief complaint/diagnosis, any relevant history,

assessment, list of current medications, allergies, or labs,

most recent vital signs, and any changes pertinent to the

problems and/or the treatment/clinical course summary.

4.2.2.2.9.4. Discussed with the case coordinator or department

manager or supervisor regarding the situation then

inform the physician.

4.2.2.2.9.5. Read the most recent progress notes from the staff who

worked the shift or day ahead of you.

4.2.2.2.9.6. Follow the SBAR process:

4.2.2.2.9.6.1. (S) Situation: What is the situation you are

calling about?

4.2.2.2.9.6.2. Identify self, person served and

Address/Location.



4.2.2.2.9.6.3. Briefly state the problem, what is it, when it

happened or started, and how severe.

4.2.2.2.9.7. (B) Background: Pertinent background information

related to the situation could include the following:

4.2.2.2.9.7.1. Briefly state the pertinent history.

4.2.2.2.9.7.2. What got the person served to this point?

4.2.2.2.9.7.3. The admitting diagnosis and co morbidities.

4.2.2.2.9.7.4. List of current medications and allergies.

4.2.2.2.9.7.5. Most recent vital signs and BSL

4.2.2.2.9.8. (A) Assessment: What is the staff assessment of the

situation?

4.2.2.2.9.9. (R) Recommendation: What is the staff

recommendation or what does he/she wants?

4.2.2.2.9.9.1. Give a recommendation (or a response)

based on the situation, background, and

assessment of the case. In other words, what

do you think needs to be done?

4.2.2.2.9.10. Document the changes in the person‟s served condition

in the progress notes.

4.2.2.2.9.11. Conclude by giving the receiving staff person the

opportunity to ask any questions or clarify information.

4.2.2.2.9.12. If verbal order is provided, document the order made in

verbal order form and let the physician sign it within 7

days.

4.2.2.2.10. Use of Daily Plan of Care. (See the appendix section for the

form).

4.2.2.2.10.1. The Daily plan of care is a written communication tool

that gives a brief summary of the person‟s served daily

health status and overall plan of care.

4.2.2.2.10.2. Staff needs to fill up this form daily, in every shift in

accordance to the person‟s served over all condition and

routine daily care.

4.2.2.3. Verbal Orders.

4.2.2.3.1. Verbal orders shall only be received and accepted by a licensed

healthcare staff.

4.2.2.3.2. Properly identified the person served whom the verbal order is

referring to using the Organization approved identifiers

4.2.2.3.3. Record the verbal order directly onto a verbal order sheet in the

person‟s served medical record.

4.2.2.3.4. The listener will concurrently transcribe the complete order on an

approved verbal order form.

4.2.2.3.5. Read the transcribed order back to the physician to ensure that

the information transcribed are correct.



4.2.2.3.6. Enunciate what is being said as clearly as possible.

4.2.2.3.7. Use aids such as “B as in Ball” or “F as in Frank” to eliminate

spelling errors.

4.2.2.3.8. Articulate numbers as “sixteen or one-six” to avoid errors.

4.2.2.3.9. Document “read back completed” next to the transcribed order.

4.2.2.3.10. Place the order in the medical record as soon as possible.

4.2.2.3.11. Flag the verbal order for authentication.

4.2.2.3.12. The staff who received verbal orders is required to sign, date,

time, and note the order according to prescribed procedures.

4.2.2.3.13. Verbal orders shall be accepted only in emergencies and are

accepted when given by a qualified physician only.

4.2.2.3.14. A verbal order is not allowed when the prescriber is present and

the person‟s served chart is available.

4.2.2.3.15. Physician shall ask for important patient information such as drug

allergies, lab values and diagnosis or comorbid conditions that

may affect the prescribed medication.

4.2.2.3.16. The Physician is mandated to verify and sign/date orders

within seven (7) days.

4.2.2.3.17. Verbal orders shall not be given or accepted for:

4.2.2.3.17.1. Cytotoxic agents;

4.2.2.3.17.2. Sedatives and narcotics;

4.2.2.3.17.3. Biological response modifiers (Immunotherapy drugs

given to strengthen the immune system; and

4.2.2.3.17.4. Investigational drugs.

4.2.2.3.18. For verbal order of medication, and due to the risk for

medication errors associated with verbal communication of orders,

it is expected that the following components of the order will be

verbalized and transcribed:

4.2.2.3.18.1. Date and time of order;

4.2.2.3.18.2. Generic and brand name of drug;

4.2.2.3.18.3. Drug dosage (strength and concentration, formulation –

tabs, pills, solution mg/cc);

4.2.2.3.18.4. Quantity and Duration;

4.2.2.3.18.5. Route of Administration;

4.2.2.3.18.6. Frequency of Administration;

4.2.2.3.18.7. Age and weight of patient (required for Pediatric patients

and in clinical circumstances where appropriate);

4.2.2.3.18.8. Known allergies;

4.2.2.3.18.9. Reason drug is ordered for PRN orders; and

4.2.2.3.18.10. Specific indications for use, as appropriate.

4.2.2.4. Reducing the Risk of Persons Served Harm Resulting from Fall.

4.2.2.4.1. Physician Identifies and initiates medical interventions to reduce

fall and fall-related injury risk.



4.2.2.4.2. Other healthcare personnel should:

4.2.2.4.2.1. Implements plan of care to address persons served

identified as high risk and implements high-risk

strategies.

4.2.2.4.2.2. Completes fall-risk assessments on transfers, following a

change in status, following a fall and quarterly.

4.2.2.4.2.3. Recognizes and reports verbalizations and behaviors

indicative of discomfort which may potentially lead to

falls.

