Comprehensive quality management programs and certification courses designed to enhance quality improvement skills, patient safety protocols, and professional development. Our programs cover quality excellence, risk management, strategic planning, and specialized quality training.
2025 - 2028
In line with the mission, vision, values of Organization, strategic plan and to ensure the provision of high-quality care to our patients and their families, the Organization-wide Quality Improvement, Patient Safety and Risk Management Program is developed. This program describe the quality improvement, patient safety and risk management activities for the coming three (3) year period and improve the effectiveness, safety, and efficiency of care, and prevent risk while respecting the dignity of those we serve.
Creating a strong organizational focus on continual learning and improvement requires actively engaged leadership and staff at all levels of the organization. Senior Leadership demonstrate their support for Quality and Safety by setting the direction, providing resources, and empowering staff. Creating a shared vision and building an environment that fosters innovation and builds excellence is essential in the continuous quality improvement and patient safety journey.
The Quality Improvement, Patient Safety and Risk Management Program uses a structured framework and guide that will be followed and implemented. It aims to achieve the mission, vision and strategic plan of Organization through a detailed set of goals and objectives within a defined operational plan. The intent is to build a reliable health care delivery system by implementing current national and international practices in quality improvement, patient safety and risk management.
The program is designed to reduce medical errors, improve effectiveness, efficiency, timeliness, patient-driven, and mitigate/reduce hazardous conditions by utilizing evidence-based, systematic, coordinated and continuous approach to improve patient safety. This approach centers on the establishment of mechanisms that support effective responses to actual occurrences and hazardous conditions; ongoing proactive reductions in medical/health care errors; and integration of patient safety/risk management priorities in the improvement of all relevant organizational processes, functions and services using the standardized approved methodology mentioned in this program.
The aim of the program is to create an environment, which embraces continuous learning and sharing. By building partnerships and promoting teamwork, employees at all levels of the organization will be encouraged and empowered to participate in the improvement of care delivery systems and patient safety/ risk management activities throughout the Organization. Establishing a defined structure, roles and responsibilities, and providing adequate education and awareness will enhance accountability and transparent communication.
The Quality Improvement, Patient Safety and Risk Management Program is developed in alignment with the approved Organization Strategy, with more emphasis and involvement in the Patient Care Excellence Theme (Appendix A) and is reflected in the Strategic Objectives and KPIs such as the Quality Composite Index and Patient Safety Always Events Index (Appendix B).
While the Governing Body carries the ultimate responsibility for ensuring the quality and safety of care provided to our patients, the Quality and Patient Safety Council is delegated the oversight and responsibility for the effective execution of the quality improvement, patient safety and risk management goals and initiative.
Organization will establish authority and information structure to monitor the progress of all Quality and Patient Safety program conducted at Organization. The structure includes committees (Appendix C) and teams that are essential to accomplish the work of the organization. These committees and team will have their membership and duties defined in their respective Committee Formation Order (CFO).
The Quality and Patient Safety Council provides the support and guidance for all Quality Improvement, Patient Safety and Risk initiatives conducted at Organization. As such, the Council is responsible for creating a shared vision, prioritize, select and approve quality improvement, patient safety and risk management operational plans, projects and activities based on performance reports using standardized processes and tools, support and monitor the progress of its initiatives by providing required resources and removing barriers. Moreover, the Council oversee the performance measurement for all departments and functions using consistent methods and tools. Standing committees reporting to the QPS Council shall provide an annual committee evaluation to the Council. The Council shall be responsible for review of Organization-wide performance reports and implement action plans as needed. The charges and the membership of the QPS Council is documented and approved in the QPS Council CFO.
The quality of patient outcomes and the safety of the environment of care require active participation of all disciplines working in a coordinated manner. The Organization Standing Committees that report to the QPS Council consist of clinical and non-clinical members who work closely with and have the best understanding of the processes involved. These multidisciplinary team where applicable, develops plans, collects and analyzes data, and provides expert assessments and recommendations for improving systems and processes related to its assigned charges. Each committee's membership and duties are defined in its respective CFOs. The committees will meet on a monthly basis or as per the CFO and reports are forwarded to the reporting authority. All Organization staff could access the approved committee through the assigned shared folder.
Successful execution of any quality improvement initiative depends on a genuine sense of shared responsibility. Department Directors and Managers demonstrate their support through active participation and involvement of department and division staff in performance and patient safety teams, as well as standing committees. Each Clinical and Non-Clinical Department Director/Chairman shall establish a committee within their department that will assist with, monitor, and assess the implementation of the QUALITY activities.
