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King Khalid University Hospital
and King Abdul-Aziz University Hospital
QUALITY MANAGEMENT
PROGRAM
2009-2010
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King Khalid University Hospital
and King Abdul-Aziz University Hospital
Dr. Farheen Shaikh Prepared by: _____________________________ Date : ______________ Director of Quality Management
Department-University Hospitals
Dr. Ayman Abdo Authorization by: _____________________________ Date: _____________
Vice Dean for Quality & Development
Prof. Mussaad Al Salman
Approved by: _____________________________ Date : _____________ Dean of College
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Quality Management Program
Introduction
Goal & Objectives
Components
Scope of implementation
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Introduction
The QMP is in line with vision, mission, and values of KKUH & KAUH . It is
developed by the Quality Management Department (QMD) in collaboration
with KKUH & KAUH Executive Management and approved by the Chief
Executive Director (CEO) at the level of the quality council
QM Program has been developed to continually and systematically plans ,
measures and improves performance of hospital wide key functions and
processes.
QM Program for improvement is based on Canadian as well as CBAHI
Standards and Guidelines. The Program defines the responsibilities for
monitoring every aspect of quality and risk management.
Quality Management Program defines:
- Top management, key leaders’ and all staff role and responsibility in practicing
and promoting QM Philosophy in the facility.
- Quality definitions and statements of all terminologies and quality processes
that being done within the facility.
- Detailed information of QMP components and scope of implementation.
- Different levels of performance monitoring.
- Reporting quality improvement activities.
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Goal & Objectives of QM Program
In keeping with KKUH & KAUH mission, this program allows a systematic,
coordinated and continuous approach to improve quality in the facility.
Objectives
To incorporate quality planning throughout the facility
To provide a systematic mechanism for the facility’s individuals,
departments and professions to function collaboratively in their efforts
toward performance improvement
To ensure that the improvement processes are organization wide.
To report and communicate information to the Hospital Board, managers
and staff that is needed to fulfill their requirements as well as their
responsibilities for the quality of services, patient care and safety.
To contribute to cost containment efforts by assisting in developing
effective utilization programs.
To collaborate with Hospital Strategic Plan, Hospital Wide Risk
Management, Patient Safety Program.
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QM Program: Scope of implementation
QM Program requires quality in all aspect of the facility’s operations, starting
from developing a foundation /framework for quality structure, going to
processes being done right the first time and every time and ending with regular
monitoring to evaluate improvement and sustainability.
The scope of TQM Program includes:
1- Quality Management ( structural framework)
2- Continuous Quality Improvement ( CQI)
3- Quality Monitoring & Evaluation
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QM Program Implementation responsibility
Top Management (Quality Council)
With active participation, approval and support to QM Program, Top
Management also has an essential role of providing QM the visible support and
initiatives for all CQI activities.
Part of Top Management responsibilities toward successful implementation of
QM Program is regular review of all the reports related to quality submitted to
them at the level of Hospital Board
The reports that needed to be submitted to the Hospital Board for review and
critics are;
Progress on Accreditation process
Hospital teams performance
M&M Reviews
Sentinel Events
Risk Management
Key Services of the Departments
Patient and Staff Satisfaction
Quality Improvement Projects & Audits
KPIs and OCIs
Hospital Surveys for Standards Compliance
Efforts for Promoting Quality and safety Culture
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Directors / Head of Departments
All the efforts and work of QM Department wouldn’t be accomplished without
full cooperation of the departments: Clinical, Administrative and Nursing
The success of QMP implementation is nothing but the degree and the extent of
QM practices by the departments/ teams and individuals in the organization.
Director/ Head of Department should go through the activities in Departmental
QM plan and review it for specific requirements to apply quality principles in
their department.
Directors of the departments are required to do the following:
1. conduct monthly departmental management team meetings
2. The agenda should include items related opportunities for improvement
3. Report department performance by regular submission of departmental
monthly performance reports
4. Monitor department performance by using indicators
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Hospital Teams Leaders/chairpersons
The responsibilities of the leaders of the teams in KKUH & KAUH to do the
following:
To conduct meetings once per month
To function within the scope developed for each team
To ensure that all team members understand their roles and
responsibilities
To monitor the function of the team by evaluating team performance
using key process and outcome indicators.