4.2.2.4.2.4. Reports any risk factors identified.

4.2.2.4.2.5. Ensures procedures for high fall-risk persons served are

in use.

4.2.2.4.2.6. Provides education to family/support system about falls

prevention strategies.

4.2.2.4.2.7. Evaluates the plan of care.

4.2.2.4.3. Assess the persons served for fall risk upon admission and

complete Morse Fall Risk Assessment tool for adult and the

Humpty Dumpty Scale for pediatrics.

4.2.2.4.4. Morse Fall Scale score will determine the risk for fall of a persons

served as follows:

4.2.2.4.4.1. Following a fall (F).

4.2.2.4.4.2. On admission to the facility (A).

4.2.2.4.4.3. Following any change of status (C).

4.2.2.4.4.4. On any transfer from one unit to another within the facility

or discharge (T).

4.2.2.4.4.5. 0 – 24 points: Low Risk.

4.2.2.4.4.6. 25 – 44 points: Moderate Risk.

4.2.2.4.4.7. > 45 points: High Risk.

4.2.2.4.5. According to the Humpty Dumpty Fall Scale, The person served is

considered at Risk for fall if the score is ≥ 12.

4.2.2.4.6. In case the person served was identified at moderate or high

risk, the fall reassessment shall be done on every shift and the

fall prevention and management interventions included in the

form shall be applied.

4.2.2.4.7. Re-assess the person served when these conditions apply to:

4.2.2.4.7.1. Change of condition

4.2.2.4.7.2. In case of a new fall.

4.2.2.4.7.3. In case of transfer from one place to another area inside

or outside home or within the facility

4.2.2.4.7.4. In case, is receiving medications that alter the level of

consciousness (sedatives, tranquilizers, barbiturates,

etc.).

4.2.2.4.7.5. In case, is post-operative.



4.2.2.4.8. Coordinate the result of the reassessment with the physician and

document on the person served medical record.

4.2.2.4.9. Standards Fall Precautions measures shall be applied to all

persons served.

4.2.2.4.9.1. Provide person served and family/support system fall

prevention education.

4.2.2.4.9.2. Room shall be well lit at all times.

4.2.2.4.9.3. Person served with orthostatic hypotension should be

taught to change position slowly to allow blood pressure

stabilization.

4.2.2.4.9.4. Bedside rails shall always be elevated.

4.2.2.4.9.5. If not transporting a person served, wheelchairs and

beds shall be kept in a locked position.

4.2.2.4.9.6. Keep bed at lowest position.

4.2.2.4.9.7. Keep tissues and other articles for personal use within

person‟s served reach.

4.2.2.4.9.8. Ensure clothing doesn‟t interfere with mobility.

4.2.2.4.9.9. Monitor environment for clutter, spills or other hazards.

4.2.2.4.9.10. Keep bathroom lights on and floor dry.

4.2.2.4.9.11. Use of raised toilet seat or stool in the shower as

necessary.

4.2.2.4.9.12. Use of safety straps on stretcher, wheelchair while

transporting persons served.

4.2.2.4.9.13. Monitor for change in falls risks.

4.2.2.4.9.14. Children shall not be left unattended.

4.2.2.4.10. Implement the following fall management plan in the event of

a fall:

4.2.2.4.10.1. Assess the level of consciousness.

4.2.2.4.10.2. Check the vital signs.

4.2.2.4.10.3. Do not move the person served until potential injuries are

identified and safety assured.

4.2.2.4.10.4. Notify the physician.

4.2.2.4.10.5. Complete the Occurrence Variance Report. (Refer to

Incident Reporting Policy).

4.2.2.4.10.6. Reassure the person served and family/support system

at all times regarding condition and procedures to follow.

4.2.2.4.11. Communication and Education about person’s served fall

risk:

4.2.2.4.11.1. Communicate to all staff information regarding person

served who are at risk of falling or at risk for sustaining a

fall-related injury.

4.2.2.4.11.2. Use visual indicator to quickly communicate with the care

team about at risk of fall or injury.



4.2.2.4.11.3. Ensure safe, standardize handoffs between nurses (e.g.

at shift change) and communicate with family/support

system.

4.2.2.4.11.4. Educate the person served and the family/support

system about risk of injury from a fall and about what

they can do to help prevent a fall.

4.2.2.4.11.5. Familiarize the person served with the surroundings.

4.2.2.4.11.6. Place the person served to a bed that enables him to exit

towards his stronger side whenever possible.

4.2.2.4.11.7. Teach person served proper ambulation and use of

assistive devices like not turning on the heel of the foot;

use handrails in hallways, bathrooms and tub rooms;

wheelchair safety (brakes, pedals); and not pulling down

on walkers when rising to a standing position.

4.2.2.4.11.8. Teach to sit on the edge of the bed for several minutes

before rising.

4.2.2.4.11.9. Caution to avoid bending his/her head sharply

backwards.

4.2.2.4.11.10. Instruct to refrain from working with his arm above their

head.

4.2.2.4.11.11. Instruct person served and family/support system

regarding appropriate footwear such as the use of

treaded socks and/or non-skid footwear.

4.2.2.4.11.12. Instruct to request assistance with ambulation. Repeat

instructions to call for help on each shift.

4.3. Appendices.

4.3.1. SBAR Form

4.3.2. Patient Daily Plan of Care

4.3.3. Verbal Order Form

4.3.4. Adult Fall Risk Assessment

4.3.5. Pediatric Fall Risk Assessment



5. Risk Management.

5.1. Policy.

5.1.1. The Organization ensures that levels of risk and uncertainty are properly

identified, analyzed and managed.