The membership and duties of the committee is defined in a CFO. The committee will meet on a monthly basis and submit reports through their respective Directors or Managers, to their respective Chiefs with copies to the Manager of QUALITY Department for record keeping and reports to the Quality and Patient Safety Council on a regular basis. The Quality and Patient Safety Council will act to remove obstacles and provide support for the implementation of the Quality Improvement, Patient Safety and Risk Management Program and Plans.
The QUALITY Department provides the structure within which all Quality Improvement, Patient Safety and Risk Management activities conducted at Organization. The QUALITY Department coordinates and facilitates all continuous improvement efforts while keeping ownership for the progress of the project within the respective teams and departments. The Quality Improvement, Patient Safety and Risk Management program and its operational plan are designed to provide more effective tools to assist the organization in implementing, monitoring, measuring, and improving Quality Improvement, Patient Safety and Risk Management. The development and implementation of these programs will occur within the department's establish structure.
The QUALITY Department is structured into three integrated Sections (Appendix D) Patient Safety and Risk Management, Accreditation Readiness and Policy Development, and Continuous Improvement. While each section will have direct responsibility for development and execution of the programs within its domain, activities of all sections will be implemented in a coordinated fashion.
The Manager of QUALITY will have oversight responsibility for ensuring all activities of the QUALITY Department are on target, and will work closely with each section to remove roadblocks and barriers. Each section will report its progress at the QUALITY Departmental staff meeting and the Manager of QUALITY will discuss action that requires support from the leadership in their regular meeting with the CEO.
The CEO will act on data and information to ensure full implementation of the organization's Quality, Patient Safety and Risk Management Program.
Building and sustaining safe care delivery systems requires the support of healthcare quality, patient safety and risk management professionals who understand the clinical arena and who are well educated and trained in current concepts of quality improvement, patient safety, risk management, data management, accreditation and standards implementation.
In order to effectively educate, mentor and coach the Organization staff in the development, implementation, and monitoring of Quality and Patient Safety initiatives, and to prepare the organization for the Accreditation process, the QUALITY Department must be staffed with qualified professional in quality improvement, patient safety, risk management, data management and accreditation process and standards.
Open transparent communication with staff, patients and families, and other stakeholders is vital. The QPS Council being the highest forum on Quality and Patient Safety, which is chaired by the CEO and co-chaired by the Chief Medical Officer (CMO), is ultimately responsible for timely communication of the changes, updates of the Organization Quality Improvement, Patient Safety and Risk Management Program and plans. The Quality Structure provides an integrated flow of information from the QPS Council through all teams and committees down to the various departments and frontline staff.
The Department Quality Improvement and Patient Safety Committees chaired by the Department Chairman/Directors are responsible to operationalize the priorities set by the QPS Council. The Department Committees will be responsible to communicate the strategies, priorities, policies, and any other important issues within its area(s) of responsibility. Communication can also occur at regularly scheduled departmental staff meetings where there will be a regular standing item related to Quality Improvement, Patient Safety, and Risk Management Activities related to the service or other forms of formal or informal communication used within the service.
The QUALITY Department will coordinate all Quality Improvement, Patient Safety, and Risk Management activities conducted throughout the Organization. The QUALITY Department will utilize multiple modes of communication, including General Staff Meeting, committee attendance, memos, posters, newsletters, reports, and within the units of the QUALITY Department.
The QPS Council is the highest forum on Quality Improvement, Patient Safety and Risk Management program and within Organization and is responsible for the annual evaluation of the programs and operational plans related to Quality Improvement, Patient Safety and Risk Management. The program is executed through annual operational plans that contain integrated goals, objectives, KPIs and targets. The Operational Plan shall be monitored through its performance measures defined within each initiative. The Goals of the Program will be evaluated through the established KPIs. The Plan will be adjusted for the subsequent year based on the performance of each KPI. The QUALITY Department provides the QPS Council with quarterly reports on the progress of the operational plans. The Council will re-evaluate the plans annually and make necessary recommendations. The feedback with its lessons learned from the process of annual evaluation of the operational plan will be considered for the three (3) years life cycle of reviewing and updating the program.
Quality improvement program provides structured framework, education and training on quality improvement concepts, tools, data and techniques, and other related subjects. To support that, coaching will be offered to staff and teams working on quality improvement activities, both clinical and non-clinical. Moreover, facilitating the development and the use of performance indicators, performance analysis, and reporting will provide a platform for performance monitoring and improvement initiatives.