To report quarterly for the progress and achievement of the team.
To conduct
i. Audits
ii. Quality Improvement Projects
.
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All the Staff of KKUH & KAUH
The front line and the processes owners of the organization the “STAFF” ,
have big responsibility in making QM Program capable for implementation ,
their understanding, practicing QM activities makes the positive change .
Therefore, it is very important to involve the processes owner in all quality
improvement activities as they can be the best who can identify the gaps,
problems and suggest the improvement.
Also QM Department will ensure that all the staff will have a chance to
participate in by becoming a member in hospital teams and get opportunities to
be trained for QM issues
QM Department
QM Department has a huge responsibility in implementing and facilitating
implementation of QM Program.
QM Department is fully responsible for successful implementation of QM
Program with its scope and elements by establishing the framework of quality
management going through continuous quality improvement activities and
ending by regular monitoring, trending and evaluation.
Good communication, reporting and liaison with departments/ teams as well as
with staff are the key for QM Program launching.
The responsibilities of QM Department for implementing QM Program are:
Integration of QM Program with QM Department Strategic Plan
Development of QM Operational Plan (TOP)
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Development of QM Training and Education Program which includes
the basics, principles and tools of Continuous Quality Improvement
(CQI)
Facilitating, selection and conduction of Quality Improvement Projects
at different departments/ teams level
Periodical and regular reinforcement for data collection and reviews
Maintaining data entries and efficient utilization of information
Regular trending and monitoring
Timely reporting and feedback
Celebrating success and maintaining sustainability through monitoring.
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A- Quality Management Program Structural Framework
Structural Framework
Documents:
1. Strategic Plan
2. Organizational Charts
3. Scope of Services
4. Job Description
5. Staffing plan
6. Staff Bylaws
7. Standards & Guidelines
8. Hospital Policy & Procedures
9. Hospital Manuals
10. Ethics & code of professional conduct
Quality Designees
a. Quality professionals
b. Quality Improvement Teams
c. QM Facilitators
d. Safety Officers
Processes
1- Q. Tools
2- Q. Techniques
3- QM Systems
3.1C.Q.I
3.2 Quality Education & Training
3.3 Accreditation
3.4 Follow up & Monitoring
3.5 Orientation
3.3
Documents
Quality Designees
Processes
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Quality Management: Structural framework
Introduction
QM Program seeks to integrate all organizational functions by distributing
roles and responsibilities along various lines of authorities and processes
owners, to make this possible, an organizational quality structure will be
develop to serves the following functions:
1. Producing organizational outputs and to achieve organizational quality
objectives.
2. Minimization or controlling the influence of individual variations on
organization functions and systems.
3. Facilitation decision making.
In order to develop QMP structure and foundation in our organization to
support and facilitate continuous quality improvement the following required:
1- Departmental and Hospital wide documents
2- Quality designees
3- Processes consist of tools, techniques and systems
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1- Documents
The following documents will be required to fulfill the requirements of QMP
structural framework; each document has been explained for its purpose and for the
lines of authorities and approval, each of these documents is respectively required at
QM Department level and /or hospital departments (clinical, administrative &
Nursing) and Hospital top management
1. Strategic Plan
2. Organizational Charts
3. Scope of Services
4. Job Description
5. Staffing plan
6. Staff Bylaws
7. Standards & Guidelines
8. Hospital Policy & Procedures
9. Hospital Manuals
10. Ethics & code of professional conduct
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Strategic Plan
Strategic plan is required to be developed at all levels , starting with Hospital Strategic
plan to be later use as a guideline and reference for all the department including QM
Department
Strategic plan will be developed for minimum of 3 years and has to be reviewed and
updated every year according to process and outcome indicators
The plan is guided by:
Organization vision and mission
SWOT analysis
Objectives and the key issues
Organizational Charts (OC’s)
In order to facilitate leadership directions, decision making, reporting and
liaison ship Organizational Charts have to developed at those levels: hospitals
and departments , also to enhance team work quality organizational chart will
be developed to show the quality committees
The chart exhibits the structure of the organization/ departments with position
(titles) and names of the Key Leaders.