5.1.2. The Organization develops and deploys mitigation strategies to reduce the

likelihood and/or impact of risk.

5.1.3. The Organization sets monitoring of actions to reduce risk.

5.1.4. The Organization risk identification and management considers risk related to the

following:

5.1.4.1. Financial practices;

5.1.4.2. Human Resources;

5.1.4.3. Services Provided;

5.1.4.4. Persons Served;

5.1.4.5. Information Technology;

5.1.4.6. Emergency Preparedness; and

5.1.4.7. Health and Safety.

5.1.5. The Organization has the primary duty to mitigate the risk of above activities

through the following risks management:

5.1.5.1. Eliminating risks so far as is reasonably practicable; and

5.1.5.2. If it is not reasonably practicable to eliminate the risks, by minimizing those

risks so far as is reasonably practicable.

5.1.6. The Organization risk management involves four steps:

5.1.6.1. Identify risks – find out what could cause harm.

5.1.6.2. Assess risks – understand the likelihood of a hazard causing harm and how

serious it could be.

5.1.6.3. Control risks – implement the most effective control and rectification

measure that is reasonably practicable in the circumstances.

5.1.6.4. Review control measures to ensure they are working as planned.

5.1.7. The administration exercises due diligence to gain an understanding of the

hazards and risks associated with the operations of the Organization, and

ensures that the Organization has and uses appropriate resources and

processes to eliminate or minimize risks to the company.

5.1.8. The risk management team ensures that personnel and the persons served are

not put at risk from work and service carried out by the physical facility and the

Organization operation.

5.1.9. The risk management team keeps an up-to date risk and future risk register.

DOCUMENT TITLE: RISK MANAGEMENT


VERSION: 2.0




5.1.10. During the induction program, newly hired personnel shall receive education

regarding raising concerns when quality and patient safety is compromised.

5.1.11. All personnel shall be made aware of the clinical risk registers through education

program on risk management.

5.1.12. All issues and concerns about risk identified and reported by the personnel shall

be studied and made an action plan.

5.2. Procedures.

5.2.1. Risk Identification.

5.2.1.1. Use the Organization Risk Identification Tool in identifying risks.

5.2.1.2. With the use of the Risk Identification Tool, follow these steps to simplify

and fasten risk identification process:

5.2.1.2.1. Consultation with each department head and their staff is required

at each step of the risk management process. By drawing on the

experience, knowledge and ideas of these people are more likely

to identify all risks and choose effective risk controls.

5.2.1.2.2. Encourage staff to report any risks and operation problems

immediately so that risks can be managed before an incident

occurs. Encouragement must be set starting from the personnel

induction phase.

5.2.1.2.3. Inspection of the workplace through regular walks around the

facility and observes how things are done helps to predict what

could or might go wrong.

5.2.1.2.4. Review available information about any risks relevant to the

Organization.

5.2.1.2.5. Review of the Organization critical incident records and data.

5.2.1.2.6. Review of the Organization Occupational Related Diseases and

Injuries.

5.2.2. Risk Assessment.

5.2.2.1. Use the Organization Risk Assessment Tool in analyzing risks.

5.2.2.2. With the use of the Risk Assessment Tool, follow these steps to simplify

and fasten risk assessment process:

5.2.2.2.1. Work out the amount of risk that could occur. To estimate the

amount of risk that could result from each exposures you should

consider the following questions:

5.2.2.2.1.1. What type of risk could occur? How severe is the risk?

Could the risk cause death, serious injuries, operation

shut down? Bankruptcy? Etc.

5.2.2.2.1.2. What factors could influence the severity of risk that

occurs?

5.2.2.2.1.3. How many people are exposed to the risk and how many

could be affected (in and outside the Organization)?



5.2.2.2.1.4. Could one failure lead to other failures? For example,

could the failure of the utilities make any risk controls that

rely on utilities ineffective?

5.2.2.2.1.5. Could a small event escalate to a much larger event with

more serious consequences? For example, a minor

delay claims submission can affect operating income

thus affect the company cash flow.

5.2.2.2.2. Work out the likelihood of risk occurring. The likelihood of

exposures can be estimated by considering the following:

5.2.2.2.2.1. How often is the task done – does this make the harm

more or less likely?

5.2.2.2.2.2. How often are situation near the risk? How close the

situation gets to it?

5.2.2.2.2.3. Has it ever happened before, either in our company or

somewhere else? How often?

5.2.2.2.3. Rate the likelihood. The level of risk will increase as the likelihood

of harm occurring and its severity increases. Assess the level of

risk through the following:

5.2.2.2.3.1. Assign a number on a scale from 1 (lowest probability or

impact) to 10 (highest probability or impact) to quantify

the probability and potential impact of the risk.

5.2.2.2.3.2. Determine the overall severity or importance of the risk

by multiplying the probability number by the impact

number to come up with a measure of severity.

5.2.2.2.3.3. Determine which risks are the most important for further

action. We establish a “risk threshold,” which is a

severity number of 40 or higher.

5.2.2.2.3.4. Risks with less severity than this are not considered for

further analysis.

5.2.3. Risk Mitigation.

5.2.3.1. Use the Organization Risk Management Worksheet in Risk Mitigation.

5.2.3.2. With the use of the Risk Management Worksheet, follow these steps to

simplify and fasten risk management process:

5.2.3.2.1. Consult department head and staffs who will be directly affected

by the mitigation plan. Their experience help in choosing

appropriate control measures and their involvement increase the

level of acceptance of any changes that may be needed.

5.2.3.2.2. The ways of controlling risks are ranked from highest risk

threshold to lowest risk threshold.