Provided that, the Quality and Patient Safety (QPS) Council and the organization's leaders must identify Key Performance Measures which are assessed and reported on a regular basis. Performance measurement covers structures, processes, and outcomes for both clinical services and non-clinical departments. Selection of processes to be monitored will include but are not limited to services that are high risk, high volume, problem prone, and high cost areas. Selecting performance indicators (PIs) and analyzing the data and information on a regular basis allows actions to be taken as needed and identifies opportunities for performance improvement.
A performance indicator is a quantitative tool that provides concise information about the performance of a process, service, function, or outcome. Selection of performance indicators follows a systematic step-by-step process that is carried out as a team with the concerned stakeholders from all levels involved.
In general, performance indicators should be important and relevant to the Organization strategy and the department/function being measured (which is based on scope of work, high volume, high risk, and problem prone..etc), Also, data have to be feasible to collect and manage. Large number of indicators are prioritized using a simple selection matrix that considers the above criteria (Appendix E).
QUALITY Department also provides ongoing consultation and support for selection or modification of existing performance indicators.
Each and every selected indictor must have an operational definition to describe a clear definition, sample size, data collection method, frequency, analysis, and expression (e.g., a ratio, with defined numerator and denominator). Indicator template include the standardize calculations involved, and plan the collection of data for each indicator.
A thorough template referred to as "Indicator ID" that covers best-known practices for indicator definitions is used to document each indicator (Appendix F). This has to be done as an iterative process with feedback from all concerned personnel including the frontline staff and QUALITY department, until a final version is agreed upon.
Performance data will be regularly collected by each department as identified in the data collection plan, which is included in the Indicator ID.
Ensuring accurate and continuous data collection is the responsibility of each indicator owner. In addition, validation of sample of data is done by a second person following the policies and guidelines in Organization. The data will then be reported to the BI Office in collaboration with QUALITY Department and other individuals/groups as determined in the Indicator ID, using the standardized reporting form provided by the QUALITY Department.
External databases such as National Database of Nursing Quality Indicator (NDNQI) are accessed on regular basis to learn and compare the performance of Organization departments with other institutions and identify opportunities for improvement. Organization will maintain security and confidentiality when using the external databases.
Each individual department should do initial basic analysis; come up with preliminary interpretations and conclusions.
BI in collaboration with QUALITY Department will conduct more analysis and aggregate data to identify trends, patterns, variation, and potential areas for improvement. This is performed utilizing the technology and resources available.
Performance information of high priority Organization-wide indicators will be reported to the QPS Councils to identify areas for improvement and to plan for actions.
Validated performance information including data of performance indicators will be shared on regular basis with the QPS Council, relevant committees, departments, teams, and other stakeholders such as patient, community and other regulatory bodies, as applicable.
Periodic performance reports will be posted online to provide continuous and open access for all Organization staff.
Opportunities for quality improvement are identified by but not limited to; regular performance information, safety events reporting, patient safety and risk management activities, patient and family feedback, employee satisfaction surveys, tracer activities, learning management system, best practices based on evidence, and other sources of information. The aims of improvement activities should align with the IOM six (6) dimensions of improvement.
In case the identified quality improvement activities and projects exceeds the resources available for training, facilitation, coaching, monitoring, and support, initiatives and ideas can be prioritized using the QI Prioritization Matrix (Appendix G) which is a weighted-matrix tool that considers several criteria for selection leading to a less biased and more objective decision making. The criteria include:
The Model for Improvement developed by Associates in Process Improvement (API) and adopted by the Institute for Healthcare Improvement (IHI) is the main improvement framework adopted in Organization. Other methodologies can be introduced on individual basis after consulting with QUALITY Department. The Model for Improvement is a simple, yet powerful tool for accelerating improvement, and is based on the scientific method of improvement. The major steps of the IHI framework based on the model of improvement are:
Based on this model, a quality improvement path was created which incorporates best practices in project management, along with the required tools and templates such as the project charter, action plans, PDSA sheet, and progress reports.
To build and improve the capability of all Organization staff at all levels, starting with the executive management, open education and training activities are implemented on regular and ad-hoc basis related to performance measurement and improvement. The treatment modalities are formal and informal, and include presentations, online self-studies, workshops, immersion events, accessible guides and instructions on the Organization online portals.
The following are some of the regular education and training programs:
The education and training activities are delivered by QUALITY staff qualified and experienced in quality improvement tools and methodologies, with track records of training and coaching.
Performance information are shared with all Organization staff at different levels through different channels and means. Regular performance indicator data are reported to departmental leaders and the QUALITY according to the data reporting agreed and documented for each indicator.