It will the responsibility of top management to exhibit and finalized the
organization chart of the facility and to approve the authorized OCs of the
departments
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Scope of Service
Scope of service will be written for the hospital as well as for each
department. The scope of service is part of strategic plan and of each
Department Policy Manual. To make it public, scope of service is part of
hospital/ patient information booklet.
Scope of Service of the hospital includes the following:
Range of service: medical, surgical, preventive, and diagnostic
or as level of care: primary, secondary, tertiary or general and
specialized care.
The age group who receive care
Number of patient seen annually
Major diagnostic or therapeutic method used
Job Description (JD)
At King Saud University Hospitals, all categories of staff will have a clearly
written job description which will be reviewed at least every three (3) years
or as needed.
Leadership team will be responsible to develop and finalize JDs of top
management and each Director/ Chairman of the department will be
responsible to develop JD of each position in the department, QM
Department along with HR department will facilitate development of all these
JDs.
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Staffing Plan
To ensure customer satisfaction and for better healthcare outcomes, the
facility requires appropriate variety of skilled, qualified staff to fulfill its
mission, and this best accomplished by having hospital wide staffing plan.
Staffing plan has to be carried out at two levels, departmental and facility
wide.
Facility Staffing Plan
This plan should be written as a part of Human Resource Department
(HRD) policies and has to be developed in collaboration with clinical and
managerial leaders.
Departmental Staffing Plan
This is applicable to all departments; the staffing plan in here explains staff
coverage, schedule, weekend coverage, and transferring of responsibilities.
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Staff Bylaws
KKUH & KAUH leadership will be responsible to develop set of documents
that describe the medical, administrative as well as Nursing Bylaws, the
documents contain the following:
Organizational structure of the hospital with divisions and units and
reporting relationship
Job responsibilities of the top management
The membership categories (full time, part time, locum, visitor, etc.)
Promotion, appointment and re-appointment
Disciplinary process and corrective actions and appeals
Credentialing and privilege processes
Standards and Guidelines
Canadian standards and guidelines have been chosen to provide the
framework for the facility by its leaders with a commitment to provide
quality in patient care, safety and the services.
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Hospital Policy and Procedures
Internal Policy &Procedure is a written document which outlines the rules,
regulation and expected performance of staff within the organization.
For that, the facility as well as each department/ division/ unit are subject for
having clearly written IPPs.
The IPPs should be:
Consistent with organization mission
Able to guide performing and decision making
Capable for implementation
Written for owned processes with defined responsibilities
Recorded in Departmental IPPs
Signed, dated and subject for review
Development of IPPs is a responsibility of each Director/ Head of
Department (or for whom he/ she will delegate).
All IPPs developed in consistence with AC and/or other applicable standards
could be adopted as needed.
All IPPs will be written on a specific format and must be authorized and
approved
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Hospital Wide Manuals
Hospital Wide Policy & Procedure Manual
Hospital Safety plan
Disaster Management Plan
Leadership manual
Hospital Wide Policy & Procedure Manual
The manual will be applicable organizational wide, designed to be flexible so it
can be implemented as the policy states or to be as a guideline or reference for
developing specific IPPs.
The manual will include only those HPPS which will be developed by different
disciplines but involve significant organizational wide issues, mandatory rules
by the hospital or local authorities and/ or requirement for QMP /Risk
Management Program.
The manual will be divided in following sections according to the area of
issues:
Clinical HWPP
Quality HWPP
Administrative HWPP
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Hospital Safety Manual
Hospital Fire & Safety Department with coordination with Fire & Safety
team has to develop this manual in consistence with Canadian, CBAHI
Standard, Local Body’s policies and other International rules and regulations
as required.
The purpose of the program is to ensure that:
The facility, occupants and environment is safe from fire and smoke
No smoking policy implementation
Hazardous Material and Waste Management System is intact
Medical Equipment are maintained
Evacuation Plan in place
Major Disaster Management Plan
The Major Disaster Management team must this plan so the facility as well as
the staff will be able to respond to possible community emergencies,
epidemics, natural or internal disaster.
