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ARABIC CANADIAN MEDICAL CENTER QUALITY MANAGEMENT POLICIES AND PROCEDURES
1 Approved by ACMC CEO
CONTENTS
Section Title
2 Performance Measurement and Management
3 Clinical Audit
4 Person Served Safety
5 Risk Management
6 Culture of Quality and Person Served Safety
7 Person Centered Care
8 Interdisciplinary Person served Education
9 Complaint Management
10 Incident Reporting
ARABIC CANADIAN MEDICAL CENTER QUALITY MANAGEMENT POLICIES AND PROCEDURES
2 Approved by ACMC CEO
2. Performance Measurement and Management.
2.1. Policy.
2.1.1. The Organization must constantly assess and monitor its performance against a
series of performance indicators and targets.
2.1.2. The Organization determines the degree it is achieving the desired service and
business outcome by setting specific and measurable goals.
2.1.3. The quality performance indicators data collection process must ensure evidence
based, reliability, validity, completeness and accuracy of the information.
2.1.4. Purpose of each performance indicator must be well defined and understood.
2.1.5. The data collection system shall be in continuous basis from a variety of internal
and external sources. Data collected must be traceable from the sourced and is
signed off by the owner.
2.1.6. The Organization measures both its business function and service delivery
performance indicators.
2.1.7. An analysis of performance measurement must be conducted at least annually in
relation to the performance targets.
2.1.8. An action plan must be formulated to address the improvements needed to reach
established or revised performance targets.
2.1.9. The Organization will use its present technology available which is manual
submission of data through excel sheet to generate electronic reliable reports.
2.1.10. The IT department is responsible for backing up and protecting the integrity of all
data collected.
2.1.11. The Organization should communicate its performance information to its persons
served, personnel and other stakeholders for transparency.
2.2. Procedures.
2.2.1. The data collected from internal and external sources will be consolidated in the
Quality and Compliance Department.
2.2.2. Departments involved in the Organization‟s data collection process are provided
a unique template to be used for data gathering purposes.
2.2.3. Departments involved shall submit their collected data in quarterly basis to the
Quality and Compliance Office.
2.2.4. All data will be consolidated and tabulated at the Quality and Compliance Office
for performance measurement against the Organization established or revised
target.
DOCUMENT TITLE: PERFORMANCE MEASUREMENT AND MANGEMENT
REFERENCE NUMBER: HR-002
VERSION: 2.0
EFFECTIVE DATE: 01 DEC 2016 REVIEWED: 01 DEC 2017
ARABIC CANADIAN MEDICAL CENTER QUALITY MANAGEMENT POLICIES AND PROCEDURES
3 Approved by ACMC CEO
2.2.5. Results of performance measurement are subject for analysis by the responsible
person designated by the Quality and Compliance Office.
2.2.6. Performance measurement, analysis, and action plan will be done quarterly and
annually by the Quality and Compliance Department and its designees which
includes both the business functions and service delivery.
2.2.7. Ongoing performance issue that enormously impacts the organization business
functions and service deliveries will be address urgently.
2.2.8. An annual performance meeting (November of each year, headed by the Quality
and Compliance Team, communicates performance information to the
administration and personnel.
2.2.9. A summary copy of the performance information may also be available upon
Chairman‟s approval and can be access on the organization website for its
persons served and other stakeholders.
2.3. Appendices.
2.3.1. Rate of Emergency Attendance.
2.3.2. Rate of Unplanned Hospital Admission.
2.3.3. Rate of DVT.
2.3.4. Rate of Newly Acquired or Worsening Pressure Ulcers.
2.3.5. Percentage of Denials, Ineligibility, and Interrupted Service.
2.3.6. Percentage of Accessibility Barriers Resolved.
2.3.7. Rate of Health Care Acquired Infection.
2.3.8. Personnel Retention Rate.
2.3.9. Personnel Turnover Rate.
2.3.10. Rate of Reportable Occupational Related Incident.
2.3.11. Percentage Personnel Satisfaction.
2.3.12. Percentage of Risk Identified Resolved.
2.3.13. Percentage of Accomplished Technology Improvement Plans.
2.3.14. Personnel Overtime Variance.
2.3.15. Persons Served Satisfaction Rating.
2.3.16. Percentage of Persons Served Complaint Resolution.
2.3.17. HAAD Audit Compliance Rating.
2.3.18. TASNEEF Audit Compliance Rating.
ARABIC CANADIAN MEDICAL CENTER QUALITY MANAGEMENT POLICIES AND PROCEDURES
4 Approved by ACMC CEO
3. Clinical Audit.
3.1. Policy.
3.1.1. The Organization must develop, maintain and support a culture of best practice
in the management and delivery of clinical audit.
3.1.2. The Organization must use the findings from clinical and other audits reviews to
drive actions that will improve the quality of care delivered and, if any unsafe
clinical practice is identified during audit, to ensure that a risk assessment is
undertaken, and measures put in place and monitored effectively in order to
deliver safe care.
3.1.3. The Organization shall assess how closely its clinical practice resembles the
recommended practice.
3.2. Procedures.
3.2.1. The Director for Quality and Compliance is the accountable officer of the
Organization and as such has overall accountability and responsibility for
ensuring it meets its statutory and legal requirements and adheres to guidance
issued by the Health Authority Abu Dhabi.
3.2.2. The Medical Director has executive accountability for clinical effectiveness and is
responsible for providing assurance to the CEO and Chairman on the
implementation of this policy.
3.2.3. Involving Persons Served.
3.2.3.1. The Organization promotes a commitment to the principle of involving
persons served and family/support system in the clinical audit process
either indirectly through the use of persons served surveys/questionnaires
or directly through the participation of identified individuals on project
steering groups, or forums.
3.2.4. Multi-Disciplinary and Multi-Professional Audit, and Partnership Working
with Other Organizations.
3.2.4.1. The Organization encourages clinical audit undertaken jointly across
professions and across organizational boundaries. Partnership working with
other local and international organizations will be encouraged where
improvements to the persons served journey may be identified through
shared clinical audit activity.
3.2.5. Working with Health Authority Abu Dhabi.
3.2.5.1. As a provider organization, clinical audit activity should reflect HAAD‟s
requirements and aspirations. The findings of any audit must be made
DOCUMENT TITLE: CLINICAL AUDIT
REFERENCE NUMBER: QM-003
VERSION: 2.0
EFFECTIVE DATE: 01 DEC 2016 REVIEWED: 01 DEC 2017
ARABIC CANADIAN MEDICAL CENTER QUALITY MANAGEMENT POLICIES AND PROCEDURES
5 Approved by ACMC CEO
available to the HAAD on request and the HAAD can appoint an auditor to
audit quality and outcomes and the recording and coding of clinical activity.
3.2.6. Annual Clinical Audit.
3.2.6.1. On an annual basis, the Organization will conduct planned program of
clinical audit activity for quality improvement and quality assurance.
3.2.6.2. The annual clinical audit will be comprised of the following:
3.2.6.2.1. HAAD Audit;
3.2.6.2.2. TASNEEF Audit;
3.2.6.2.3. OSHAD Audit;
3.2.6.2.4. CARF Audit;
3.2.6.2.5. External Health and Safety Audit;
3.2.6.2.6. Internal Health and Safety Audit; and
3.2.6.2.7. PHD Laboratory Audit.
3.2.6.3. To facilitate the monitoring of audit listed above, an audit database is
maintained by the Quality and Compliance Office, identifying all audits
undertaken and their progress, which will support assurance of the
completion of the audit cycle, and identify any risks along with changes in
practice, if appropriate.
3.2.6.4. The Quality and Compliance Office monitor the completion of audit action
plans, to support the achievement of those action plans within the agreed
timescales.
3.2.7. Action Plans.
3.2.7.1. Details of completed audits will be presented at audit meetings where the
findings will be reviewed, risks identified and discussed.
3.2.7.2. Action plans will then be developed with a commitment to re-audit made if
required.
3.2.7.3. Action plans should be specific, measurable and achievable/realistic. They
should have clear implementation timescales with identified leads for each
action.
3.2.7.4. Action plans should be approved by the Director for Quality and
Compliance included in the Audit Report.
3.2.7.5. Not all clinical audits will require an action plan e.g. where an audit shows
that standards are being met or guidance followed. For such audits there
should be an explicit statement saying „no further action required‟ in the
audit report and a reason given for no re-audit.