The results of performance data analysis and aggregation are reported to the QPS Council on regular basis for discussion, action planning, and follow-up. Performance information reports are shared with all staff thru different means, which is updated regularly and is accessible by all Organization staff at any time.
Status of quality improvement projects are presented using the standard format to the Performance Improvement Project Executive Committee (PIPEC) on regular basis, and is also available for all staff to access.
The IHI-OS dashboard is generated and updated on monthly basis to show the rate of staff registration and progress through the courses during the subscription period.
Quality and Patient Safety related tools, templates, guides, and educational materials are uploaded in the Organization network such as Q Library folder for all staff to access and benefit from them at any time. These include a Q Dictionary that explains some of the common terms used in the field of quality and safety to unify the language used in Organization.
Outcomes of quality improvement projects will be shared with all staff through summary reports that are accessible on the shared folder, poster/storyboarding sessions that will be held at least annually to share achievements and interact with Organization staff.
Tracer methodology is an ongoing system for assessing and improving compliance to quality standards and best practices. The main aim of conducting tracers is to create a room for focused assessment and prioritization of areas and issues most relevant to quality of care and patient safety moving towards a data driven improvement rather than inspection focused approach. It involves following or "tracing" the treatment path an individual patient has taken in the healthcare delivery system and involves: a) Following a process from beginning to an endpoint. b).Identifying performance gaps. c) Identifying opportunities for improvement.
At Organization, Tracer activities are initiated, planned and organized by Accreditation Readiness and Policy Development Unit and the multidisciplinary team conducts the Tracer visits across the Organization under the supervision of Quality Improvement and Patient Safety Department that ensure the consistency and comprehensiveness of Tracer methodologies and activities.
E-Learning is an educational online system managed by Accreditation Readiness and Policy Development unit. The main aim of the system is to assess the awareness of Organization-wide policies and procedures, programs, plans and other regulatory documents required to perform his/ her duties. The content in the E-learning system is developed in collaboration with the business owner and the monthly dashboard is shared with the stakeholders.
In 1999, the IOM landmark report "To Err is Human" estimated that over 100,000 deaths due to medical errors occur in U.S. Organizations yearly. The annual cost associated with these preventable adverse events ranges from 17 to 29 billion US dollars of which half is incurred by healthcare institutions. Numerous studies looking at efforts to improve patient safety confirm that conventional solutions such as education, developing policies and procedures and dissemination of information alone are ineffective. Building sustainable patient safety program requires changing systems to make it difficult for a practitioner to commit errors or making it easy to detect an error before it reaches the patient. Successful strategies for implementing patient safety rely on creating a culture where staff feel comfortable identifying and communicating errors and systems failures without fear of punitive consequences. Creating a just culture requires organization leaders to carefully balance professional accountability with the recognition that poor systems design is associated with 80% of errors. A combination of mandatory and voluntary non-punitive reporting systems is key to early identification of events that can lead to harm. The following programs, when implemented in tandem, can assist leaders to create a culture of safety within the organization. The Patient Safety Program and the listed goals, objectives, and initiatives will be defined in its annual operational plan, which will be reviewed annually.
[Goals and objectives will be defined in the annual operational plan]
Patient Safety experts believe that an organization in which staff feel comfortable to openly discuss adverse events and near misses without fear, and take immediate corrective actions is an organization that reflects a culture of safety. Continuously monitoring the Culture of the Organization using a standardized tool will assists the Organization to plan strategies to overcome the gaps in culture.
Tool: The Agency for Healthcare Research and Quality (AHRQ) Organization Survey on Patient Safety Culture will be utilized to conduct our annual Safety Culture Survey.
Aim:
Table 2. Survey Composite Target:
Table 3. Sample Size Analysis: Analysis will consist of frequency percentage per question and Composite Score using the following table as suggested by AHRQ.
Table 4. AHRQ Analysis Scoring
Feedback: Feedback will be provided to all levels of the organization from the Board to the QPS Council and individual units that participated in the survey. In addition, the Organization profile will be shared though formal and informal communication channels such as committee meetings and newsletters.
Root Cause Analysis (RCA) Team: The team will consist of knowledge experts from each discipline involved in the event, as well as a QUALITY facilitator who is knowledgeable in conducting Root Cause Analysis.
Review: A credible RCA using Organization approved method, and resulting recommendations must be completed and forwarded to the CMO within ten (10) working days. The comprehensive systematic analysis identifies the causal and contributory factors. The resulting Action Plan includes strong corrective actions that eliminate or control system hazards or vulnerabilities and result in sustainable improvement over time. Each Corrective Action will be assigned to a Business owner with a target date for completion and a Measure of Success to track progress. The RCA is considered closed only after the implementation of Corrective Action have been monitored to completion.