The plan should be tested and reviewed annually and as necessary, and staff
must be trained and oriented by conducting at least one drill annually.
Leadership Manual Administrative: Leadership responsibilities, Standards of patient services,
culture of safety and quality, leadership support to quality improvement ,
administrative on call, budget process, confidentiality of information,
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community need assessment , IM Plan, release of information to media Dress
Code, inappropriate behavior
Ethics: research, end of life issues, sexual harassment t, conflict of interest
Medical Staff Bylaws: 18 articles : hiring, appointment evaluation of medical
staff, clinical privileges, promotion, meetings, CME, leave coverage
- Patient Safety plan
Clinical Risk Management is an approach to improve Patient safety in
healthcare by emphasizing on identifying the circumstances which put
patients at risk of harm, and then acting to prevent or control these risks.
Patient safety plan will be developed to help the organization to implement,
assess and to improve patient safety activities through defined safety
indicators.
The plan works as resource to assist in development and improvement of
patient safety issues. The plan is an attempt to identify and define critical
elements, activities, ROPs , principles and functions of an effective patient
safety environment..
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Ethics and Code of Professional Conduct
Code of Professional Conduct is a document that describes the standards
by which staff may determine the propriety of his/ her conduct in relation
to patient, colleagues, and members of organization and with public.
Code of conduct provides guidance to ensure that all hospital activities,
functions and services are conducted in legal manner.
Code of conduct must be developed in accordance with Islamic, Medical
,Country cultural values.
The document will be prepared by Ethics team/committee and should
explains in detail the policy and procedure to implement and monitor code
of conduct and how to the deal with ethical issues as related to staff and
patient care.
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2- Quality Designee
To fulfill the requirements of QM structural framework that is needed to establish QM
Program in the facility, following staff, teams and personnel should be assigned in
each facility according to facility complexity and services provided.
1. Quality Professionals
2. Quality Facilitators
3. Safety officers
4. Hospital Teams
Q Professionals
To ensure implementation of QM Program at all levels of the
organization, each facility King Saud University Hospitals will have QM
professionals, who report to Voice Dean of Quality Affairs , and are
responsible for development, implementation , improvement and
continuous monitoring for QM activities.
QM Professionals will be also representing in all hospital and
departments quality improvement teams
Q Facilitators
To fulfill the requirement of QM Program, at least two volunteers
(according to the size of the department and its complexity) will be
selected in every department to follow and implement QM Department
instructions and plans
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Those volunteers will be known as TQM Facilitator, and will be
assigned by QM Department staff and /or Director of the department
recommendation.
The facilitator will go through extensive QM Training and will be
consider as an extension of QM Department in his/her respective
department.
Patient Safety Officer
To ensure patient safety, a safety officer will be assigned to discuss,
report, identify, review, investigate and advise on safety issues related to
patients
The safety officer is a full time staff working at QM Department and or
a part time staff working as coordinator for safety such as in ICU,
Radiology, OR and at inpatient floors.
Patient safety officer should be a trained staff who can to carry out all the
responsibilities as related to audits, surveys and staff training for safety
issues.
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3- Process
TQM is a method by which management and employees are involved to bring positive
and continuous change in the facility, to fulfill these requirements of TQM following
processes and systems will be established and adopted in the facility.
1. QM Tools
2. QM Techniques
3. QM Systems
QM Systems
QM Department will be organized in a manner to facilitate systematic
approach to all the quality activities that will be carried out in the facility
to ensure quality control, continuous improvement and staff development.
It is a responsibility of QM Department to facilitate implementation of
those systems and have effective monitoring for their compliance.
The systems are:
1- Follow up and Monitoring
The system monitor and do follow up of all type of documents and
activities related to documentation process. The system also looks at
appropriateness of reporting and on time performance.
The system comprises the following:
1- Control of Documents and Documentation
2- Review and Amendments
3- Authorization and Approval
4- Environmental Control
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5- Standing Teams Meeting
6- Reporting Channels
7- Development of New Documents
2- Continuous Quality Improvement
The system is mainly concerned with continuous improvement in all
processes, from high level of strategic planning and decision making, to
detailed steps of work elements at every levels of care.