3.2.8. Re-Audit.
3.2.8.1. Re-audit is necessary to determine whether agreed actions have been
implemented according to the action plan, where audits have demonstrated
a need for change in practice it is expected that a timescale for
implementation of the actions will include a planned re-audit and findings of
the re-audit will be submitted to the audit meeting and to Quality and
Compliance Office. This provides assurance that the audit cycle has been
completed.
ARABIC CANADIAN MEDICAL CENTER QUALITY MANAGEMENT POLICIES AND PROCEDURES
6 Approved by ACMC CEO
3.2.9. Reports.
3.2.9.1. Once data has been collected, analyzed and an agreement reached as to
any actions required, it is the responsibility of the designee undertaking the
audit to populate the clinical audit report templates and when fully
completed, forward to Quality and Compliance Department.
3.2.9.2. Any clinical audit reports that are received with missing information (e.g.
author, action plan not completed) will be returned to the auditor for
completion and return. This will ensure that all evidence required to inform
changes in practice, or re-audit meets the Organization requirements.
3.2.10. Retention of Audit Records.
3.2.10.1. It is a fundamental requirement that all of the Organization‟s records are
retained for the correct period of time prior to secure destruction. In terms of
clinical Audits, records need to be retained for 5 years after completion of
the audits.
3.3. Appendices.
3.3.1. HAAD Audit Form.
3.3.2. TASNEEF Audit Report.
3.3.3. OSHAD Audit Report.
3.3.4. CARF Conformance Checklist.
3.3.5. External Health and Safety Audit Report.
3.3.6. Internal Health and Safety Audit Form.
3.3.7. PHD Laboratory Audit Report.
ARABIC CANADIAN MEDICAL CENTER QUALITY MANAGEMENT POLICIES AND PROCEDURES
7 Approved by ACMC CEO
4. Persons Served Safety.
4.1. Policy.
4.1.1. The Organization commits on persons served safety goals that promotes
prevention of errors and adverse effects to persons served associated with
health care. The following safety goals are as follows:
4.1.1.1. Improve accuracy of person served identification.
4.1.1.2. Improve effectiveness of communication among care providers.
4.1.1.3. Improve the safety of using medications and medical devices.
4.1.1.4. Reduce the risk of healthcare associated infections.
4.1.1.5. Adherence to hand hygiene.
4.1.1.6. Reduce the risk of patient harm resulting from falls.
4.1.2. Person Served Identification:
4.1.2.1. Persons served identification is a fundamental part of the delivery of
healthcare in any discipline, and should be second nature to all care
providers.
4.1.2.2. Persons served identification must apply for all interactions to ensure the
correct their identity, particularly before any procedure or receive therapy.
4.1.2.3. Healthcare personnel shall use at least two identifiers to ensure the right
persons served get the right care. At least two identifiers will be used to the
following but not limited to administering medication, blood/blood
components, collecting samples, treatments and procedure.
4.1.3. Effective Communication among Care Providers.
4.1.3.1. Reporting Critical Results
4.1.3.1.1. The facility shall determine which tests performed by the affiliated
outside laboratory fulfill the criteria for critical values / critical
results and describes the processes for notification, read-back and
report documentation of those results.
4.1.3.2. Hand Over Process.
4.1.3.2.1. Person served information is communicated during transfers of
care from one provider to another to assure continuity of care.
4.1.3.2.2. The Hand-off Communication Forms will be used during the hand
off of care discussion for all service and care transfers within the
Organization.
4.1.3.2.3. The Hand-off Communication Form will be a permanent part of the
person served medical record.
4.1.3.3. Verbal Orders.
DOCUMENT TITLE: PERSON SERVED SAFETY
REFERENCE NUMBER: QM-004
VERSION: 2.0
EFFECTIVE DATE: 01 DEC 2016 REVIEWED: 01 DEC 2017
ARABIC CANADIAN MEDICAL CENTER QUALITY MANAGEMENT POLICIES AND PROCEDURES
8 Approved by ACMC CEO
4.1.3.3.1. Verbal orders should be used in situations where any delay in
writing the order could cause harm or have a possible negative
outcome to the person served.
4.1.3.3.2. Verbal and telephone orders may be accepted by a licensed
healthcare staff when it is impossible or impractical for the
authorized prescriber to write them.
4.1.3.3.3. Generic drug names should be used when drug orders are given.
4.1.3.3.4. Abbreviations should be avoided in all possible circumstances to
ensure safety of the person served and avoid medication errors.
4.1.4. Safety use of Medications and Medical Devices.
4.1.4.1. For safety use of medication, refer to Medical Policies and Procedures.
4.1.4.2. For safety use of medical devices, refer to Facility and Medical Equipment
Management Policies and Procedures.
4.1.5. Reduce the Risk of Healthcare Associated Infections.
4.1.5.1. For reducing the risk of healthcare associated infections, refer to Infection
Control Policies and Procedures.
4.1.6. Adherence to Hand Hygiene.
4.1.6.1. For adherence to hand hygiene, refer to Infection Control Policies and
Procedures.
4.1.7. Reduce the Risk of Persons Served Harm Resulting from Fall.
4.1.7.1. Health care personnel are responsible for assessing all persons served for
risk of fall using the Modified Morse Fall Scale for Adults and Humpty
Dumpty Fall Scale for Pediatrics.
4.1.7.2. Fall assessment shall be completed upon person‟s served initial contact.
4.1.7.3. Fall reassessment of persons served shall be completed as follows:
4.1.7.3.1. Low risks shall be reassessed weekly.
4.1.7.3.2. Moderate or high risks shall be reassessed on every shift or daily.
4.1.7.3.3. Following any changes in person served condition related to fall
risk factors.
4.1.7.3.4. Following a fall.
4.1.7.3.5. Following procedural sedation.
4.1.7.3.6. Any medication effects (sedation/diuretics).
4.1.7.3.7. Narcotic administration.
4.1.7.3.8. Change in level of consciousness or mental status.
4.1.7.4. Fall prevention measures shall be implemented for persons served at risk
for fall.
4.1.7.5. Occurrence variance report shall be completed following patient fall.
4.1.7.5.1. None – no injury.
4.1.7.5.2. Minor - resulted in application of a dressing, ice, cleaning of a
wound, limb elevation, topical medication, bruise or abrasion.
4.1.7.5.3. Moderate – resulted in suturing, application of Steris trip/skin
glue, splinting or muscle joint strain.
ARABIC CANADIAN MEDICAL CENTER QUALITY MANAGEMENT POLICIES AND PROCEDURES
9 Approved by ACMC CEO
4.1.7.5.4. Major – resulted in surgery, casting, traction, fracture or required
consultation for neurological or internal injury.
4.1.7.5.5. Death- person served died as a result of injuries sustained from
the fall.
4.2. Procedures.
4.2.1. Improving Accuracy of Persons Served Identification.
4.2.1.1. The following are the Organization approved identifiers for the persons
served:
4.2.1.1.1. Complete Name (Name, Middle and last Name);
4.2.1.1.2. Location or complete address;
4.2.1.1.3. Medical Record Number (MRN); and
4.2.1.1.4. Full date of birth (inclusive of day, month, and year).
4.2.1.2. When a person served has capacity and is assessed to be a reliable
informant, healthcare personnel can simply request verbal confirmation of
identity from him, asking him to confirm at least two of the above identifiers
and compare the information provided against the national ID and/or
insurance card located in the persons served medical records.
4.2.1.3. Staff should not read his details to them and allow them to passively agree
with you.
4.2.1.4. Instead staff should ask him to give his full details.
4.2.1.5. None of the following but not limited to administering medication,
blood/blood components, collecting samples, treatments and procedure
shall be performed to any person served until the identity of the person
served has been duly determined.
4.2.1.6. Identification for Minor Persons Served and/or are Disabled.
4.2.1.6.1. The capacity or reliability of some persons served can fluctuate
depending on age and disability.
4.2.1.6.2. If the person served does not have the capacity to identify himself
or otherwise does not have consistent reliability as an informant
the identification must initially be confirmed by another member of
staff who knows the patient, family member or other appropriate
person - if necessary accompanied by another member of staff
who knows the patient, family member or other appropriate
person.
4.2.1.7. Reporting Identification Errors.
4.2.1.7.1. If there is an error in administration of medication due to
misidentification the person served must be physically assessed
by a nurse or a doctor and any physical signs such as pulse rate
and blood pressure monitored as necessary. All this must be fully
documented.
4.2.1.7.2. Any error occurs must be reported immediately to the person in
charge of the service such as the department manager or
ARABIC CANADIAN MEDICAL CENTER QUALITY MANAGEMENT POLICIES AND PROCEDURES
10 Approved by ACMC CEO
supervisor and an incident report must be completed. This must
include any error where an incident has
4.2.1.7.3. Refer to the Organization Incident Reporting Policy and
Procedures.
4.2.2. Improving Effectiveness of Communication among Care Providers.
4.2.2.1. Reporting Critical Results.
4.2.2.1.1. A critical value is defined as a value that represents a
pathophysiological state at such variance with normal (expected
values) as to be life-threatening unless something is done
promptly and for which some corrective action could be taken.
NOTE: The critical values do not necessarily correspond directly
with normal reference values, toxic ranges, or therapeutic ranges.
4.2.2.1.2. Notification.
4.2.2.1.2.1. The affiliated laboratory will notify the person served care
provider, normally the physician, when critical limits of
specified test results are exceeded and/or critical results
are obtained.
4.2.2.1.2.2. In addition to the usual normal results reporting process
(e.g. fax, computer interface). Affiliated Laboratory staff
telephone the ordering physician within 60 minutes
following laboratory release of the critical result(s)
according to their established procedures.
4.2.2.1.2.3. In the event that contact is not made within the 60-minute
period, the affiliated laboratory will continue to telephone
until the designated party is reached and the result is
conveyed.
4.2.2.1.2.4. Critical results obtained by Point of Care (POC) testing
are communicated to the treating healthcare provider.
4.2.2.1.3. Read-Back of Critical Value / Critical Results.
4.2.2.1.3.1. To verify the accuracy of information communicated via
the telephone, the physician or designee responsible for
person served care is required to read-back the name,
unique numeric identification, and the critical test
result(s) of the person served.
4.2.2.1.4. Documentation.
4.2.2.1.4.1. The critical high and low values are place in the person
served medical record. NOTE: Records of notification
and read back are documented in the progress notes.
4.2.2.2. Handover Procedures of the Persons Served.
4.2.2.2.1. Person-to-person contact is preferred when transferring care.
4.2.2.2.2. When this is not possible, it is acceptable to provide this
information via phone, allowing for appropriate feedback and
opportunity to ask questions, between and among care providers.
ARABIC CANADIAN MEDICAL CENTER QUALITY MANAGEMENT POLICIES AND PROCEDURES
11 Approved by ACMC CEO
4.2.2.2.3. When possible and appropriate, include the person served and
family in the dialogue at the time of the transfer.
4.2.2.2.4. At a minimum, the transferring staff makes the person
served/family aware of the hand-off and provides the name and
the title of the person or agency that will be assuming
responsibility for their continued care.
4.2.2.2.5. SBAR communication tool will be used during the transfer of
professional responsibility and accountability as follows:
4.2.2.2.5.1. Transfer to other Organization units.
4.2.2.2.5.2. Transfer to other healthcare facilities.
4.2.2.2.5.3. Change of staff during home visits services (Home
Nursing and Home Supportive Therapy Services).
4.2.2.2.5.4. Initiation of new services.
4.2.2.2.5.5. Transfer of care from one physician to another.
4.2.2.2.6. The handover communication form (SBAR) will be used to
facilitate communication of the hand-off process between staff
and/or other receiver of care.
4.2.2.2.7. SBAR form will be placed on the person served medical record.
4.2.2.2.8. Separate form “Patient Daily Plan of Care” shall be used as
hands-off communication tool on the following services:
4.2.2.2.8.1. 12 hours Home Nursing Service; and
4.2.2.2.8.2. 24 hours Home Nursing Service.
4.2.2.2.9. Use of the SBAR Form. (See the appendix section for the
form).
4.2.2.2.9.1. Familiarize yourself with the person‟s served information
before initiating the communication.
4.2.2.2.9.2. Identify yourself, your position, the person‟s served
name, MRN number.
4.2.2.2.9.3. Review chief complaint/diagnosis, any relevant history,
assessment, list of current medications, allergies, or labs,
most recent vital signs, and any changes pertinent to the
problems and/or the treatment/clinical course summary.
4.2.2.2.9.4. Discussed with the case coordinator or department
manager or supervisor regarding the situation then
inform the physician.
4.2.2.2.9.5. Read the most recent progress notes from the staff who
worked the shift or day ahead of you.
4.2.2.2.9.6. Follow the SBAR process:
4.2.2.2.9.6.1. (S) Situation: What is the situation you are
calling about?
4.2.2.2.9.6.2. Identify self, person served and
Address/Location.
ARABIC CANADIAN MEDICAL CENTER QUALITY MANAGEMENT POLICIES AND PROCEDURES
12 Approved by ACMC CEO
4.2.2.2.9.6.3. Briefly state the problem, what is it, when it
happened or started, and how severe.
4.2.2.2.9.7. (B) Background: Pertinent background information
related to the situation could include the following:
4.2.2.2.9.7.1. Briefly state the pertinent history.
4.2.2.2.9.7.2. What got the person served to this point?
4.2.2.2.9.7.3. The admitting diagnosis and co morbidities.
4.2.2.2.9.7.4. List of current medications and allergies.
4.2.2.2.9.7.5. Most recent vital signs and BSL
4.2.2.2.9.8. (A) Assessment: What is the staff assessment of the
situation?
4.2.2.2.9.9. (R) Recommendation: What is the staff
recommendation or what does he/she wants?
4.2.2.2.9.9.1. Give a recommendation (or a response)
based on the situation, background, and
assessment of the case. In other words, what
do you think needs to be done?
4.2.2.2.9.10. Document the changes in the person‟s served condition
in the progress notes.
4.2.2.2.9.11. Conclude by giving the receiving staff person the
opportunity to ask any questions or clarify information.
4.2.2.2.9.12. If verbal order is provided, document the order made in
verbal order form and let the physician sign it within 7
days.
4.2.2.2.10. Use of Daily Plan of Care. (See the appendix section for the
form).
4.2.2.2.10.1. The Daily plan of care is a written communication tool
that gives a brief summary of the person‟s served daily
health status and overall plan of care.
4.2.2.2.10.2. Staff needs to fill up this form daily, in every shift in
accordance to the person‟s served over all condition and
routine daily care.
4.2.2.3. Verbal Orders.
4.2.2.3.1. Verbal orders shall only be received and accepted by a licensed
healthcare staff.
4.2.2.3.2. Properly identified the person served whom the verbal order is
referring to using the Organization approved identifiers
4.2.2.3.3. Record the verbal order directly onto a verbal order sheet in the
person‟s served medical record.
4.2.2.3.4. The listener will concurrently transcribe the complete order on an
approved verbal order form.
4.2.2.3.5. Read the transcribed order back to the physician to ensure that
the information transcribed are correct.
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4.2.2.3.6. Enunciate what is being said as clearly as possible.
4.2.2.3.7. Use aids such as “B as in Ball” or “F as in Frank” to eliminate
spelling errors.
4.2.2.3.8. Articulate numbers as “sixteen or one-six” to avoid errors.
4.2.2.3.9. Document “read back completed” next to the transcribed order.
4.2.2.3.10. Place the order in the medical record as soon as possible.
4.2.2.3.11. Flag the verbal order for authentication.
4.2.2.3.12. The staff who received verbal orders is required to sign, date,
time, and note the order according to prescribed procedures.
4.2.2.3.13. Verbal orders shall be accepted only in emergencies and are
accepted when given by a qualified physician only.
4.2.2.3.14. A verbal order is not allowed when the prescriber is present and
the person‟s served chart is available.
4.2.2.3.15. Physician shall ask for important patient information such as drug
allergies, lab values and diagnosis or comorbid conditions that
may affect the prescribed medication.
4.2.2.3.16. The Physician is mandated to verify and sign/date orders
within seven (7) days.
4.2.2.3.17. Verbal orders shall not be given or accepted for:
4.2.2.3.17.1. Cytotoxic agents;
4.2.2.3.17.2. Sedatives and narcotics;
4.2.2.3.17.3. Biological response modifiers (Immunotherapy drugs
given to strengthen the immune system; and
4.2.2.3.17.4. Investigational drugs.
4.2.2.3.18. For verbal order of medication, and due to the risk for
medication errors associated with verbal communication of orders,
it is expected that the following components of the order will be
verbalized and transcribed:
4.2.2.3.18.1. Date and time of order;
4.2.2.3.18.2. Generic and brand name of drug;
4.2.2.3.18.3. Drug dosage (strength and concentration, formulation –
tabs, pills, solution mg/cc);
4.2.2.3.18.4. Quantity and Duration;
4.2.2.3.18.5. Route of Administration;
4.2.2.3.18.6. Frequency of Administration;
4.2.2.3.18.7. Age and weight of patient (required for Pediatric patients
and in clinical circumstances where appropriate);
4.2.2.3.18.8. Known allergies;
4.2.2.3.18.9. Reason drug is ordered for PRN orders; and
4.2.2.3.18.10. Specific indications for use, as appropriate.
4.2.2.4. Reducing the Risk of Persons Served Harm Resulting from Fall.
4.2.2.4.1. Physician Identifies and initiates medical interventions to reduce
fall and fall-related injury risk.
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14 Approved by ACMC CEO
4.2.2.4.2. Other healthcare personnel should:
4.2.2.4.2.1. Implements plan of care to address persons served
identified as high risk and implements high-risk
strategies.
4.2.2.4.2.2. Completes fall-risk assessments on transfers, following a
change in status, following a fall and quarterly.
4.2.2.4.2.3. Recognizes and reports verbalizations and behaviors
indicative of discomfort which may potentially lead to
falls.
4.2.2.4.2.4. Reports any risk factors identified.
4.2.2.4.2.5. Ensures procedures for high fall-risk persons served are
in use.
4.2.2.4.2.6. Provides education to family/support system about falls
prevention strategies.
4.2.2.4.2.7. Evaluates the plan of care.
4.2.2.4.3. Assess the persons served for fall risk upon admission and
complete Morse Fall Risk Assessment tool for adult and the
Humpty Dumpty Scale for pediatrics.
4.2.2.4.4. Morse Fall Scale score will determine the risk for fall of a persons
served as follows:
4.2.2.4.4.1. Following a fall (F).
4.2.2.4.4.2. On admission to the facility (A).
4.2.2.4.4.3. Following any change of status (C).
4.2.2.4.4.4. On any transfer from one unit to another within the facility
or discharge (T).
4.2.2.4.4.5. 0 – 24 points: Low Risk.
4.2.2.4.4.6. 25 – 44 points: Moderate Risk.
4.2.2.4.4.7. > 45 points: High Risk.
4.2.2.4.5. According to the Humpty Dumpty Fall Scale, The person served is
considered at Risk for fall if the score is ≥ 12.
4.2.2.4.6. In case the person served was identified at moderate or high
risk, the fall reassessment shall be done on every shift and the
fall prevention and management interventions included in the
form shall be applied.
4.2.2.4.7. Re-assess the person served when these conditions apply to:
4.2.2.4.7.1. Change of condition
4.2.2.4.7.2. In case of a new fall.
4.2.2.4.7.3. In case of transfer from one place to another area inside
or outside home or within the facility
4.2.2.4.7.4. In case, is receiving medications that alter the level of
consciousness (sedatives, tranquilizers, barbiturates,
etc.).
4.2.2.4.7.5. In case, is post-operative.
ARABIC CANADIAN MEDICAL CENTER QUALITY MANAGEMENT POLICIES AND PROCEDURES
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4.2.2.4.8. Coordinate the result of the reassessment with the physician and
document on the person served medical record.
4.2.2.4.9. Standards Fall Precautions measures shall be applied to all
persons served.
4.2.2.4.9.1. Provide person served and family/support system fall
prevention education.
4.2.2.4.9.2. Room shall be well lit at all times.
4.2.2.4.9.3. Person served with orthostatic hypotension should be
taught to change position slowly to allow blood pressure
stabilization.
4.2.2.4.9.4. Bedside rails shall always be elevated.
4.2.2.4.9.5. If not transporting a person served, wheelchairs and
beds shall be kept in a locked position.
4.2.2.4.9.6. Keep bed at lowest position.
4.2.2.4.9.7. Keep tissues and other articles for personal use within
person‟s served reach.
4.2.2.4.9.8. Ensure clothing doesn‟t interfere with mobility.
4.2.2.4.9.9. Monitor environment for clutter, spills or other hazards.
4.2.2.4.9.10. Keep bathroom lights on and floor dry.
4.2.2.4.9.11. Use of raised toilet seat or stool in the shower as
necessary.
4.2.2.4.9.12. Use of safety straps on stretcher, wheelchair while
transporting persons served.
4.2.2.4.9.13. Monitor for change in falls risks.
4.2.2.4.9.14. Children shall not be left unattended.
4.2.2.4.10. Implement the following fall management plan in the event of
a fall:
4.2.2.4.10.1. Assess the level of consciousness.
4.2.2.4.10.2. Check the vital signs.
4.2.2.4.10.3. Do not move the person served until potential injuries are
identified and safety assured.
4.2.2.4.10.4. Notify the physician.
4.2.2.4.10.5. Complete the Occurrence Variance Report. (Refer to
Incident Reporting Policy).
4.2.2.4.10.6. Reassure the person served and family/support system
at all times regarding condition and procedures to follow.
4.2.2.4.11. Communication and Education about person’s served fall
risk:
4.2.2.4.11.1. Communicate to all staff information regarding person
served who are at risk of falling or at risk for sustaining a
fall-related injury.
4.2.2.4.11.2. Use visual indicator to quickly communicate with the care
team about at risk of fall or injury.
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4.2.2.4.11.3. Ensure safe, standardize handoffs between nurses (e.g.
at shift change) and communicate with family/support
system.
4.2.2.4.11.4. Educate the person served and the family/support
system about risk of injury from a fall and about what
they can do to help prevent a fall.
4.2.2.4.11.5. Familiarize the person served with the surroundings.
4.2.2.4.11.6. Place the person served to a bed that enables him to exit
towards his stronger side whenever possible.
4.2.2.4.11.7. Teach person served proper ambulation and use of
assistive devices like not turning on the heel of the foot;
use handrails in hallways, bathrooms and tub rooms;
wheelchair safety (brakes, pedals); and not pulling down
on walkers when rising to a standing position.
4.2.2.4.11.8. Teach to sit on the edge of the bed for several minutes
before rising.
4.2.2.4.11.9. Caution to avoid bending his/her head sharply
backwards.
4.2.2.4.11.10. Instruct to refrain from working with his arm above their
head.
4.2.2.4.11.11. Instruct person served and family/support system
regarding appropriate footwear such as the use of
treaded socks and/or non-skid footwear.
4.2.2.4.11.12. Instruct to request assistance with ambulation. Repeat
instructions to call for help on each shift.
4.3. Appendices.
4.3.1. SBAR Form
4.3.2. Patient Daily Plan of Care
4.3.3. Verbal Order Form
4.3.4. Adult Fall Risk Assessment
4.3.5. Pediatric Fall Risk Assessment
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5. Risk Management.
5.1. Policy.
5.1.1. The Organization ensures that levels of risk and uncertainty are properly
identified, analyzed and managed.
5.1.2. The Organization develops and deploys mitigation strategies to reduce the
likelihood and/or impact of risk.
5.1.3. The Organization sets monitoring of actions to reduce risk.
5.1.4. The Organization risk identification and management considers risk related to the
following:
5.1.4.1. Financial practices;
5.1.4.2. Human Resources;
5.1.4.3. Services Provided;
5.1.4.4. Persons Served;
5.1.4.5. Information Technology;
5.1.4.6. Emergency Preparedness; and
5.1.4.7. Health and Safety.
5.1.5. The Organization has the primary duty to mitigate the risk of above activities
through the following risks management:
5.1.5.1. Eliminating risks so far as is reasonably practicable; and
5.1.5.2. If it is not reasonably practicable to eliminate the risks, by minimizing those
risks so far as is reasonably practicable.
5.1.6. The Organization risk management involves four steps:
5.1.6.1. Identify risks – find out what could cause harm.
5.1.6.2. Assess risks – understand the likelihood of a hazard causing harm and how
serious it could be.
5.1.6.3. Control risks – implement the most effective control and rectification
measure that is reasonably practicable in the circumstances.
5.1.6.4. Review control measures to ensure they are working as planned.
5.1.7. The administration exercises due diligence to gain an understanding of the
hazards and risks associated with the operations of the Organization, and
ensures that the Organization has and uses appropriate resources and
processes to eliminate or minimize risks to the company.
5.1.8. The risk management team ensures that personnel and the persons served are
not put at risk from work and service carried out by the physical facility and the
Organization operation.
5.1.9. The risk management team keeps an up-to date risk and future risk register.
DOCUMENT TITLE: RISK MANAGEMENT
REFERENCE NUMBER: QM-005
VERSION: 2.0
EFFECTIVE DATE: 01 DEC 2016 REVIEWED: 01 DEC 2017
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5.1.10. During the induction program, newly hired personnel shall receive education
regarding raising concerns when quality and patient safety is compromised.
5.1.11. All personnel shall be made aware of the clinical risk registers through education
program on risk management.
5.1.12. All issues and concerns about risk identified and reported by the personnel shall
be studied and made an action plan.
5.2. Procedures.
5.2.1. Risk Identification.
5.2.1.1. Use the Organization Risk Identification Tool in identifying risks.
5.2.1.2. With the use of the Risk Identification Tool, follow these steps to simplify
and fasten risk identification process:
5.2.1.2.1. Consultation with each department head and their staff is required
at each step of the risk management process. By drawing on the
experience, knowledge and ideas of these people are more likely
to identify all risks and choose effective risk controls.
5.2.1.2.2. Encourage staff to report any risks and operation problems
immediately so that risks can be managed before an incident
occurs. Encouragement must be set starting from the personnel
induction phase.
5.2.1.2.3. Inspection of the workplace through regular walks around the
facility and observes how things are done helps to predict what
could or might go wrong.
5.2.1.2.4. Review available information about any risks relevant to the
Organization.
5.2.1.2.5. Review of the Organization critical incident records and data.
5.2.1.2.6. Review of the Organization Occupational Related Diseases and
Injuries.
5.2.2. Risk Assessment.
5.2.2.1. Use the Organization Risk Assessment Tool in analyzing risks.
5.2.2.2. With the use of the Risk Assessment Tool, follow these steps to simplify
and fasten risk assessment process:
5.2.2.2.1. Work out the amount of risk that could occur. To estimate the
amount of risk that could result from each exposures you should
consider the following questions:
5.2.2.2.1.1. What type of risk could occur? How severe is the risk?
Could the risk cause death, serious injuries, operation
shut down? Bankruptcy? Etc.
5.2.2.2.1.2. What factors could influence the severity of risk that
occurs?
5.2.2.2.1.3. How many people are exposed to the risk and how many
could be affected (in and outside the Organization)?
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5.2.2.2.1.4. Could one failure lead to other failures? For example,
could the failure of the utilities make any risk controls that
rely on utilities ineffective?
5.2.2.2.1.5. Could a small event escalate to a much larger event with
more serious consequences? For example, a minor
delay claims submission can affect operating income
thus affect the company cash flow.
5.2.2.2.2. Work out the likelihood of risk occurring. The likelihood of
exposures can be estimated by considering the following:
5.2.2.2.2.1. How often is the task done – does this make the harm
more or less likely?
5.2.2.2.2.2. How often are situation near the risk? How close the
situation gets to it?
5.2.2.2.2.3. Has it ever happened before, either in our company or
somewhere else? How often?
5.2.2.2.3. Rate the likelihood. The level of risk will increase as the likelihood
of harm occurring and its severity increases. Assess the level of
risk through the following:
5.2.2.2.3.1. Assign a number on a scale from 1 (lowest probability or
impact) to 10 (highest probability or impact) to quantify
the probability and potential impact of the risk.
5.2.2.2.3.2. Determine the overall severity or importance of the risk
by multiplying the probability number by the impact
number to come up with a measure of severity.
5.2.2.2.3.3. Determine which risks are the most important for further
action. We establish a “risk threshold,” which is a
severity number of 40 or higher.
5.2.2.2.3.4. Risks with less severity than this are not considered for
further analysis.
5.2.3. Risk Mitigation.
5.2.3.1. Use the Organization Risk Management Worksheet in Risk Mitigation.
5.2.3.2. With the use of the Risk Management Worksheet, follow these steps to
simplify and fasten risk management process:
5.2.3.2.1. Consult department head and staffs who will be directly affected
by the mitigation plan. Their experience help in choosing
appropriate control measures and their involvement increase the
level of acceptance of any changes that may be needed.
5.2.3.2.2. The ways of controlling risks are ranked from highest risk
threshold to lowest risk threshold.
5.2.3.2.3. The risk mitigation strategies adapt the hierarchy of control (from
work safe Australia 2010).
5.2.3.2.4. Level 1:
5.2.3.2.4.1. Eliminate the risk.
ARABIC CANADIAN MEDICAL CENTER QUALITY MANAGEMENT POLICIES AND PROCEDURES
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5.2.3.2.5. Level 2:
5.2.3.2.5.1. Substitute the risk with something safer.
5.2.3.2.5.2. Isolate the risk from people
5.2.3.2.5.3. Reduce the risks through engineering controls.
5.2.3.2.6. Level 3:
5.2.3.2.6.1. Reduce the level of harm using administrative actions.
5.2.3.2.6.2. Use of Personal Protective Equipment.
5.2.4. Monitoring of Actions to Reduce Risk.
5.2.4.1. The Organization uses the following method to monitor the control
measures implemented and ensure that they remain effective:
5.2.4.1.1. Accountability of Risk Management Team.
5.2.4.1.1.1. The monitoring of risk management policies and
procedures is the primary duty of the Risk Management
Team. The team ensures that their responsibilities are
performed and resources are available to meet them.
5.2.4.1.2. Regular Review.
5.2.4.1.2.1. The Risk Management Team will regular review the work
and procedures and will consult with department head
and staff. All incident investigations should include a
review of any relevant procedures.
5.2.4.1.3. Effective Communication.
5.2.4.1.3.1. The Organization commits in effective communication
using appropriate language, signs and symbols.
5.2.4.1.4. Up-to-Date Training and Competency.
5.2.4.1.4.1. Training will be provided to all staff to maintain
competencies and to ensure new personnel are capable
of working safely.
5.2.4.1.5. Up-to-Date Risk Information and Risk Assessments.
5.2.4.1.5.1. The Risk Management Team commits in continuous
seeking of relevant, evidenced-based information about
risks, and uses this to change and update the
Organization‟s operating conditions and risk
management system.
5.2.5. Reporting Results of Actions Taken to Reduce Risks.
5.2.5.1. The Risk Management Team reports all of its findings, analysis and action
taken to the administration in its monthly meeting.
5.2.5.2. The monthly meeting will be use as well to get inputs from each department
for any risks they identified and for any recommendations to control the
risks identified.
5.2.5.3. The report regarding results of actions will be included in the Organization
performance improvement activities.
5.2.6. Reviews and Updates.
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21 Approved by ACMC CEO
5.2.6.1. The following situations will be required to review the risk management
measures and if necessary, revise them. A review is generally required
when:
5.2.6.1.1. A significant change occurs to the workplace, work process or
system of work.
5.2.6.1.2. There is evidence that a risk control measure does not adequately
control the risk.
5.2.6.1.3. A notifiable incident occurs.
5.2.6.2. Check control measures considering the following questions:
5.2.6.2.1. Are the control measures working effectively in both their design
and operation?
5.2.6.2.2. Have the control measures introduced new problems?
5.2.6.2.3. Have all risks been identified?
5.2.6.2.4. Have new work methods, new equipment made the job safer?
5.2.6.2.5. Are safety procedures being followed?
5.2.6.2.6. Has instruction and training provided to workers on how to work
safely been successful?
5.2.6.2.7. Are staffs actively involved in identifying risks and possible control
measures? Are they openly raising exposures concerns and
reporting problems promptly?
5.2.6.2.8. Are the frequency and severity of critical incidents reducing over
time?
5.2.6.2.9. If new legislation or new information becomes available, does it
indicate current controls may no longer be the most effective?
5.2.6.3. If problems are found, go back through the risk management steps, review
our information and make further decisions about risk control.
5.3. Appendix.
5.3.1. Risk Identification Tool.
5.3.2. Risk Assessment Tool.
5.3.3. Risk Management Worksheet.
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6. Culture of Quality and Person Served Safety.
6.1. Policy.
6.1.1. The Organization summarizes the essential elements of the Organization
commitment for excellence and safety which includes:
6.1.1.1. Fostering a quality mind-set with the objective of developing and providing
effective, excellent and safe health care services that are trusted and
preferred by persons served and families/supports system and deliver on
our commitment to enable healthier and quality lives.
6.1.1.2. Complying with relevant laws and regulations as well as internal
requirements.
6.1.1.3. Continuously challenging ourselves to improve the quality management
system to guarantee persons served safety, prevent quality incidents and
eliminate risks through the review of quality objectives and results.
6.1.1.4. Encouraging participation and promotion of quality and persons served
safety responsibilities amongst all personnel through standards, education,
training and coaching, supervision and effective communication.
6.2. Procedures.
6.2.1. As part of the Organization initiative to quality and persons served safety, the
administration will be proactively engaged in its quality improvement program
through utilization of the policies and procedures stated herein.
6.2.2. The administration includes in its financial planning specifically in its annual
budget, allocation of sufficient funds and other needed resources like additional
manpower that will be dedicated to its quality improvement and persons served
safety program.
6.2.3. All Personnel will be encouraged and provided education, training or coaching
that will promote involvement in the Organization quality improvement and
persons served safety measures.
6.2.4. A non-retaliation approach is in place for those personnel who in good faith
report any errors that compromised quality improvement and persons served
safety.
6.2.5. Regular meeting either formal or informal on quality initiatives will be maintained
to assure internal communication among all staff.
6.3. Appendix.
6.3.1. Culture of Quality and Person Served Safety Framework.
DOCUMENT TITLE: CULTURE OF QUALITY AND PERSON SERVED
SAFETY
REFERENCE NUMBER: QM-006
VERSION: 2.0
EFFECTIVE DATE: 01 DEC 2016 REVIEWED: 01 DEC 2017
ARABIC CANADIAN MEDICAL CENTER QUALITY MANAGEMENT POLICIES AND PROCEDURES
23 Approved by ACMC CEO
7. Person Centered Care.
7.1. Policy.
7.1.1. The Organization follows the following person centered care guiding policies to
ensure the Organization health service delivery puts the person served first in
every decision:
7.1.1.1. All team members are considered caregivers.
7.1.1.2. Care is based on continuous healing relationships.
7.1.1.3. Care is customized and reflects persons served needs, values and
choices.
7.1.1.4. Knowledge and information are freely shared between and among persons
served, family/support system, care partners, physicians and other
caregivers.
7.1.1.5. Families and friends of the persons served are considered an essential part
of the care team.
7.1.1.6. Persons served safety is a visible priority.
7.1.1.7. Transparency is the rule in the care of the persons served.
7.1.1.8. All caregivers cooperate with one another through a common focus on the
best interests and personal goals of the persons served.
7.1.1.9. The persons served are the source of control for their care.
7.2. Procedures.
7.2.1. Everyone in the workforce, from housekeeping staff to the CEO, is part of care
experience of the person served. Regardless of one's role, each person is
expected to put the person served first.
7.2.2. To create a person-centered culture, all personnel must be aware of our person-
centered starting from the induction phase of employment.
7.2.3. The Organization will be working together to reinforce a focus on the continuum
of care for person served rather than episodes of care. Proper referral has to be
done to avoid gaps on care until goal is reached.
7.2.4. The policy for customizing care recognizes that each person served is different
and may have different needs and preferences. In addition to customizing the
care plan for each person served, the Organization works to make the
environment comfortable to individual person served. For example, one person
served may want music in the room, where another patient may not. It allows
the person served individuality to be a component of care.
DOCUMENT TITLE: PERSON CENTERED CARE
REFERENCE NUMBER: QM-007
VERSION: 2.0
EFFECTIVE DATE: 01 DEC 2016 REVIEWED: 01 DEC 2017
ARABIC CANADIAN MEDICAL CENTER QUALITY MANAGEMENT POLICIES AND PROCEDURES
24 Approved by ACMC CEO
7.2.5. In the Organization person-centered environment, all members of the care team,
including the person served, need to be aware of the person served status and
care plan. The person served is absolutely needs to be informed and part of the
decision-making.
7.2.6. The Organization recognizes that family and support system are essential
supports for the person served healing process. Family and support system
support person served not only emotionally, but also physically, as they can help
person served understand physicians' instructions. Person served may be in a
state of discomfort and pain or fear, and don't always hear information, so it
allows a trusted family member or support system identified by the person
served to participate in the sharing of information and guidance we give before
sending person served to the next level of care.
7.2.7. Making person served safety a visible priority demonstrates the Organization's
commitment to person served care. The Organization implements policies and
procedures to enforce person served safety best practices. For example, the
system had a campaign around personnel immunization and hand hygiene.
7.2.8. The transparency policy recognizes that true person-centered care requires
transparency between providers and person served and among providers.
Providers should be upfront and honest with information so person served can
make informed decisions with us. One way the Organization supports
transparency is by posting its scope and service on its website.
7.2.9. All processes at the Organization, even those that don't involve person served,
should be performed from a person served-value perspective. The Organization
coding and billing process is done from the perspective of the patient; staff has
worked to make bills clear and easy to understand for person served.
7.2.10. A core tenet of person-centered care is that the person served controls his or
her care. Making persons served the source of control of their care is the result
of effective deployment of all other guiding policies. To be the source of control,
The Organization has transparency and share information, create an
environment that allows the person served to heal and focus work on the person
served. After discharge, person served can still have a degree of control by
participating in a survey to provide input on how the system can improve care
and become more person-centered. Soliciting suggestions from those on the
receiving end of healthcare gives persons served some control over future
healthcare services and helps the Organization continue to put persons served
first in the Organization decisions.
7.3. Appendix.
7.3.1. Person Centered Organizational Structure.
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8. Interdisciplinary Person Served Education.
8.1. Policy.
8.1.1. The Organization shall commit to this policy to ensure that each person served
and family/support system educational needs are assessed, with proper referral
to concerned health care providers (if needed) and documented in his record.
8.1.2. Every person served medical record should have health education needs
assessment and education form.
8.1.3. The healthcare team must offer the persons served encouragement and
enforcement to be actively involved in their care and take a more proactive role
in their own care and safety by empowering person served to speak up and be
active in decision making in the care provided to them.
8.1.4. The healthcare team during the admission or assessment interview should
determine and identify any barriers that may influence the person served and
family/support system ability to learn.
8.1.5. The healthcare team should document any identified barriers and its intervention
in the Interdisciplinary patient/family education record.
8.1.6. The healthcare team shall seek the assistance from the appropriate available
health services such as language interpreter, speech and language therapist,
religious guidance to assists with the educational needs assessment and
subsequent person served education, when such barrier(s) is identified.
8.1.7. All Healthcare Personnel shall collaborate to provide education to persons
served and families/supports system.
8.2. Procedures.
8.2.1. Assessment / Re-assessment of Person Served and Family/Support
System Learning Needs.
8.2.1.1. The educational process shall include assessment and individualized plan
of care to include persons served and families/supports system learning
needs, activities, preferences, and readiness to learn. Considerations shall
be given to:
8.2.1.1.1. Cultural and religious practices.
8.2.1.1.2. Emotional barriers.
8.2.1.1.3. Physical and cognitive limitations.
8.2.1.1.4. Barriers to Communication (i.e. Language, unable to speak).
8.2.1.1.5. Health literacy.
8.2.1.1.6. Desire and motivation to learn.
DOCUMENT TITLE: INTERDISCIPLINARY PERSON
SERVED EDUCATION
REFERENCE NUMBER: QM-008
VERSION: 2.0
EFFECTIVE DATE: 01 DEC 2016 REVIEWED: 01 DEC 2017
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8.2.1.1.7. Financial implication of care choices
8.2.2. Person Served and Family/Support System Education Planning.
8.2.2.1. The education process shall include as appropriate to assess the needs of
the person served:
8.2.2.1.1. The plan for care, treatment and services.
8.2.2.1.2. Basic health and safety practices.
8.2.2.1.3. Safe and effective use of medications.
8.2.2.1.4. Nutrition interventions and modified diets.
8.2.2.1.5. Safe and effective use of medical equipment or supplies.
8.2.2.1.6. Importance of understanding effective pain management,
assessment process, risk, and methods prescribed to achieve
optimal comfort measures.
8.2.2.1.7. Rehabilitation techniques to help reach maximum independence
possible.
8.2.2.1.8. When and how to obtain further treatment if needed.
8.2.2.1.9. Regarding the ongoing health care needs.
8.2.2.1.10. Maintenance of good personal health practices, including oral
hygiene.
8.2.2.1.11. Fall reduction strategies.
8.2.3. Implementation of Person Served and Family/Support System Education
Plan.
8.2.3.1. The healthcare team, who assess the patient, shall enter his name,
signature and staff number in the assessment form and record it in the
person served medical record.
8.2.3.2. The staff identifies and incorporates in the assessment forms, the data for
person served and family/support system need for teaching, readiness and
barriers for learning.
8.2.3.3. The staff shall indicate in the assessment Form the person served and
family/support system needs for learning or re-assessment in case of any
change in person served conditions.
8.2.3.4. The staff shall teach and inform person served and family/support system
the nature of his illness, complications, treatment, its benefits and
importance of follow-ups to the hospital.
8.2.3.5. If the staff finds that the person served needs more education, he will refer
the person served to the concerned parties.
8.2.3.6. The concerned parties (doctors, physiotherapist etc.) will do more
assessment and record that in the interdisciplinary form.
8.2.3.7. The educational need assessment and education subjects should include
but not be limited to:
8.2.3.7.1. Diagnosis;
8.2.3.7.2. Care plan and treatment;
8.2.3.7.3. When and how to call for assistance;
8.2.3.7.4. Infection prevention and control;
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27 Approved by ACMC CEO
8.2.3.7.5. Informed Consent;
8.2.3.7.6. Medication (safety, effects/ side effect, interactions);
8.2.3.7.7. Diet / Nutrition;
8.2.3.7.8. Medical equipment;
8.2.3.7.9. Implants/Prosthesis/Implantable/remote monitoring device;
8.2.3.7.10. Discharge education including explanation about when to seek
emergency care;
8.2.3.7.11. Fall Risk Education;
8.2.3.7.12. Pain Management;
8.2.3.7.13. Rehabilitation; and
8.2.3.7.14. Persons Served Bill of Rights.
8.2.3.8. The method of education can include verbal instruction and skills
demonstration
8.2.3.9. Instruction and education will be in the primary language of person served
and family/support system when possible.
8.2.3.10. When available, education leaflets should be provided to act as
reinforcement to the provided education but cannot be substituted as the
only means of education method.
8.2.3.11. The staff shall indicate re-assessment of patient/family learning needs in
case of any change in person served condition and arise of new needs.
8.2.4. Discharge Planning.
8.2.4.1. Discharge planning is initiated on initial assessment and is ongoing.
8.2.4.2. Discharge instructions are given to the person served and family/support
system in a manner that they can understand.
8.2.4.3. The person served and family/support system is educated on how to obtain
continuing care, treatment and services to meet his identified needs.
8.2.5. Evaluation of Outcomes.
8.2.5.1. The person served and family/support system understandings of learning
needs are continually evaluated by members of the health care team.
8.2.5.2. Evaluate learning objectives via return demonstration and / or verbal
discussion / follow-up care.
8.2.5.3. When behavioral objectives are not met, revision of the educational plan
with alternate educational strategies are utilized and re-evaluated by
members of the health care team.
8.2.5.4. Review and Approval of Education Materials.
8.2.5.5. The content of the t education materials are periodically submitted to
Quality and Compliance Office for review and revision. The Quality and
Compliance Office seeks recommendation and suggestions from the health
professional experts that may include physicians, nurses, therapists and
other healthcare professionals with expertise in the content area. This
process shall include:
8.2.5.5.1. Evaluation of material for demonstrated need;
8.2.5.5.2. Visual effectiveness;
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28 Approved by ACMC CEO
8.2.5.5.3. Potential duplication or replacement of existing education
materials;
8.2.5.5.4. Format;
8.2.5.5.5. Graphics;
8.2.5.5.6. Cost;
8.2.5.5.7. Length; and
8.2.5.5.8. Readability.
8.3. Appendix.
8.3.1. Interdisciplinary patient/family education record
ARABIC CANADIAN MEDICAL CENTER QUALITY MANAGEMENT POLICIES AND PROCEDURES
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9. Complaint Management.
9.1. Policy.
9.1.1. The Organization establishes a complaints management system that is
accessible to all people, that identifies the process of making a complaint and
the roles and responsibilities of those involved in dealing with complaints and a
procedure by which complaints will be addressed and resolved within the
abilities of the Organization.
9.1.2. The Organization Complaint Management is not to apportion blame, it is to
investigate complaints to the possible satisfaction of the complainant, whilst
being scrupulously fair to staff, and to learn lessons for improvements in service
delivery.
9.1.3. The Organization complaint management system satisfies patients‟ rights and
responsibilities, confidentiality and the quality and safety of healthcare services
provided.
9.1.4. The complaint procedures are published in Arabic and English Languages and
are made visible in the facility‟s website, reception, waiting areas and on
patient‟s residence for those with 8/12/24 hour‟s home nursing service.
9.1.5. The complaint management system ensures the responsiveness, transparency,
and time-bound.
9.1.6. Investigation of the complaint is conducted in a fair, comprehensive, and
impartial manner that assures and respects the rights of the complainant without
prejudice to their right to access services or the quality of services provided to
them.
9.1.7. The Organization endeavor to resolve complaints to the satisfaction of the
complainant, wherever possible, and refer the complainant to HAAD Complaints
Management process where a complainant is not satisfied with the facility‟s
outcome.
9.1.8. The complainant is offered a meeting to communicate findings of the
investigation and that all communications are documented.
9.1.9. The facility establishes a complaint committee that ensures each complaint is
risk assessed to determine whether additional actions need to be taken at the
Organization level. This includes where a complaint may require a Sentinel
Event/Serious Clinical Incident reporting or review by Root Cause Analysis
and/or investigation of clinical error and subsequent rectification of issues
identified.
9.1.10. The Organization measures complainants‟ satisfaction with the facility
complaints management process; identify deficiencies in the complaints process
DOCUMENT TITLE: COMPLAINT MANGEMNET
REFERENCE NUMBER: QM-009
VERSION: 2.0
EFFECTIVE DATE: 01 DEC 2016 REVIEWED: 01 DEC 2017
ARABIC CANADIAN MEDICAL CENTER QUALITY MANAGEMENT POLICIES AND PROCEDURES
30 Approved by ACMC CEO
or the quality and safety of care, and formulate recommendations and action
plans to ensure changes implemented accordingly.
9.2. Procedures.
9.2.1. Time limits apply to the initiation of a complaint. A formal complaint should
normally be made within 6 months of the incident that caused the problem, or
within 6 months of the discovery of the problem. The management, at its sole
discretion, may consider and accept exceptions to this, upon application by a
complainant.
9.2.2. The complainant is required to apply to the management in writing seeking an
exception and explaining the reasons to justify such a request.
9.2.3. Anyone working in the Organization that received or encountered a complaint
whether verbal/written must acknowledge it with professionalism, respect and
fairness.
9.2.4. Anyone working in the Organization who received or encountered a complaint
whether verbal/written must secure the following details and must be transcribed
on the complaint form:
9.2.4.1. Name of complainant;
9.2.4.2. Name of the patient involve;
9.2.4.3. Date when complaint was made;
9.2.4.4. Complainant contact number or email;
9.2.4.5. Address;
9.2.4.6. Relationship to the patient involve;
9.2.4.7. Date of the incident that is subject for complaint;
9.2.4.8. Name of the involve healthcare professional; and
9.2.4.9. Summary of the complaint.
9.2.5. Any personnel who receive a complaint whether verbal/written must relay
immediately the information to the Patient Relation Officer. In the absence of the
Patient Relation Officer, report could be relayed directly to the Quality
Improvement and Patient safety Officer.
9.2.6. The Patient Relation Officer:
9.2.6.1. Must acknowledge the complaint as soon as he received by giving a call,
sending an SMS or email to the complainant and must be documented on
the complaint log.
9.2.6.2. Should only acknowledge the received complaint but must not or in other
way give assurance or resolution comment to the complainant until decision
for corrective action has been made by the complaint committee.
9.2.6.3. Ensures that every received complaint be given a case number and must
be logged.
9.2.6.4. Analyzed the complaint with the help of the Quality Improvement Officer as
to whether the complaint will fall under Clinical Complaint or Service
Complaint.
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9.2.7. The Patient Relation Officer and the Quality Improvement Officer will form a
committee based from the involved department that will help them in
investigating the complaint and gathering more substantial details.
9.2.8. The investigation and corrective actions should only take maximum 7 business
days or less, as possible.
9.2.9. In case that investigation and corrective actions cannot be done within 7
business days, an SMS, email, or a call shall be given to the complainant
explaining the process going on and the reason of the delay and must be
documented on the complaint log.