Feedback: The findings of all RCA will be discussed in the Medical Executive Committee (MEC) meetings. The recommendations are evaluated and prioritized. The MEC will communicate the final outcome to the concerned departments for implementation of the Corrective Actions. QUALITY Department will monitor the progress of implementation of all recommended improvements, as well as maintain a database of all RCAs conducted at Organization and provide a quarterly summary report to the QPS Council. Lessons learned will be shared through formal and informal channels such as Grand Rounds, News Letters and Intranet postings. The CEO and Managerof QUALITY will send the final report to CBAHI and other relevant authorities within thirty (30) days of the notification of event. Patterns and trends in identified risks along with corrective actions will be tracked through the Risk Registry.
Patients and families have a fundamental right to voice concerns about the care they receive and conflicts arising during their Organization encounter, and to have the healthcare organization address and resolve these concerns in a timely manner. Organizations at the forefront of the Patient Experience Journey develop well-defined processes for receiving and reviewing of complaints, and communicating the outcomes of these reviews back to patients and/or families. The Patient Experience Specialists will orient all Organization employees, during the Organization General Orientation, about complaints management and resolution process to support the overall commitment of the organization towards implementing this policy. Any employee who receives a patient complaint and could not resolve by the concerned department, either verbally or in writing will refer the patient to the Patient Experience Specialist, who will primarily try to resolve the complaint upon receiving it. If unable to resolve it within the shift, the complaint will follow the process that adhere to the nature of the complaint. Patients will be informed by Organization staff that submitting a complaint will not compromise their care at the Organization and all the information will be handled with confidentiality. This Patient Complaints Management system will be managed by the Patient Experience Department and integrated into this Patient Safety Program.
Reporting Tool: All Patient complaints will be received and processed by the Patient Experience Department using the Patient Complaints and Suggestion Form (Appendix H).
Review: Patient Complaints are categorized into three (3) levels depending on the severity and nature of the complaint. Each level requires a different resolution processes to ensure prompt and adequate resolution.
Direct Assistant (Verbal Complaint): Patient Experience Department Office will be the first point of contact and directly responsible for facilitating and receiving all verbal complaints from complainer. Non-clinical complaints will be forwarded to the head of the involved department for investigation and will be resolved within ten (10) business days. Clinical complaints will be forwarded to the CMO who will forward the complaint to the Patient Complaints and Grievance Committee to conduct a full investigation and meet to discuss the complaint and will be resolved within fifteen (15) business days. Medico-legal complaints received from governmental entities through TARASOL system will be directed to CEO Office for investigation. Patient Experience Specialist will classify the complaint into clinical or non-clinical, notify the complainer about receipt of complaint (if received by E-mail), obtain full details regarding the complaint and enter complaint into the Complaint Excel Database and SafeCare system for clinical complaints.
Feedback: Patient Services, as part of the Organization's Patient Orientation Plan, will notify all patients upon admission or their visit to the Organization, that they have the right to submit a complaint or grievance regarding their care, service or healthcare provider anytime during their course of treatment. The complaints and grievances status will be reported on a monthly basis to the CEO, CMO and CNO to have recommendations for improvement, also an annual trends report of the Patient Complaints and Grievances will be reported at the Quality and Patient Safety Council, to determine areas that require Performance Improvement, and actions to be taken on strategic level.
Medication Safety plays a key role in Organization care and focusing on improvement in this area is an important part of wider quality and safety improvement programs. Medication errors can impact patient outcomes, therefore safe and appropriate use of medicines is an important part of patient safety in Organizations. There is increasing knowledge on how to improve medication practices and implement strategies so that Medication Errors can be avoided. The Medication Safety Self-Assessment helps Organizations assess their medication safety systems so they can be aware of the measures they need to take to enhance patient safety. Medication Safety Self- Assessment will be conducted by the Medication Safety Program and integrated into this Patient Safety Program.
Tool: The 2011 ISMP Medication Safety Self-Assessment® for Organizations will be utilized to conduct our annual Medication safety self-assessment.
Aim:
Assessment Composite:
Team:
Assessment Areas: For all self-assessment items: Unless otherwise stated, self-assessment items refer to medications prescribed, dispensed, and administered to all inpatients and outpatients typically seen in most Organizations, including patients admitted to the emergency department and ambulatory surgery/procedure units.