The system is based on using the quality improvement model, quality
tools and techniques by individuals or through team approach.
Quality Models, Tools and Techniques
Although that there are various models adopted by different organizations for
implementing QM to fulfill the requirement of accreditation considering the
continuous change and the culture.
QM Department will be adopting the model of improvement that is FOCUS
PDCA.
The model is simple and easy to implement and should be repeatedly
implemented in upward spiral that moves toward the ultimate goal of CQI.
While implementing the improvement model, different quality tools will be
used for issues/ problems identification, prioritization, solving, decision
making and implementation.
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The recommended Quality Tools to be used in the facility are:
1. Brainstorming
2. Fish Bone Analysis (Cause – Effect Diagram)
3. Pareto Chart
4. Histogram
5. Control Chart
6. Run Chart
7. Prioritization Matrix
8. Affinity Diagram
9. Failure Mode and Effect Analysis (FMEA)
10. Indicators
The team can also use the following techniques & methods:
Audit
Surveys ( Hospitals, customers)
Reviews
Development/ Identification of Indicators
Hospital Information System (HIS)
Patient Medical Record
The areas for implementation include and not limited to:
1-Performance Improvement
2-Quality Improvement
3-Risk Management
4-Utilization Management
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3- Quality Training & Education
The system demands plans & program for quality education and training
of the staff concern to the general requirements of the organization as
related to quality.
Education and Training as related to QM concepts and implementation is
very important for all the employees to be highly productive.
Key leaders and managers are responsible for implementing QM within
their areas and departments by coaching, educating and training their staff
on how to use and develop IPPs, guidelines, forms and other documents
and how to conduct continuous improvement activities.
Training of the employees required skills, knowledge, ability to observe
and absorb, the thinking of creativity and out of the box ideas.
4- Orientation
The system deals with putting plans for orientation both organizational wide
and at departmental level, it’s also deals with quality publications, news letters
and marketing for Quality management Department.
5- Accreditation
In recent years, accreditation bodies have changed their accreditation
policies and standards shifting from focusing on availability of documents
and compliance with the standards to incorporating of CQI approach in all
activities, by that, looking more and more to data collection, analysis,
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trending and improving the outcomes along with patient safety
applications.
Keeping this in mind, QM Department, with the approval of top
management and higher authorities will be calling for accreditation and to
maintain the certification by focusing on continuous quality improvement
activities such as more and more audits, quality improvement projects and
the outcome management.
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B- Continuous Quality Improvement (CQI)
One of the objectives of QM Program is to ensure that there is continuous
improvement applied organizational wide throughout all activities and
functions and manifested in a fundamental and shared belief in Quality
Management.
Everyone in the organization, from the directors, hospital administrators,
physicians, other professionals and employees must adopt the concept of
continuous quality improvement (CQI) principles and embrace the philosophy
and culture where quality is the key for every process.
The following section briefly indicates the specific activities and elements
needed for continuous improvement.
It is a responsibility of all directors/ team leaders to implement those activities
accordingly as and applicable to their scope of service.
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1- Quality Improvement Plans
These plans should be targeting specific areas for improvement. Project topics
are determined through the use of data collection and analysis and include both
clinical and non-clinical topics.
Plans are considered complete when a year of sustainable improvement has
been demonstrated.
Conducting these plans is a responsibility of team leader in the organization.
The plan should be based or criteria and all projects must be conducted using
PDCA model of improvement
2- Quality Reviews
As a part of overall quality improvement system, all staff as appropriate and as
directed by their team leaders or head of department should conduct the
following reviews and not limited to:
Case-Specific Review
Peer Review
Medical Record Review
Surgical and Procedure Case Review
Medication Usage
Blood and Blood Products Use
Morbidity & Mortality Reviews
Utilization Review
Code Blue Review
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Sentinel Events
Annual Performance Review
A review could be done retrospective and concurrent. Each review has its own
methodology and frequency as designed by TQM Department.
3- Audits
Quality Audit is an assessment to determine whether agreed requirements
are being met. It is associated with formal examinations, checking and
reviewing the performance against standards or criteria.
Audits should be initiated upon instructions from the team leader/ director
of specific area depending on certain criteria.