9.2.10. Once the committee had made a decision for corrective action, the resolution
must be documented on the Complaint Action Form by the head of the
department involve.
9.2.11. The Patient Relation Officer should inform the complainant of the decision and
action made in writing within 2 business days and must be documented on the
complaint log.
9.2.12. The Patient Relation Officer may also send Complaint Resolution Survey Form
and inform the complainant to answer it for service quality assessment.
9.2.13. The case is considered resolved when formal communication from the Patient
Relation Officer responsible for the complaints management system, is sent to
the complainant informing them of the findings of the investigation and the
actions decided by the responsible body(s).
9.2.14. When the implementation of any action or action plan decided by the facility is
confirmed as completed by the Complaints Committee or the assigned
responsible Senior Manager at the facility the case will be considered closed and
must be documented both on the Complaint Log and Complaint Action Form.
9.2.15. In case that complaint is withdrawn by the complainant, a Complaint Withdrawal
Form must be filled up, signed and sent back to the Patient Relation Officer.
9.2.16. All records about complaint must be filed and kept for five years by the Patient
Relation Officer arranged by case number for future references.
9.3. Appendices.
9.3.1. Complaint Process Flow Chart.
9.3.2. Complaint Form.
9.3.3. Patient Complaints Log.
9.3.4. Complaint Resolution Satisfaction Survey.
9.3.5. Complaint Withdrawal Form.
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10. Incident Reporting Policy.
10.1. Policy.
10.1.1. The Organization defines the following terms:
10.1.1.1. Adverse Event- an event that causes harm, or has potential to cause harm
to a patient. For the purposes of this Policy, an adverse event includes
sentinel events and near misses defined below.
10.1.1.1.1. Near Miss- circumstances or events that had the capacity to
cause an adverse event, but which did not reach the patient.
10.1.1.1.2. Sentinel Event- any unanticipated adverse event or „Near Miss‟
event in a healthcare setting resulting in death or serious physical
or psychological injury to a patient or patients, not arising from the
natural course of the patient's illness, including:
10.1.1.1.2.1. A patient fall that results in death or major permanent
loss of function as a direct result of the injuries sustained
in the fall.
10.1.1.1.2.2. Any intra-partum (related to the birth process) maternal
death.
10.1.1.1.2.3. Any peri-natal death unrelated to a congenital condition
in an infant having a birth weight greater than 2,000
grams.
10.1.1.1.2.4. Discharge of an infant to the wrong family e. Hemolytic
transfusion reaction involving administration of blood or
blood products having major blood group
incompatibilities.
10.1.1.1.2.5. Prolonged fluoroscopy with cumulative dose >1500 rads
to a single field or any delivery of radiotherapy to the
wrong body region or >25% above the planned
radiotherapy dose.
10.1.1.1.2.6. Severe neonatal hyperbilirubinemia (bilirubin >30
milligrams/deciliter).
10.1.1.1.2.7. Suicide of any patient or within 72 hours of inpatient
discharge.
10.1.1.1.2.8. Surgery on the wrong patient or wrong body part (all
events of surgery on the wrong patient or wrong body
part are reviewable under the policy, regardless of the
magnitude of the procedure or the outcome.)
DOCUMENT TITLE: INCIDENT REPORTING POLICY
REFERENCE NUMBER: QM-010
VERSION: 2.0
EFFECTIVE DATE: 01 DEC 2016 REVIEWED: 01 DEC 2017
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10.1.1.1.2.9. Unanticipated death of a full-term infant.
10.1.1.1.2.10. Unintended retention of a foreign object in a patient
after surgery or other procedure.
10.1.1.1.2.11. Rape or physical assault of a patient.
10.1.2. It is the responsibility of all personnel to immediately report the details of any
adverse event that may negatively impacts the care of the person served.
10.1.3. The OVR form will be initiated immediately following any near miss and sentinel
events.
10.1.4. All sections of the OVR form must be completed and submitted to the Head of
the department within 24 hours from the time of incident.
10.1.5. This report is to be used to identify the facts surrounding the incident and will not
be used to criticize or speculate on actions of the personnel involved.
10.1.6. Corrective actions shall be taken to minimize risk of adverse outcomes.
Corrective action(s) shall be documented.
10.1.7. The OVR Form shall not be photocopied or placed in the medical record. The
terms “incident” and “error” shall not be used in the medical record when making
an entry regarding an incident or the results of an incident.
10.1.8. It is the responsibility of Quality Improvement and Patient Safety Officer to
provide the Director for Quality and Compliance with a quarterly summary of
person served incidents.
10.1.9. All OVR shall be handled and maintained in a confidential manner, with access
to such documentation restricted to authorized individuals.
10.1.10. The information contained in the OVR form cannot and shall not be used
against any individual as the sole basis for disciplinary action.
10.1.11. The process of reporting incident must be in place with clear communication
process within the Organization.
10.1.12. All adverse event report shall be investigated to determine the root cause and
must be analyze to determine trends and create action plan for improvement.
10.1.13. Feedback must be provided to the person served following investigation and
creation of action plan addressing the incident happened.
10.1.14. The Organization shall use this process as a tool for learning and improving its
health service delivery towards quality improvement and person served safety
goal.
10.1.15. Adverse events related to Occupational and Environmental Health and Safety
EHSMS) and Medications are excluded from the scope of this policy, but must
be reported in accordance with the requirements of the HAAD OSHAD
standards and the HAAD policies on Reporting Medication Errors and
Reporting Adverse Reaction, respectively.
10.2. Procedures.
10.2.1. Internal Reporting for Near Miss not Resulting to Sentinel Event.
10.2.1.1. Fill up appropriate spaces of the OVR form using blue or black ink. Do not
use pencil.
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10.2.1.2. Write in clear, legible hand-writing objectively avoiding personal opinions.
10.2.1.3. Place the person served MRN and records the diagnosis.
10.2.1.4. Record time of occurrence using 24 hours timing, enter approximate time, if
possible.
10.2.1.5. Narrate briefly but objectively the statement of facts without including
personal judgment, or opinions and accusations to any individual involved
in the event. If a physician was notified or actually attended the patient,
he/she should write a brief statement in the space provided for-Physician
Follow-Up with regard to the injured person; and to sign on the space
provided.
10.2.1.6. Let the witness to fill up the spaces provided for him/her and to sign on the
OVR under-Witness.
10.2.1.7. Forward the filled up OVR to the immediate supervisor within 24 hours, who
will forward it to the Department Head for investigation.
10.2.1.8. Initial report with an action plan has to be submitted by the Department
Head to the Quality and Patient Safety Officer within 7 days.
10.2.1.9. Report and Action Plan Acceptable:
10.2.1.9.1. Quality and Patient Safety Officer will keep a copy on its
database.
10.2.1.9.2. The Organization Decision will be communicated to the person
served or family/support system through the Patient Relation
Officer.
10.2.1.10. Report and Action Plan Unacceptable:
10.2.1.10.1. Quality and Patient Safety Officer returns the report to the
Department Head for revision and must then, is resubmit back.
10.2.2. Internal Reporting for Near Miss Resulting to Sentinel Event.
10.2.2.1. Follow procedures 10.2.1.7.
10.2.2.2. Investigation shall be done together with the Quality and Patient Safety
Officer.
10.2.2.3. Initial report with an action plan has to be submitted by the team within 2
days to Director for Quality and Compliance with a copy to Medical Director.
10.2.2.4. Report and Action Plan Acceptable:
10.2.2.4.1. Director for Quality and Compliance and the Medical Director
submits the report to HAAD.
10.2.2.5. Report and Action Plan Unacceptable:
10.2.2.5.1. Quality and Patient Safety Officer returns the report to the
investigating team for revision and must then, is resubmit back
within 24 hours.
10.2.3. External Reporting to HAAD.
10.2.3.1. The Quality Improvement and Patient Safety Officer for sentinel events
defined in this Policy, report occurrence of a sentinel event to HAAD within
48 hours through HAAD complaint system.
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10.2.3.2. The Director for Quality and Compliance and Medical Director submit an
initial investigation report of the event within seven days of its occurrence to
HAAD with details of the investigation and actions taken including
minimizing risk of recurrence.
10.2.3.3. Submit a full report to HAAD with details of the investigation, root-cause
analysis and action plan to minimize risk of recurrence (within 45 working
days).
10.3. Appendix.
10.3.1. Occurrence Variance and Incident Report Form
Recommended