Scoring:
Analysis: Once the Self-Assessment is completed and submitted to ISMP on-line, a report of the entered information with a weighted score for each item, core characteristic, key element, and for the entire self -assessment will be made available for the organization.
Feedback: Feedback will be provided to all levels of the organization from the Board to the QPS Council and individual units that participated in the survey. In addition, the Organization profile will be shared though formal and informal communication channels such as committee meetings and newsletters.
The Joint Commission defines Medication Reconciliation is a formal process for creating the most complete and accurate list possible of a patient's current medications and comparing the list to those in the patient record or medication orders. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner, or level of care. Medication Reconciliation will be implemented by the Medication Safety Program and integrated into this Patient Safety Program.
Process: Health care professionals need to clearly identify team roles and responsibilities for medication reconciliation. This needs to include evaluating existing processes; identifying a standard location in the patient chart where the medication history is kept; and determining who will put the medication history onto the agreed upon place in the Record, the time frame for resolving variances, and how to document medication changes. These processes would eliminate the duplication of history taking and documentation that currently exists in many settings.
Monitoring and Feedback: The Medication Safety Program should implement a medication reconciliation review of both open and/or closed Medical Records. Regular reports are shared with key stakeholders. Lessons learned should be communicated through Grand Rounds, Newsletters and email etc.
Estimates suggest that approximately 5–10% of patients in high-income countries experience harm, and about one third of these harmful events are preventable. The patient safety initiatives that have been designed over the last decade have almost all failed to demonstrate significant impact. Reducing harm across a Organization requires behavioral change at a ward team level. Safety Huddles provide real time information that improves system wide communication and risk management. This approach reinforces a mechanism to resolve issues before they impact on safety. Safety huddles has been shown to reduce the number of falls, an increase in overall staff morale and improved teamwork.
Aim: Establish timely proactive review and mitigation of clinical and operational risks. Ensure patients receive optimal care.
Process:
Result: Issues are categories as the following
Feedback: Safety culture survey conducted regularly will allow the ward team to assess teamwork and communication over time. Patterns and trends in identified risks along with corrective actions will be tracked through the Risk Registry.
Patient safety has become a major concern for patients and providers alike. AHRQ defines patient safety practice as a type of process or structure whose application reduces the probability of adverse events resulting from exposure to the health care system across a range of diseases and procedures. This definition is consistent with the dominant conceptual framework in patient safety, which holds that systemic change will be far more productive in reducing medical errors than targeting and punishing individual providers. Researchers now believe that most medical errors cannot be prevented by perfecting the technical work of individual physicians, nurses, or pharmacists. Improving patient safety often involves the coordinated efforts of multiple members of the health care team, who may adopt strategies from outside health care. The Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI), Joint Commission International (JCI), and other national and international entities such as the Saudi National Patient Safety Center, have established a set of evidence based goals/ recommendations that if implemented effectively will assist in creating safer healthcare. The following goals/ recommendations will be integrated as part of this Patient Safety Program:
Monitoring and Feedback: The Business owner shall develop Process and Outcome Key Performance Indicators (KPIs) for the relevant Goal. The analyzed information will be shared will be shared with frontline staff involved in the implementation of the Goal. Improvement opportunities will be incorporated into the relevant department Quality Improvement Projects. Regular reports will be shared in the Departmental Staff meetings, the Medical Executive Committee and the QPS Council. Lessons learned will be communicated through Newsletters, Emails and other informal channels.
According to WHO, Health care-associated infection (HAI) is one of the most frequently occurring adverse events and a major public health problem. HAI impacts on morbidity and mortality, quality of life and presents an economic burden at the societal level. A large percentage of the various types of HAI are thought to be preventable. A bundle is a structured way of improving processes of care and patient outcomes. It is a small straightforward set of practices - generally three to five - that, when performed collectively, reliably and continuously, have been proven to improve patient outcomes. The following are Bundles to be implemented as part of the Infection Control Program and integrates with this Patient Safety Program:
Monitoring and Feedback: The Business owner shall develop Process and Outcome Key Performance Indicators (KPIs) for the relevant Bundle. The analyzed information will be shared with frontline staff involved in the implementation of the Bundle. Improvement opportunities will be incorporated into the relevant department Quality Improvement Projects. Regular reports will be shared in the Departmental Staff meetings, the Medical Executive Committee, Infection Control Committee and the QPS Council. Patterns and trends in identified risks along with corrective actions will be tracked through the Risk Registry. Lessons learned will be communicated through Emails and other formal and informal channels.