The audit like other quality improvement activities has to be authorized,
conducted by scientific methods, documented and reported with especial
consideration to professional conduct, ethics and liability issues. Audit can
be chosen for any organization functions and services.
4- Surveys
Surveys are considered as a powerful technique as well as tool to
determine the level of compliance or performance.
As part of continuous improvement, regular surveys should be conducted
to identify areas for improvement and to determine the sustainable areas.
As instructed by TQM/ MSD, all MHS has to conduct an internal survey
(self-assessment) every 2-3 years, and customer satisfaction survey (both
for patients as well as for staff) at least once per year.
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The results should be reviewed and reported to the top management to
review the findings and develop action plans and follow-up plan as well.
5- Promoting Quality and Patient Safety Culture
QM to be successful, quality and patient safety culture should be
embedded in the organization.
Every organization in the world has its own culture and characteristic, built
by their leaders and managers into the employees. QM culture to be built
up high and strong, continuous commitment from top management and
key leaders towards QM philosophy and principles is required.
There are methodologies and culture build up activities needed to be
practiced by the leaders and to be shared with the staff to make the culture
on-going. Such activities are not limited to:
Owning the Vision
Participative Leadership
Customer Focus
Value Added Processes
Process Owner Concept
Continuous TQM Training & Education
Rewarding (Quality Day)
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Patient safety culture will be spread through implementation of patient safety
standards and Required Organizational Practices (ROPSs)
6- Evidence – Based Quality Management (EBQM)
The aim of EBQM is to improve patient outcome and to improve work
processes and systems of care, and this could be possible by promoting the
collaboration between quality management and clinical research as well as
with health service research.
Quality Management also promotes Evidence – Based Practice (EBP)
where multiple disciplines are involved in providing patient health care,
which is possible through following guidelines:
Clinical Practice Guideline
Patient Care Protocol
Clinical Pathway
Care Management
Case Management
Peer Review
Case Specific Review
Disease Management
Demand Management
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7- Grand Rounds (Safety, QM, Clinical)
Safety Rounds
To promote safe environment in the facility, Environmental Health and
Safety Department should conduct regular rounds on monthly basis in the
whole facility, using specific checklist to look at:
Safety of the Building (Physical)
Collection, storage and disposal of waste
Safety of the Department
Hazardous Materials: handling, collection, storage,
labeling
Radioactive Waste Management
Sharp Collection
Chemical, Pathological and Pharmaceutical waste
OPD and ER Safety
Facility Walkthrough Safety Round
Patient Safety
The result of those rounds has to be discussed in the monthly meeting of
Hospital Safety Team. The data must be trended and close observation for
safety issue must be done with immediate reporting and pro-active actions.
QM Rounds
To promote QM Culture, better communication and develop close
relationship with the staff, the Director of QM along with Key /Top
Management will be doing regular rounds to the facility on monthly basis.
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During the rounds, staff will be asked for their perception and benefits from
QM and how QM Department can help and facilitate to improve the work
and their satisfaction.
Clinical Grand Rounds
This has to be conducted in every Clinical Departments. The round should
be at least once a month.
All the members of the department should be participating. The aim is to
promote high quality, integrated and collaborative healthcare to the patient.
The rounds’ findings should be documented and to be reviewed by the
Director of the Department for better outcome of patient care and to be
utilized as a guideline for further patient management.
Head of the department is responsible for assuring that clinical grand
rounds are done .
8- Utilization Management
To serve the purpose of cost-effective care provision, and by looking at the
dimensions of quality improvement, utilization management team had
developed different programs and plans for effective and efficient
utilization of:
Bed
Supplies
Equipments
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Space
Radiology Service Utilization
Laboratory Service Utilization
Medication
Human Resource
An ad-hoc team has to be developed to look at each area to ensure proper
utilization and recommend for better utilization.
9- Performance Appraisal
To ensure staff active involvement in quality improvement activities, the
new system of performance evaluation of the staff along with credentialing
(promotion) process has included the staff performance towards improving
the quality. The activities include:
Being leader of any Hospital Team
Being member of any Hospital Teams
Active presence and participation in teams’ activities
Incident Reporting
Morbidity Reporting
Completion of Medical Record
Appropriate patient discharging plan (LOS/ diagnosis)
Involvement in any Quality Improvement Projects
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C- Quality Monitoring and Evaluation
The main purpose of monitoring in QM is to evaluate the improvement and to
check the stability and sustainability of the improvement over time.
Monitoring helps reducing risk and error. It also facilitates in monitoring safe
environment for patient, staff and the facility. It is the responsibility of the
leader and directors to set priority on what they want to monitor and have
frequency on evaluating staff as well as the processes of care/ services and
outcomes.
On the other hand, facility Top Management needed to support the activity by
providing all necessary technologies and develop motivational strategies for
active staff involvement in the process.
QM Department will monitor all the activities with the help of the Directors of
Departments through submission of regular reports.
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Clinical Performance Monitoring
Along with Directors of Clinical and Paramedical Departments, QM
Department will also be in close monitoring of the following:
Laboratory Quality Control Program
Radiology Quality Control Program
Surgical Procedures
High Risk Procedures
High Risk and High Cost Medication
Invasive Procedures
High Risk Services
Utilization: Antibiotics, Blood and Blood Products
Morbidity and Mortality Review
Clinical Documentation
Infection Control
Clinical Guidelines and Pathways
Length of Stay
Sentinel Events
EMS Performance
Managerial Performance Monitoring
Completion of Medical Records
Major Disaster Management
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Fire Management
Utilization: Supplies, Equipments
Hospital Staffing Plan
Incidents related to safety
Patient Registration
PPM Program
Utility System
Monitoring Environmental and Patient Safety
Facility safety
Waste Management
Hazardous Material Management
Radiology Safety Program
Laboratory Safety Program
ER and OPD Safety
Monitoring Documentation
IPPs Compliance
Forms
Quality Records
Job Descriptions
Cross Functional Agreements
Departments and Teams Meetings
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Monitoring Key Services and Organizational Functions
Key Services of the facility
Cardiac Science Service
Clinical Laboratory Services
Diagnostic Radiology Services
Pharmaceutical Services
Oncology Services
Emergency Services
Nuclear Medicine
Nursing Services
Nutritional Care
Social Services and Discharge Policy
Rehabilitation Services
Organizational Functions include:
Patient/ Family Rights
Code of Professional Conduct
Patient/ Family Education
Leadership Performance
Human Resource
Staff Credentialing
Reporting
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Patient/ Family and Staff Satisfaction and rights
Staff Performance (Staff Responsibilities)
Staff Development Activities
Orientation Program
Reporting QM Activities
For QM Program to be implemented successfully, reporting of all QM/ CQI
related activities is very essential. Reporting is required at following levels:
Departmental Reporting
Teams Reporting
Staff Reporting
QM Department Reporting
All Departments/ Teams/ Individuals in King Saud University Hospitals are
subject to report to QM Department.
Departmental Reporting
Department Meeting Minutes
Departmental Monthly Performance Reports
Morbidity & Mortality Reviews(clinical)
documentation:
PPGs
Job Description
Forms
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Quality Improvement Activities
Opportunities for improvement
Compliance to CBAHI/Canadian Standards
Staff Orientation
Customers Satisfaction
Teams Reporting
All Hospital Teams are subject to report to TQM Department except Quality
Council
The teams are required to meet at least once a month and report to QM
Department through minutes of the meetings attached with meeting agenda and
attendance of the members with their signature.
Teams are also required to submit quarterly reports on their progress and
achievements to QM Department. The report should be based on Key Process
Indicators (KPIs) and Key Outcome Indicators (KOIs).
Staff Reporting
Department Directors/ Head and Area Administrators must encourage staff to
report:
Incidents
Morbidities ( clinical departments)
The reporting can be direct or indirect (through head of the department) to QM
Department.
QM Department also welcomes any suggestions or out of box ideas for
improvement by any staff steps in QM Department.
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QM Department Reporting
QM Department on receiving all the previous reports from departments, teams
and individuals will review them, aggregate the data and develop reports of
performance.
Feedback Reports will be submitted on quarterly and annual basis to top
management and for respective departments and teams for review, action plan
and follow-up