5.2.3.2.3. The risk mitigation strategies adapt the hierarchy of control (from

work safe Australia 2010).

5.2.3.2.4. Level 1:

5.2.3.2.4.1. Eliminate the risk.



5.2.3.2.5. Level 2:

5.2.3.2.5.1. Substitute the risk with something safer.

5.2.3.2.5.2. Isolate the risk from people

5.2.3.2.5.3. Reduce the risks through engineering controls.

5.2.3.2.6. Level 3:

5.2.3.2.6.1. Reduce the level of harm using administrative actions.

5.2.3.2.6.2. Use of Personal Protective Equipment.

5.2.4. Monitoring of Actions to Reduce Risk.

5.2.4.1. The Organization uses the following method to monitor the control

measures implemented and ensure that they remain effective:

5.2.4.1.1. Accountability of Risk Management Team.

5.2.4.1.1.1. The monitoring of risk management policies and

procedures is the primary duty of the Risk Management

Team. The team ensures that their responsibilities are

performed and resources are available to meet them.

5.2.4.1.2. Regular Review.

5.2.4.1.2.1. The Risk Management Team will regular review the work

and procedures and will consult with department head

and staff. All incident investigations should include a

review of any relevant procedures.

5.2.4.1.3. Effective Communication.

5.2.4.1.3.1. The Organization commits in effective communication

using appropriate language, signs and symbols.

5.2.4.1.4. Up-to-Date Training and Competency.

5.2.4.1.4.1. Training will be provided to all staff to maintain

competencies and to ensure new personnel are capable

of working safely.

5.2.4.1.5. Up-to-Date Risk Information and Risk Assessments.

5.2.4.1.5.1. The Risk Management Team commits in continuous

seeking of relevant, evidenced-based information about

risks, and uses this to change and update the

Organization‟s operating conditions and risk

management system.

5.2.5. Reporting Results of Actions Taken to Reduce Risks.

5.2.5.1. The Risk Management Team reports all of its findings, analysis and action

taken to the administration in its monthly meeting.

5.2.5.2. The monthly meeting will be use as well to get inputs from each department

for any risks they identified and for any recommendations to control the

risks identified.

5.2.5.3. The report regarding results of actions will be included in the Organization

performance improvement activities.

5.2.6. Reviews and Updates.



5.2.6.1. The following situations will be required to review the risk management

measures and if necessary, revise them. A review is generally required

when:

5.2.6.1.1. A significant change occurs to the workplace, work process or

system of work.

5.2.6.1.2. There is evidence that a risk control measure does not adequately

control the risk.

5.2.6.1.3. A notifiable incident occurs.

5.2.6.2. Check control measures considering the following questions:

5.2.6.2.1. Are the control measures working effectively in both their design

and operation?

5.2.6.2.2. Have the control measures introduced new problems?

5.2.6.2.3. Have all risks been identified?

5.2.6.2.4. Have new work methods, new equipment made the job safer?

5.2.6.2.5. Are safety procedures being followed?

5.2.6.2.6. Has instruction and training provided to workers on how to work

safely been successful?

5.2.6.2.7. Are staffs actively involved in identifying risks and possible control

measures? Are they openly raising exposures concerns and

reporting problems promptly?

5.2.6.2.8. Are the frequency and severity of critical incidents reducing over

time?

5.2.6.2.9. If new legislation or new information becomes available, does it

indicate current controls may no longer be the most effective?

5.2.6.3. If problems are found, go back through the risk management steps, review

our information and make further decisions about risk control.

5.3. Appendix.

5.3.1. Risk Identification Tool.

5.3.2. Risk Assessment Tool.

5.3.3. Risk Management Worksheet.



6. Culture of Quality and Person Served Safety.

6.1. Policy.

6.1.1. The Organization summarizes the essential elements of the Organization

commitment for excellence and safety which includes:

6.1.1.1. Fostering a quality mind-set with the objective of developing and providing

effective, excellent and safe health care services that are trusted and

preferred by persons served and families/supports system and deliver on

our commitment to enable healthier and quality lives.

6.1.1.2. Complying with relevant laws and regulations as well as internal

requirements.

6.1.1.3. Continuously challenging ourselves to improve the quality management

system to guarantee persons served safety, prevent quality incidents and

eliminate risks through the review of quality objectives and results.

6.1.1.4. Encouraging participation and promotion of quality and persons served

safety responsibilities amongst all personnel through standards, education,

training and coaching, supervision and effective communication.

6.2. Procedures.

6.2.1. As part of the Organization initiative to quality and persons served safety, the

administration will be proactively engaged in its quality improvement program

through utilization of the policies and procedures stated herein.

6.2.2. The administration includes in its financial planning specifically in its annual

budget, allocation of sufficient funds and other needed resources like additional

manpower that will be dedicated to its quality improvement and persons served

safety program.

6.2.3. All Personnel will be encouraged and provided education, training or coaching

that will promote involvement in the Organization quality improvement and

persons served safety measures.

6.2.4. A non-retaliation approach is in place for those personnel who in good faith

report any errors that compromised quality improvement and persons served

safety.

6.2.5. Regular meeting either formal or informal on quality initiatives will be maintained

to assure internal communication among all staff.

6.3. Appendix.

6.3.1. Culture of Quality and Person Served Safety Framework.

DOCUMENT TITLE: CULTURE OF QUALITY AND PERSON SERVED

SAFETY


VERSION: 2.0




7. Person Centered Care.

7.1. Policy.

7.1.1. The Organization follows the following person centered care guiding policies to

ensure the Organization health service delivery puts the person served first in

every decision:

7.1.1.1. All team members are considered caregivers.

7.1.1.2. Care is based on continuous healing relationships.

7.1.1.3. Care is customized and reflects persons served needs, values and

choices.