When a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to the bedside to immediately assess and treat the patient with the goal of preventing intensive care unit transfer, cardiac arrest, or death. Patients whose condition deteriorates acutely while Organizationized often exhibit warning signs (such as abnormal vital signs) in the hours before experiencing adverse clinical outcomes. Bedside staff are prompted to call the team when any of a number of pre-set criteria are met.
Tool: Organization has developed Early Warning Systems such as the Modified Early Warning System (MEWS), Pediatric Early Warning System (PEWS) and Modified Early Obstetric Warning System (MEOWS) to assist bedside staff to proactively identify signs of clinical deterioration and to be prompted to call for Medical Assistance based on pre-defined physiologic criteria.
Response: The Code Blue/Code Purple team will respond to any clinical deterioration meeting the criteria set in each Early Warning System.
Monitoring and Feedback: Each Clinical Unit shall develop Key Performance Indicators (KPIs) to monitor the effective use of its respective Early Warning System. The CPR Committee shall monitor the outcome of each event as part of the Performance Evaluation. Patterns and trends in identified risks along with corrective actions will be tracked through the Risk Registry.
The Quality and Patient Safety Council will serve as the central communication hub for all Programs described in this document. Key stakeholders will be given authority to educate staff who are involved in, or impacted by the respective program, effectively implement, monitor and feedback the progress and outcome of objectives and initiatives necessary to achieve the program goal. Each Program owner shall present a quarterly progress report to the QPS Council. Formal and informal channels such as Grand rounds, Newsletters, Big Screen Presentation and emails shall be used to communicate lessons learned. The QPS Council shall present an Annual Report on the Operational Plan and the Progress of the Program Goals to the Board.
Building Capacity and sustainability for Patient Safety activities, requires staff at all levels of the organization to become aware of general concepts as well as trained in the programs described herein. Training can be formal as in workshops and lectures or just in time such as staff orientation of Patient Safety Leadership Walkrounds. Each Business Owner shall develop education and training specific to the objectives and initiatives of their respective program. Education and Training may include but not limited to:
Risk Management Program of Organization is an integrated, comprehensive proactive program designed to oversee all aspects of risk identification, risk evaluation and coordination of corrective action implementation. The Governing Body supports the Risk Management Program through delegation to the Organization's Quality and Patient Safety Council. All healthcare providers, in partnership with the medical staff, are responsible for the safety, health and wellbeing of all patients, visitors and Organization staff thus it is the responsibility of all providers to work together continuously to promote safe work practices and improve quality of care. The program provides for the coordination of collecting internal and external data on potential Organization risk, investigated findings of the Organization's actual and potential risk, and reports the analysis to the governing body, leadership, medical staff, administration and the respective department, programs and committees. The reporting mechanism is such that all key members of the organization receives communication in a timely manner. The process establishes and monitors methods to reduce, eliminate or avoid risks in-patient care. The process incorporates the resources of the internal organization, legal counsel, external agencies and databases. The Principle objective of this framework is to ensure that ''healthcare quality and risk are effectively managed through implementation of an integrated quality and risk management system that ensures continuous quality improvement.''
The Risk Management Program is designed to proactively and reactively identify, assess, prioritize and mitigate Clinical and Non-Clinical risks Category (Appendix I) with Organization and its affiliates.
Goals:
Objective:
I. The overall responsibility of the Risk Management Unit is to manage processes and procedures for identifying and stratifying risks, including:
II. The Clinical department heads and Managers share responsibility for implementing risk management strategies and programs in their departments, as follows:
III. Non-clinical risk/or Managers Risk activities and the environment of care programs are administered, monitored, and managed by Managers and department representatives from the following:
IV. The risks of internal and external disasters have been identified and will be managed according to the Organization Internal and External Disaster plan and Drills.
