Quality improvement plan

Purpose
To have all quality improvement activities under a standardize umbrella and structure described by the total quality management system (TQM).

Plan
Suez HIO Hospital plan is to implement TQM using quality methodology PDCA

Responsibility
Quality improvement committee

Reference
ISQUA accredited national accreditation standards for hospitals, JACO standards Quality improvement and patient safety cluster.

Our mission Provide excellent and safe medical service which is characterized by high quality and acceptable cost, with commitment toward development, continuous improvement, and best utility of available resources through qualified and competent healthcare givers and modern technological tools and equipment . Our values
Excellence: as a health care provider we committed to conduct patient care with the highest standards of ethics, developing a mutual trust with each other, customers, shareholders, suppliers and the community. Innovation: we embrace change, creativity, continuous learning and personal growth. We incorporate new ideas, technology and methods to improve the health care and services we provide.. Compassion: to serve, with dignity and respect, those who come to us Teamwork: we work as a team to achieve the strategic goals of the organization. Each staff member's contribution to creating a flexible, trusting, caring and supportive team environment is valued. We build constructive relationships to achieve positive outcomes for all... Respect: we respect and respond to all individuals with honesty and integrity. Quality: focusing on patients satisfaction and cost reduction. Continuous improvement: through measuring our performance by, comparing ourselves to other equivalent hospitals and to our own progress over time .

the nine criteria developed by the quality committee members for selecting a project: 1. Chronic 2. Significance 3. Size 4. Impact 5. Urgency 6. Low risk 7. Low resistance 8. Being a sure winner 9. measurable

Performance improvement
It is the science of managing processes. Creates a positive atmosphere within which to measure, study and improve health care processes and helps to eliminate inappropriate variation.

Performance improvement monitoring quality indicators

Performance improvement monitoring involves observing, measuring, and recording the way activities are being implemented. . Monitoring should be: 1. 2. 3. 4. 5. Planned, systematic and ongoing. Comprehensive Use indicators accepted to the staff and the hospital. Result in appropriate action Compare periodically with pre-set. Goals or standards

Performance improvement methodology

All performance improvement attempts are learning experiences. The PDCA process is a cycle that enables systematic improvement to be continuously built upon. This assists in meeting the ever changing needs and expectations of our patients and employees

Focus, Plan, Do, check, Act (PDCA)

The following explains briefly how this approach works.

F = find an opportunity for improvement.

Select the process of interest Define preliminary process boundaries Decide if the selected process is the best one to improve.

O = organize a team
Identify the team leader/ process owner. Assign a facilitator/ coach who will guide the team. Select team members from appropriate levels of the organization.

C = clarify the current process

Flow chart the process. Make simple improvements to define the current best process. Identify suppliers and customers.

U = understand the sources of the problem and the process variation

Investigate special causes and seek to stabilize the process.

S = select the improvement (a change)

Identify improvement alternatives that will contribute the most to improving the process. Reduce common cause variation. the improvement

P = plan

Plan how the improvement identified in the "s" phase can be made. An action plan is used to describe proposed improvement efforts. the improvement

D = do

Implement the plan. Describe what was used to implement the plan. Collect data. the results (is the change an improvement?)

C = check

Analyze data to evaluate the improvement. Compare data with process capability and baseline data. to hold the gain

A = act

What steps will be taken next? The PDCA cycle can repeat again and again, attempting to refine the improvement with each pass.

Objectives
1. Educate the leaders and selected staff members on quality management concepts. 2. Implement the quality and risk management activities. 3. Communicate the results of all organizational improvement efforts to all staff. 4. Standardize reporting methods to assist with analysis of performance data 5. Increase data based decision-making. 6. Use team methods to improve care related processes. 7. Use performance improvement methods as a strategy to manage cost

Steps
1. Establishment of quality improvement ,patient safety & risk management committee 2. Define A consistent methodology for performance improvement. 3. developing Systems for measuring performance improvement
a. Outcome tracking measure. They can be clinical or management. b. Internal and external benchmarking. These are ways to identify best practices, compare our selves to other similar centers and measure our own performance over time.

4. Teaching programs for employees at all levels which may include the following contents:
A performance improvement methodology (focus-pdca) Communication skills Supportive management Team effectiveness & conflict management Data management in pi Leadership and management Setting and communicating standards Customer service. Managing change. Accreditation and surveying.

5. The training of skilled team facilitators. 6. Employee evaluation and reward systems that encourage performance improvement. 4

 Quality improvement, patient safety & risk management committee is a multidisciplinary membership includes members of the medical and nursing staff, other department representatives, and the performance improvement coordinator. It was established by decree No. Conduct monthly meetings

 Quality improvement, patient safety & risk management committee Adopts and approve in the following definitions.

Quality
Is the process through which we measure actual performance, compare it with standards, and act on deference to meet client's needs and expectations in a safe environment?

Accreditation:
A process in which an entity, separate from the hospital assess the hospital to determine if it meet a set of standards.

Performance improvement:
Performance refers to outcome results obtained form processes, and services that permit evaluation and comparison relative to goals, past results or other organizations. Performance improvement: measures are based on functions, processes, and outcomes. These measurements provide a statistical basis for monitoring performance improvement".

Outcome indicator:
Measure patient outcomes such as: Mortality rate. Infection rate. Customers' satisfaction.

Process indicators:
Measure the system in place for doing certain things such as: Waiting time Length of stay Turn around times Medication errors.

Sentinel event indicators:

Are the events which require an immediate response from the hospital with root cause analysis and recommendations to prevent future occurrences.

Dimensions of performance improvement

The degrees to which the care and services provide are relevant to the patient's clinical needs, given the current state of knowledge.

Continuity of care
The coordination of needed healthcare services for a patient or specified population among all practitioners and across all involved or organizations over time. Safety The degree to which the risk of an intervention and risk in the care environment are reduced for patient and others includes healthcare providers.

Timeliness
The degree to which needed care and services are provided to the patient at the most beneficial or necessary time.

Effectiveness
The degree to which a desired outcome is reached, the positive results of care delivery.

Efficiency
The relationship between outcomes and resources used to deliver patient care and services.

Quality improvement, patient safety & risk management committee has the Following roles and responsibilities ; TOR
1. Ensuring that all departments participate. 2. Establishing organization wide priorities for improvement 3. Ensuring that all required measurements are done including the frequency of data collection. 4. Reviewing the analysis of aggregate data. 5. Taking action in response to identified performance Improvement or patient safety Issues. 6. Reporting information both to leaders and to staff members.

 Quality improvement Coordinator Name: Qualification:

Bachelor degree in medicine TQM Diploma Experience & Training

The performance improvement coordinator is a member of all relevant committees.

1. IC Committee. 2. MR committee. 3. Therapeutic committee. 4. Morbidity & mortality committee. 5. ES committee. 6. Ethics committee.

The performance improvement coordinator has a written job description

Quality improvement plan is divided into five main tasks

Main Tasks ( with monthly reporting frequency ) I.

II. Clinical care monitoring Managerial monitoring

III. Incident-reporting system IV. Quality improvement plan V. Risk management program

II. First Task: VI.

Clinical care monitoring includes the following :

2. Waiting times are monitored. 3. Patient assessment is monitored. 4. Surgical and invasive procedures are monitored. 5. Use of anesthesia and moderate and deep sedation is monitored. 6. Use of medications is monitored. 7. Use of blood and blood products is monitored. 8. Medical records, including availability and content are monitored. 9. Infection control, surveillance and reporting are monitored. 10. Medication errors and adverse outcomes are monitored. 11. Use of restraints and seclusion is monitored.

Tools to be used
Monitoring tools. Clinical indicator manual. Data analysis sheet. Reporting system

II.

Second Task
Managerial monitoring includes the following :

1. Compliance with law and regulations is monitored. 2. Patient and family expectations and satisfaction is monitored. 3. Patient complaints are monitored. 4. Staff expectations and satisfaction is monitored. 5. Patient demographics, diagnoses and procedures are monitored. 6. Procurement of routinely required supplies and medications essential to meet patient needs is monitored. 7. Financial management is monitored. 8. Risk management is monitored. 9. Staff and professional performance is monitored. 10. Utilization management is monitored. 11. Cost effectiveness of clinical care is monitored.

Tools to be used
. Well established information system. Monitoring tools Data analysis sheet. Reporting system

III.

Third Task :
Incident-reporting system
1. Incidence reporting policy 2. List of reportable incidents and near misses 3. Persons responsible for initiating reports 4. How, when, and by whom incidents are investigated 5. Corrective action plan and assigned responsibilities 10

IV.

Forth Task
Risk management program
1. Definition of the scope of the programs oversight 2. Responsible persons 3. reporting system & investigation process

4. Significant events to be analyzed

Patient elopement is analyzed. Patient suicide, attempted suicide and violence are analyzed. Unexpected morbidity and mortality including those due to organization acquired infections are analyzed. Confirmed transfusion reactions are analyzed. Significant anesthesia and sedation events that cause harm to a patient are analyzed. Significant differences between pre- and post-operative diagnoses, including surgical pathology findings are analyzed. Significant adverse drug reactions that cause harm to a patient are analyzed. Significant medication errors that cause harm to a patient are analyzed.

Tools to be used
Monitoring tools Rout cause analysis . Reporting system.

Quality management structure representation the flow of information and functional structures that support performance improvement at Suez HIO Hospital This is not an organizational structure but depicts how information flows between the quality improvement committee, hospital's directors, quality improvement teams, and the quality improvement division.

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