7.1.1.4. Knowledge and information are freely shared between and among persons

served, family/support system, care partners, physicians and other

caregivers.

7.1.1.5. Families and friends of the persons served are considered an essential part

of the care team.

7.1.1.6. Persons served safety is a visible priority.

7.1.1.7. Transparency is the rule in the care of the persons served.

7.1.1.8. All caregivers cooperate with one another through a common focus on the

best interests and personal goals of the persons served.

7.1.1.9. The persons served are the source of control for their care.

7.2. Procedures.

7.2.1. Everyone in the workforce, from housekeeping staff to the CEO, is part of care

experience of the person served. Regardless of one's role, each person is

expected to put the person served first.

7.2.2. To create a person-centered culture, all personnel must be aware of our person-

centered starting from the induction phase of employment.

7.2.3. The Organization will be working together to reinforce a focus on the continuum

of care for person served rather than episodes of care. Proper referral has to be

done to avoid gaps on care until goal is reached.

7.2.4. The policy for customizing care recognizes that each person served is different

and may have different needs and preferences. In addition to customizing the

care plan for each person served, the Organization works to make the

environment comfortable to individual person served. For example, one person

served may want music in the room, where another patient may not. It allows

the person served individuality to be a component of care.

DOCUMENT TITLE: PERSON CENTERED CARE


VERSION: 2.0




7.2.5. In the Organization person-centered environment, all members of the care team,

including the person served, need to be aware of the person served status and

care plan. The person served is absolutely needs to be informed and part of the

decision-making.

7.2.6. The Organization recognizes that family and support system are essential

supports for the person served healing process. Family and support system

support person served not only emotionally, but also physically, as they can help

person served understand physicians' instructions. Person served may be in a

state of discomfort and pain or fear, and don't always hear information, so it

allows a trusted family member or support system identified by the person

served to participate in the sharing of information and guidance we give before

sending person served to the next level of care.

7.2.7. Making person served safety a visible priority demonstrates the Organization's

commitment to person served care. The Organization implements policies and

procedures to enforce person served safety best practices. For example, the

system had a campaign around personnel immunization and hand hygiene.

7.2.8. The transparency policy recognizes that true person-centered care requires

transparency between providers and person served and among providers.

Providers should be upfront and honest with information so person served can

make informed decisions with us. One way the Organization supports

transparency is by posting its scope and service on its website.

7.2.9. All processes at the Organization, even those that don't involve person served,

should be performed from a person served-value perspective. The Organization

coding and billing process is done from the perspective of the patient; staff has

worked to make bills clear and easy to understand for person served.

7.2.10. A core tenet of person-centered care is that the person served controls his or

her care. Making persons served the source of control of their care is the result

of effective deployment of all other guiding policies. To be the source of control,

The Organization has transparency and share information, create an

environment that allows the person served to heal and focus work on the person

served. After discharge, person served can still have a degree of control by

participating in a survey to provide input on how the system can improve care

and become more person-centered. Soliciting suggestions from those on the

receiving end of healthcare gives persons served some control over future

healthcare services and helps the Organization continue to put persons served

first in the Organization decisions.

7.3. Appendix.

7.3.1. Person Centered Organizational Structure.



8. Interdisciplinary Person Served Education.

8.1. Policy.

8.1.1. The Organization shall commit to this policy to ensure that each person served

and family/support system educational needs are assessed, with proper referral

to concerned health care providers (if needed) and documented in his record.

8.1.2. Every person served medical record should have health education needs

assessment and education form.

8.1.3. The healthcare team must offer the persons served encouragement and

enforcement to be actively involved in their care and take a more proactive role

in their own care and safety by empowering person served to speak up and be

active in decision making in the care provided to them.

8.1.4. The healthcare team during the admission or assessment interview should

determine and identify any barriers that may influence the person served and

family/support system ability to learn.

8.1.5. The healthcare team should document any identified barriers and its intervention

in the Interdisciplinary patient/family education record.

8.1.6. The healthcare team shall seek the assistance from the appropriate available

health services such as language interpreter, speech and language therapist,

religious guidance to assists with the educational needs assessment and

subsequent person served education, when such barrier(s) is identified.

8.1.7. All Healthcare Personnel shall collaborate to provide education to persons

served and families/supports system.

8.2. Procedures.

8.2.1. Assessment / Re-assessment of Person Served and Family/Support

System Learning Needs.

8.2.1.1. The educational process shall include assessment and individualized plan

of care to include persons served and families/supports system learning

needs, activities, preferences, and readiness to learn. Considerations shall

be given to:

8.2.1.1.1. Cultural and religious practices.

8.2.1.1.2. Emotional barriers.

8.2.1.1.3. Physical and cognitive limitations.

8.2.1.1.4. Barriers to Communication (i.e. Language, unable to speak).

8.2.1.1.5. Health literacy.

8.2.1.1.6. Desire and motivation to learn.

DOCUMENT TITLE: INTERDISCIPLINARY PERSON

SERVED EDUCATION


VERSION: 2.0




8.2.1.1.7. Financial implication of care choices

8.2.2. Person Served and Family/Support System Education Planning.

8.2.2.1. The education process shall include as appropriate to assess the needs of

the person served:

8.2.2.1.1. The plan for care, treatment and services.

8.2.2.1.2. Basic health and safety practices.

8.2.2.1.3. Safe and effective use of medications.

8.2.2.1.4. Nutrition interventions and modified diets.

8.2.2.1.5. Safe and effective use of medical equipment or supplies.

8.2.2.1.6. Importance of understanding effective pain management,

assessment process, risk, and methods prescribed to achieve

optimal comfort measures.