V. Information collection and evaluation of the performance of environmental and patient safety programs is supported by the following committees:
Risk Identification: Risk will be identified on an on-going basis and risks identified following the Risk Assessment Flowchart (Appendix K). Upon identification, risk shall be managed by following the Risk Management cycle, entered into the Risk Register Database (Appendix J), i.e., analysis and evaluation to determine existing controls, likelihood, consequence and grading, treatment, acceptance, monitoring effectiveness of implementation and ongoing review. The assessment tools are used to ensure consistency in the risk assessment process and risk grading. All Departments shall fill Departmental Risk Register Form (Appendix L) and submit to QIPS on Quarterly basis /or if any risk identified. Risk register database will be updated regularly and to be discussed with Safety Management Committee on monthly basis. All identified risks, recommendations and action plan will be presented to the QPS Council for prioritization and action plan. Risk Identification processes can be divided into two groups, according to how they are initiated:
Risk may be identified through:
Internal:
External:
Risk Assessment: Risk assessment is a careful examination/evaluation of the hazards associated with work activities and structure that can cause harm to patient, staff and visitors of the organization. This examination/evaluation shall be assessed and compare to the existing practice to determine if adequate precaution and intervention are taken to prevent and minimized harm. Risk assessment is used to determine the risk to patient, staff and visitors from the physical/structure of the workplace and the activities that are undertaken within that workplace. It can be also used in developing new services, or designing a new facility in order to identify the risk in planning and designing the necessary control measures. Anyone can undertake a risk assessment using the Departmental Risk Register Form
Risk Monitoring: The Director, Managers, or Chief who is the owner of a risk is responsible for ensuring that the risk treatment/corrective action plan and risk controls are reviewed within the agreed timescales and updating the progress of mitigation plans in the Risk Register (Appendix J). The QUALITY Department follow-up risk mitigation strategies for all Risk Registry will produce quarterly and annual reports to the Concerned Department, the Safety Management Committee, the QPS Council and the HEC for prioritization and support for improvement initiatives, and future strategic planning.
Hazard Vulnerability Analysis:
Safety Management Committee with the relevant stakeholders is required to conduct the Organization Hazard Vulnerability Analysis (HVA) annually. The HVA provides a systematic approach to recognizing hazards that may affect demand for the Organization services or its ability to provide those services. The risks associated with each hazard are analyzed to prioritize planning, mitigation, response and recovery activates. The HVA serves the need assessment for the emergency management program.
The Kaiser Permanente Hazard and Vulnerability Assessment Tool will be utilized for identifying natural and man-made hazards and the direct and indirect effect these hazards may have on the Organization and community. An HVA provides the Organization with a basis for determining the potential demands on emergency services and other resources that could occur during a crisis so that effective preventive measures can be taken and a coordinated disaster response plan can be developed.
Organization will develop specific plans for managing the top 3 to 5 hazards that has taken and will build training and exercise a round managing those hazards.
Safety Event Reporting:
Organization will continue to implement and monitor the Policy and Procedure for reporting, reviewing, and follow up of safety events reporting. The person involved in or who witnesses the event is required to report the event within twenty-four (24) hours using the electronic reporting tool. The Patient Safety Specialist will facilitate the review of each event through communication with the concerned departments. QUALITY will communicate the outcome of each event to the reporter and the initiating department. The QUALITY Department will provide an aggregated quarterly feedback report defining major categories of reporting and improvement actions resulting from data. QUALITY will also identify all risk in safety event report and register it on the registry tool.
Sentinel Event:
Mechanism for reporting, reviewing, and follow-up of each event that meets the definition of a Sentinel or Significant Event. The Chairman and Nurse Managers of the department are required to report any sentinel/significant event to the Chief Medical Officer within twenty-four (24) hours of occurrence. The CMO will notify the CEO and QUALITY Department within twenty-four (24) hours. The CMO and Nursing Affairs, QUALITY Manager and the concerned department, should conduct a focused review of the event within twenty-four (24) hours. Any eminent risks to patient safety should be addressed immediately. Subsequently, the CMO in collaboration with the CEO and Manager of QUALITY will identify and form a RCA Team. RCA assists in identifying systems problems that contribute to the adverse event. A critical component of establishing an environment that supports patient safety is to routinely conduct a RCA of adverse events to answer three (3) questions:
Failure Mode and Effect Analysis (FMEA):
Failure Modes and Effects Analysis (FMEA) is a systematic, proactive method for evaluating a process to identify where and how it might fail, and to assess the relative impact of different failures in order to identify the parts of the process that are most in need of change. FMEA includes review of the following:
Risk Registry:
The Risk Register is a tool used to identify, mitigate and monitor risk that can impact on the occupants of the organization. A risk assessment is simply a careful examination of what, in your work, could cause harm to people, so that you can identify what precautions should be taken to prevent harm. It is a simple, practical but systematic thought process involving five (5) steps (Appendix N):
A typical risk register contains:
Any and all documents and records that are part of the internal Risk Management Program as well as the proceedings, reports and records from any Organization committee shall be confidential and not subject to subpoena or discovery or introduced into evidence in any judicial or administrative proceeding.
The QIPS Department with the qualified professional staff in collaboration with business owners and key stakeholders shall conduct/coordinate regular orientation and educational activities. Topics may include but not limited to: