Health, Care, Quality, improvement, Introduction Gamal Soliman 24-2010

04/13/2304/13/23 Prepared By: Dr Gamal SolimanPrepared By: Dr Gamal Soliman

Health Care,Health Care,Not only qualityNot only quality

But also improvementBut also improvement

Rule # OneRule # One

No Blame But RewardNo Blame But Reward


Health Care Quality Management Health Care Quality Management

Introduction And PrinciplesIntroduction And Principles


Today’s Agenda Today’s Agenda

24-05-201024-05-2010


1.1. Criteria for Performance Excellence.Criteria for Performance Excellence.

2.2. Eight Disciplines Problem Solving.Eight Disciplines Problem Solving.3. Accreditation Decisions.

4.4. Ten Survey Strategies to Remember.Ten Survey Strategies to Remember.

5.5. Quality Management Standards Quality Management Standards

Flow of informationFlow of information

5-1 Plan For Implementation.5-1 Plan For Implementation. 5-2 Patient Safety Initiative. 5-3 Internet Resources


Part1Part1Criteria for Performance ExcellenceCriteria for Performance Excellence To help improve organizational To help improve organizational

performance practices, capabilities and performance practices, capabilities and resultsresults

To facilitate communication and sharing of To facilitate communication and sharing of information on best practices.information on best practices.

A working tool for, understanding, A working tool for, understanding, managing performance, for guiding managing performance, for guiding planning and opportunities for learningplanning and opportunities for learning


The seven categories of the Criteria The seven categories of the Criteria areare1. Leadership1. Leadership2. Strategic Planning2. Strategic Planning3. Customer Focus3. Customer Focus4. Knowledge Management4. Knowledge Management5. Workforce Focus5. Workforce Focus6. Process Management6. Process Management7. Results7. Results


Results to be achieved:Results to be achieved: delivery of ever-improving value to delivery of ever-improving value to

patients& owners, contributing to patients& owners, contributing to organizational sustainabilityorganizational sustainability

improvement of overall improvement of overall organizational effectiveness and organizational effectiveness and capabilitiescapabilities

organizational and personal learningorganizational and personal learning


Part2Part2

Eight Disciplines Problem SolvingEight Disciplines Problem Solving


1-Define the Problem1-Define the Problem

2-Use a Team2-Use a Team

3- 3- Implement and verify Interim Implement and verify Interim ActionsActions

4- 4- Identify and Verify Root CausesIdentify and Verify Root Causes

5- Choose and verify Permanent 5- Choose and verify Permanent Corrective Actions (PCAs)Corrective Actions (PCAs): :


6-Implement and validate PCAs6-Implement and validate PCAs

7-Prevent recurrence7-Prevent recurrence: Modify the : Modify the management systems, operation management systems, operation systems, practices and procedures systems, practices and procedures to prevent recurrence of this and all to prevent recurrence of this and all similar problems. similar problems.

8-Congratulate your Team8-Congratulate your Team


Part3Accreditation Decisions


Accredited Provisional Accreditation Conditional Accreditation Preliminary Denial of

Accreditation Denial of Accreditation Preliminary Accreditation


Part4Part4

Ten Survey Strategies to RememberTen Survey Strategies to Remember


1. Be confident - you are the expert not the survey team!

2. Anticipating the survey is more stressful than the actual survey

3. You will pass by meeting regulatory requirements, 4. Preparation for the survey includes

documentation, organization - effectively communicating what you know.


5. Show the surveyors completed risk assessments, “RCA’s” and :FOCUS 6. First impressions are extremely

important; 7. “Closing the loop” on identified

problems can be more important than the problem itself!

8. Facts not documented, don’t exist!


9. Prepare for the survey by organizing the required planning documents, practicing interview and pre-planning the building tour

10. If you disagree with a surveyor, tactfully uncover their perspective, - - - - - -------Relax!

Resource: www.ahrq.org


5-1 Quality Management Standards 5-1 Quality Management Standards

Plan For ImplementationPlan For Implementation


1-A sufficient staff to QM 1-A sufficient staff to QM committee,committee,

2-QM2-QM

Mission, Vision, Value, scope of Mission, Vision, Value, scope of services, Organizational Chart and services, Organizational Chart and job descriptions Templates job descriptions Templates MethodMethod: This week templates of : This week templates of designs for each department,designs for each department,


3-Define high problem prone areas.3-Define high problem prone areas. 3- 1 Invasive procedures.3- 1 Invasive procedures. 3-2 High risk procedures.3-2 High risk procedures. 3-3 unusually expensive 3-3 unusually expensive

medications.medications. 3-4 All high risk medications.3-4 All high risk medications.


MethodMethod: Flow of information to head : Flow of information to head departments, departments,

Print and give high problem prone Print and give high problem prone areas PFR-16 teaching file,areas PFR-16 teaching file,

To be modified accordingly.To be modified accordingly.


5-2 Patient Safety Initiative


Assign individuals (team) Scope of program activities Safety culture Focus to improve patient safety processes, No

blame No punishment against staff making errorsBut correct them and reward the competent Components of programDescription of how Al-Rashid Hospital integrates

safety elements into wide effort


Adverse Events (medical errors) Plan provides for:

Procedures for immediate response. 1- Care of the affected patients 2- Containment of risk to others 3- Preservation of information for subsequent analysis Definition of the systems in place for internal and

external reporting of information Definition of mechanisms in place for responding to

unexpected clinical events including sentinel events-SE, root cause analysis-RCA, Plan Do Check Act-PDCA and FOCUS


Measurement and analysis Corrective actions for high-risk processes Resourced allocation1-A good design of adequate parameters2-Assignment of competent personnel3-Provision of information systems and data

management process4-Leadership assessment


5-5-Barriers and solutions to:

Effective communication, Analysis of major adverse events Knowledge-based systems


6- Information analysis on:A-Confirmed transfusion reactions B-Significant adverse drug reactions C-Significant medication errors and

hazardous conditions D-Major discrepancies between pre- and

postoperative diagnosis E-Adverse events associated with anesthesia


7-Identification of staff roles and 7-Identification of staff roles and responsibilities.responsibilities.

8-Quality concepts and Risk 8-Quality concepts and Risk Management.Management.

9-Problem identification, information 9-Problem identification, information gathering, implementing actions, and gathering, implementing actions, and evaluation.evaluation.


10- Data measurements, analysis and 10- Data measurements, analysis and implementation evaluation implementation evaluation

11- Quality improvement projects 11- Quality improvement projects prioritization, teams reports and flow prioritization, teams reports and flow of information to all staffof information to all staff

12- Quality plans approval by the QM 12- Quality plans approval by the QM and the Hospital Directorand the Hospital Director

13- Annual plans’ revisions by GM13- Annual plans’ revisions by GM


MethodMethodQM supplies hard and soft P&P this QM supplies hard and soft P&P this

week to all committees of the next:week to all committees of the next:


Checklist for Patient SafetyChecklist for Patient Safety Template for Developing Your Quality ManTemplate for Developing Your Quality Man

agement Planagement Plan The Focus: PDCA MethodologyThe Focus: PDCA Methodology Action Minutes TemplateAction Minutes Template Indicator & PDCA WorksheetIndicator & PDCA Worksheet Organizational QI PlanOrganizational QI Plan Application Form For PDCA ProjectsApplication Form For PDCA Projects Quality Management PlanQuality Management Plan


6-3 Internet Resources:6-3 Internet Resources:

www.cbahi.orgwww.cbahi.org

www.jointcommissioninternational.orgwww.jointcommissioninternational.org

www.ahrq.orgwww.ahrq.org

www.apic.orgwww.apic.org


ENDEND

Primo Non NocerePrimo Non Nocere

= =

Before All No ObstaclesBefore All No Obstacles

Health & Medicine

Health, Care, Quality, improvement, Introduction Gamal Soliman 24-2010