8.2.2.1.7. Rehabilitation techniques to help reach maximum independence

possible.

8.2.2.1.8. When and how to obtain further treatment if needed.

8.2.2.1.9. Regarding the ongoing health care needs.

8.2.2.1.10. Maintenance of good personal health practices, including oral

hygiene.

8.2.2.1.11. Fall reduction strategies.

8.2.3. Implementation of Person Served and Family/Support System Education

Plan.

8.2.3.1. The healthcare team, who assess the patient, shall enter his name,

signature and staff number in the assessment form and record it in the

person served medical record.

8.2.3.2. The staff identifies and incorporates in the assessment forms, the data for

person served and family/support system need for teaching, readiness and

barriers for learning.

8.2.3.3. The staff shall indicate in the assessment Form the person served and

family/support system needs for learning or re-assessment in case of any

change in person served conditions.

8.2.3.4. The staff shall teach and inform person served and family/support system

the nature of his illness, complications, treatment, its benefits and

importance of follow-ups to the hospital.

8.2.3.5. If the staff finds that the person served needs more education, he will refer

the person served to the concerned parties.

8.2.3.6. The concerned parties (doctors, physiotherapist etc.) will do more

assessment and record that in the interdisciplinary form.

8.2.3.7. The educational need assessment and education subjects should include

but not be limited to:

8.2.3.7.1. Diagnosis;

8.2.3.7.2. Care plan and treatment;

8.2.3.7.3. When and how to call for assistance;

8.2.3.7.4. Infection prevention and control;



8.2.3.7.5. Informed Consent;

8.2.3.7.6. Medication (safety, effects/ side effect, interactions);

8.2.3.7.7. Diet / Nutrition;

8.2.3.7.8. Medical equipment;

8.2.3.7.9. Implants/Prosthesis/Implantable/remote monitoring device;

8.2.3.7.10. Discharge education including explanation about when to seek

emergency care;

8.2.3.7.11. Fall Risk Education;

8.2.3.7.12. Pain Management;

8.2.3.7.13. Rehabilitation; and

8.2.3.7.14. Persons Served Bill of Rights.

8.2.3.8. The method of education can include verbal instruction and skills

demonstration

8.2.3.9. Instruction and education will be in the primary language of person served

and family/support system when possible.

8.2.3.10. When available, education leaflets should be provided to act as

reinforcement to the provided education but cannot be substituted as the

only means of education method.

8.2.3.11. The staff shall indicate re-assessment of patient/family learning needs in

case of any change in person served condition and arise of new needs.

8.2.4. Discharge Planning.

8.2.4.1. Discharge planning is initiated on initial assessment and is ongoing.

8.2.4.2. Discharge instructions are given to the person served and family/support

system in a manner that they can understand.

8.2.4.3. The person served and family/support system is educated on how to obtain

continuing care, treatment and services to meet his identified needs.

8.2.5. Evaluation of Outcomes.

8.2.5.1. The person served and family/support system understandings of learning

needs are continually evaluated by members of the health care team.

8.2.5.2. Evaluate learning objectives via return demonstration and / or verbal

discussion / follow-up care.

8.2.5.3. When behavioral objectives are not met, revision of the educational plan

with alternate educational strategies are utilized and re-evaluated by

members of the health care team.

8.2.5.4. Review and Approval of Education Materials.

8.2.5.5. The content of the t education materials are periodically submitted to

Quality and Compliance Office for review and revision. The Quality and

Compliance Office seeks recommendation and suggestions from the health

professional experts that may include physicians, nurses, therapists and

other healthcare professionals with expertise in the content area. This

process shall include:

8.2.5.5.1. Evaluation of material for demonstrated need;

8.2.5.5.2. Visual effectiveness;



8.2.5.5.3. Potential duplication or replacement of existing education

materials;

8.2.5.5.4. Format;

8.2.5.5.5. Graphics;

8.2.5.5.6. Cost;

8.2.5.5.7. Length; and

8.2.5.5.8. Readability.

8.3. Appendix.

8.3.1. Interdisciplinary patient/family education record



9. Complaint Management.

9.1. Policy.

9.1.1. The Organization establishes a complaints management system that is

accessible to all people, that identifies the process of making a complaint and

the roles and responsibilities of those involved in dealing with complaints and a

procedure by which complaints will be addressed and resolved within the

abilities of the Organization.

9.1.2. The Organization Complaint Management is not to apportion blame, it is to

investigate complaints to the possible satisfaction of the complainant, whilst

being scrupulously fair to staff, and to learn lessons for improvements in service

delivery.

9.1.3. The Organization complaint management system satisfies patients‟ rights and

responsibilities, confidentiality and the quality and safety of healthcare services

provided.

9.1.4. The complaint procedures are published in Arabic and English Languages and

are made visible in the facility‟s website, reception, waiting areas and on

patient‟s residence for those with 8/12/24 hour‟s home nursing service.

9.1.5. The complaint management system ensures the responsiveness, transparency,

and time-bound.

9.1.6. Investigation of the complaint is conducted in a fair, comprehensive, and

impartial manner that assures and respects the rights of the complainant without

prejudice to their right to access services or the quality of services provided to

them.

9.1.7. The Organization endeavor to resolve complaints to the satisfaction of the

complainant, wherever possible, and refer the complainant to HAAD Complaints

Management process where a complainant is not satisfied with the facility‟s

outcome.

9.1.8. The complainant is offered a meeting to communicate findings of the

investigation and that all communications are documented.

9.1.9. The facility establishes a complaint committee that ensures each complaint is

risk assessed to determine whether additional actions need to be taken at the

Organization level. This includes where a complaint may require a Sentinel

Event/Serious Clinical Incident reporting or review by Root Cause Analysis

and/or investigation of clinical error and subsequent rectification of issues

identified.

9.1.10. The Organization measures complainants‟ satisfaction with the facility

complaints management process; identify deficiencies in the complaints process

DOCUMENT TITLE: COMPLAINT MANGEMNET


VERSION: 2.0




or the quality and safety of care, and formulate recommendations and action

plans to ensure changes implemented accordingly.

9.2. Procedures.

9.2.1. Time limits apply to the initiation of a complaint. A formal complaint should

normally be made within 6 months of the incident that caused the problem, or

within 6 months of the discovery of the problem. The management, at its sole

discretion, may consider and accept exceptions to this, upon application by a

complainant.

9.2.2. The complainant is required to apply to the management in writing seeking an

exception and explaining the reasons to justify such a request.

9.2.3. Anyone working in the Organization that received or encountered a complaint

whether verbal/written must acknowledge it with professionalism, respect and

fairness.

9.2.4. Anyone working in the Organization who received or encountered a complaint

whether verbal/written must secure the following details and must be transcribed

on the complaint form:

9.2.4.1. Name of complainant;

9.2.4.2. Name of the patient involve;

9.2.4.3. Date when complaint was made;

9.2.4.4. Complainant contact number or email;

9.2.4.5. Address;

9.2.4.6. Relationship to the patient involve;

9.2.4.7. Date of the incident that is subject for complaint;

9.2.4.8. Name of the involve healthcare professional; and

9.2.4.9. Summary of the complaint.

9.2.5. Any personnel who receive a complaint whether verbal/written must relay

immediately the information to the Patient Relation Officer. In the absence of the

Patient Relation Officer, report could be relayed directly to the Quality

Improvement and Patient safety Officer.

9.2.6. The Patient Relation Officer:

9.2.6.1. Must acknowledge the complaint as soon as he received by giving a call,

sending an SMS or email to the complainant and must be documented on

the complaint log.

9.2.6.2. Should only acknowledge the received complaint but must not or in other

way give assurance or resolution comment to the complainant until decision

for corrective action has been made by the complaint committee.

9.2.6.3. Ensures that every received complaint be given a case number and must

be logged.

9.2.6.4. Analyzed the complaint with the help of the Quality Improvement Officer as

to whether the complaint will fall under Clinical Complaint or Service

Complaint.



9.2.7. The Patient Relation Officer and the Quality Improvement Officer will form a

committee based from the involved department that will help them in

investigating the complaint and gathering more substantial details.

9.2.8. The investigation and corrective actions should only take maximum 7 business

days or less, as possible.

9.2.9. In case that investigation and corrective actions cannot be done within 7

business days, an SMS, email, or a call shall be given to the complainant

explaining the process going on and the reason of the delay and must be

documented on the complaint log.

9.2.10. Once the committee had made a decision for corrective action, the resolution

must be documented on the Complaint Action Form by the head of the

department involve.

9.2.11. The Patient Relation Officer should inform the complainant of the decision and

action made in writing within 2 business days and must be documented on the

complaint log.

9.2.12. The Patient Relation Officer may also send Complaint Resolution Survey Form

and inform the complainant to answer it for service quality assessment.

9.2.13. The case is considered resolved when formal communication from the Patient

Relation Officer responsible for the complaints management system, is sent to

the complainant informing them of the findings of the investigation and the

actions decided by the responsible body(s).

9.2.14. When the implementation of any action or action plan decided by the facility is

confirmed as completed by the Complaints Committee or the assigned

responsible Senior Manager at the facility the case will be considered closed and

must be documented both on the Complaint Log and Complaint Action Form.

9.2.15. In case that complaint is withdrawn by the complainant, a Complaint Withdrawal

Form must be filled up, signed and sent back to the Patient Relation Officer.

9.2.16. All records about complaint must be filed and kept for five years by the Patient

Relation Officer arranged by case number for future references.

9.3. Appendices.

9.3.1. Complaint Process Flow Chart.

9.3.2. Complaint Form.

9.3.3. Patient Complaints Log.

9.3.4. Complaint Resolution Satisfaction Survey.

9.3.5. Complaint Withdrawal Form.



10. Incident Reporting Policy.

10.1. Policy.

10.1.1. The Organization defines the following terms:

10.1.1.1. Adverse Event- an event that causes harm, or has potential to cause harm

to a patient. For the purposes of this Policy, an adverse event includes

sentinel events and near misses defined below.

10.1.1.1.1. Near Miss- circumstances or events that had the capacity to

cause an adverse event, but which did not reach the patient.

10.1.1.1.2. Sentinel Event- any unanticipated adverse event or „Near Miss‟

event in a healthcare setting resulting in death or serious physical

or psychological injury to a patient or patients, not arising from the

natural course of the patient's illness, including:

10.1.1.1.2.1. A patient fall that results in death or major permanent

loss of function as a direct result of the injuries sustained

in the fall.

10.1.1.1.2.2. Any intra-partum (related to the birth process) maternal

death.

10.1.1.1.2.3. Any peri-natal death unrelated to a congenital condition

in an infant having a birth weight greater than 2,000

grams.

10.1.1.1.2.4. Discharge of an infant to the wrong family e. Hemolytic

transfusion reaction involving administration of blood or

blood products having major blood group

incompatibilities.

10.1.1.1.2.5. Prolonged fluoroscopy with cumulative dose >1500 rads

to a single field or any delivery of radiotherapy to the

wrong body region or >25% above the planned

radiotherapy dose.

10.1.1.1.2.6. Severe neonatal hyperbilirubinemia (bilirubin >30

milligrams/deciliter).

10.1.1.1.2.7. Suicide of any patient or within 72 hours of inpatient

discharge.

10.1.1.1.2.8. Surgery on the wrong patient or wrong body part (all

events of surgery on the wrong patient or wrong body

part are reviewable under the policy, regardless of the

magnitude of the procedure or the outcome.)

DOCUMENT TITLE: INCIDENT REPORTING POLICY


VERSION: 2.0




10.1.1.1.2.9. Unanticipated death of a full-term infant.

10.1.1.1.2.10. Unintended retention of a foreign object in a patient

after surgery or other procedure.

10.1.1.1.2.11. Rape or physical assault of a patient.

10.1.2. It is the responsibility of all personnel to immediately report the details of any

adverse event that may negatively impacts the care of the person served.

10.1.3. The OVR form will be initiated immediately following any near miss and sentinel

events.

10.1.4. All sections of the OVR form must be completed and submitted to the Head of

the department within 24 hours from the time of incident.

10.1.5. This report is to be used to identify the facts surrounding the incident and will not

be used to criticize or speculate on actions of the personnel involved.

10.1.6. Corrective actions shall be taken to minimize risk of adverse outcomes.

Corrective action(s) shall be documented.

10.1.7. The OVR Form shall not be photocopied or placed in the medical record. The

terms “incident” and “error” shall not be used in the medical record when making

an entry regarding an incident or the results of an incident.

10.1.8. It is the responsibility of Quality Improvement and Patient Safety Officer to

provide the Director for Quality and Compliance with a quarterly summary of

person served incidents.

10.1.9. All OVR shall be handled and maintained in a confidential manner, with access

to such documentation restricted to authorized individuals.

10.1.10. The information contained in the OVR form cannot and shall not be used

against any individual as the sole basis for disciplinary action.

10.1.11. The process of reporting incident must be in place with clear communication

process within the Organization.

10.1.12. All adverse event report shall be investigated to determine the root cause and

must be analyze to determine trends and create action plan for improvement.

10.1.13. Feedback must be provided to the person served following investigation and

creation of action plan addressing the incident happened.

10.1.14. The Organization shall use this process as a tool for learning and improving its

health service delivery towards quality improvement and person served safety

goal.

10.1.15. Adverse events related to Occupational and Environmental Health and Safety

EHSMS) and Medications are excluded from the scope of this policy, but must

be reported in accordance with the requirements of the HAAD OSHAD

standards and the HAAD policies on Reporting Medication Errors and

Reporting Adverse Reaction, respectively.

10.2. Procedures.

10.2.1. Internal Reporting for Near Miss not Resulting to Sentinel Event.

10.2.1.1. Fill up appropriate spaces of the OVR form using blue or black ink. Do not

use pencil.



10.2.1.2. Write in clear, legible hand-writing objectively avoiding personal opinions.

10.2.1.3. Place the person served MRN and records the diagnosis.

10.2.1.4. Record time of occurrence using 24 hours timing, enter approximate time, if

possible.

10.2.1.5. Narrate briefly but objectively the statement of facts without including

personal judgment, or opinions and accusations to any individual involved

in the event. If a physician was notified or actually attended the patient,

he/she should write a brief statement in the space provided for-Physician

Follow-Up with regard to the injured person; and to sign on the space

provided.

10.2.1.6. Let the witness to fill up the spaces provided for him/her and to sign on the

OVR under-Witness.

10.2.1.7. Forward the filled up OVR to the immediate supervisor within 24 hours, who

will forward it to the Department Head for investigation.

10.2.1.8. Initial report with an action plan has to be submitted by the Department

Head to the Quality and Patient Safety Officer within 7 days.

10.2.1.9. Report and Action Plan Acceptable:

10.2.1.9.1. Quality and Patient Safety Officer will keep a copy on its

database.

10.2.1.9.2. The Organization Decision will be communicated to the person

served or family/support system through the Patient Relation

Officer.

10.2.1.10. Report and Action Plan Unacceptable:

10.2.1.10.1. Quality and Patient Safety Officer returns the report to the

Department Head for revision and must then, is resubmit back.

10.2.2. Internal Reporting for Near Miss Resulting to Sentinel Event.

10.2.2.1. Follow procedures 10.2.1.7.

10.2.2.2. Investigation shall be done together with the Quality and Patient Safety

Officer.

10.2.2.3. Initial report with an action plan has to be submitted by the team within 2

days to Director for Quality and Compliance with a copy to Medical Director.

10.2.2.4. Report and Action Plan Acceptable:

10.2.2.4.1. Director for Quality and Compliance and the Medical Director

submits the report to HAAD.

10.2.2.5. Report and Action Plan Unacceptable:

10.2.2.5.1. Quality and Patient Safety Officer returns the report to the

investigating team for revision and must then, is resubmit back

within 24 hours.

10.2.3. External Reporting to HAAD.

10.2.3.1. The Quality Improvement and Patient Safety Officer for sentinel events

defined in this Policy, report occurrence of a sentinel event to HAAD within

48 hours through HAAD complaint system.



10.2.3.2. The Director for Quality and Compliance and Medical Director submit an

initial investigation report of the event within seven days of its occurrence to

HAAD with details of the investigation and actions taken including

minimizing risk of recurrence.

10.2.3.3. Submit a full report to HAAD with details of the investigation, root-cause

analysis and action plan to minimize risk of recurrence (within 45 working

days).

10.3. Appendix.

10.3.1. Occurrence Variance and Incident Report Form

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