Embed Size (px)
Citation preview
uality
Management
and Patient
Safety
Mary Kaye Tacuel, R.N.Quality Management Coordinator
23 November 2014
23 November 2014 / [email protected]
uality Management &
Patient Safety
ORIENTATION
PROGRAM
STATEMENT
The mission of the Quality Management and Patient
Safety Department of Mohammad Dossary Hospital is
to improve performance through quality and patient
safety culture, appropriate data management process,
improvement approach (FOCUS-PDCA) and ongoing
staff development and training.
uality Management &
Patient Safety
ORIENTATION
PROGRAM
STATEMENT
The vision of the Quality Management and Patient
Safety Department of Mohammad Dossary Hospital
is to implement and maintain national and
international quality and patient safety standards
through the SCBAHI and JCI Accreditation.
• To ensure continuous improvement of the
quality of services rendered to the MDH
internal and external customers.
• To improve patient safety and
reduce risk to patients.
uality Management &
Patient Safety
ORIENTATION
PROGRAM
uality Management &
Patient Safety
ORIENTATION
PROGRAM
FUNCTIONS:
1. Performance Improvement
2. Accreditation
3. Patient Safety
4. Risk Management
5. Utilization Management
6. Audit
uality Management &
Patient Safety
ORIENTATION
PROGRAM
Utilization Review &
Clinical Audit Coordinator
(VACANT)
Ext. 674
Ext. 571
uality Management &
Patient Safety
ORIENTATION
PROGRAM
FUNCTIONS
Implementation, monitoring and evaluation of Patient and
Employee Satisfaction Survey.
Monitoring the Quality Improvement Guidelines.
Reporting of Performance/Quality Indicators.
Evaluation of evidenced-based practice (clinical practice
guidelines compliance monitoring).
Compliance and validation audit.
Identification, monitoring and evaluation of high-risk,
problem-prone and high-cost areas (high-risk
medications, invasive procedures, high risk procedures
and unusually expensive medications).
Data repository of all Quality Improvement, Patient
Safety and Risk Management activities.
with HR & PFR
as per the QM Plan
by the Depts.
with the Medical Committees
with MOI
1. Performance Improvement
uality Management &
Patient Safety
ORIENTATION
PROGRAM
FACILITATING…
self-assessment of the accreditation standards.
QI and Accreditation activities.
the formulation, implementation, monitoring and evaluation of
the organization compliance .
development of clinical guidelines and pathways .
INTEGRATING…
data analysis results into opportunities for improvement.
quality findings into the policies and procedures.
all accreditation standards into patient care processes.
Providing EDUCATION and TRAINING to all hospital staff on the
standards.
Identifying areas of non-compliance with the standards.
2. AccreditationFUNCTIONS
uality Management &
Patient Safety
ORIENTATION
PROGRAM
Ongoing assessment of patient safety-related
occurrence and incidence.
Investigation of Sentinel/ Critical Event and Near Miss.
Implementation of Proactive Analysis and Root Cause
Analysis (RCA).
Provide guidance in the formulation, implementation,
monitoring and evaluation of the 6 International
Patient Safety Goals.
Patient Safety Orientation, Training and Education
Program.
Implementation of Patient Safety Culture Survey.
3. Patient Safety
Hospital-wide
December 2014
FUNCTIONS
uality Management &
Patient Safety
ORIENTATION
PROGRAM
Monitoring the compliance for all Preventive
Maintenance Program.
Monitoring and evaluation of Emergency and
Disaster Guidelines.
Monitoring of Infection Control Program.
Sentinel Events and Near Miss investigation.
Risk Assessment, Risk identification thru OVR
and Patient Complaints.
Analyzing Medical Record Review results.
Credentialing & Privileging Audit.
Audit of Highly Critical, Problem Prone, High
Volume and High Cost Processes.
4. Risk Management
Safety Com.
IC Com.
PFR Com.
MR/MOI Com.
for PI Project
FUNCTIONS
uality Management &
Patient Safety
ORIENTATION
PROGRAM
Monitor the appropriate allocation of the hospital's
resources by provision of quality patient care in
the most cost effective manner.
Timely review of the medical necessity for
admissions, continued stays and services
rendered.
Monitor over utilization, underutilization,
inefficient scheduling of resources.
Develop, formulate and monitor Utilization Review
Guidelines.
Timely monitoring, review and evaluation
leadership performance indicators related to the
utilization of resources of the organization.
5. Utilization Management
Committees
FUNCTIONS
uality Management &
Patient Safety
ORIENTATION
PROGRAM
Identify High Risks, High Volume, Problem-Prone and
High Cost Processes.
Development of a flexible Annual Audit Guidelines.
Implement the annual Audit Guidelines.
Conduct clinical and compliance audits.
Maintain teams, staff with sufficient knowledge, skills
and experience in auditing.
Keep the executive team informed of emerging trends.
Provide audit recommendation.
6. Audit
Presently done by the departments in collaboration with the QM&PS.
FUNCTIONS
uality Management &
Patient Safety
ORIENTATION
PROGRAM
SN Name of Committee
1 Hospital Executive Management Committee
2 Medical Executive Committee
3 Blood Utilization and Tissue Review Committee
4 Morbidity and Mortality Committee
5 Medical Records Review and Hospital Formats / MOI Committee
6 Quality Improvement and Patient Safety Committee
7 Operating Room and Surgical Case Review Committee
8 Medical Credentialing and Privileging Committee
9 Pharmacy and Therapeutic Committee
10 CPR Committee
11 Patient and Family Rights Committee
12 Infection Control Committee
13 Hospital Safety Committee
Hospital-wide Committees
uality Management &
Patient Safety
ORIENTATION
PROGRAM
Hospital-wide Committees
Quality Improvement and
Patient Safety Committee
Multidisciplinary
Provides coordination and oversight for the implementation of the hospital-wide quality, performance improvement, risk management and patient safety programs.
Ensures that high standards of care provided are adequate, and that appropriate governance structures andcontrols are in place throughout MDH.
uality Management &
Patient Safety
ORIENTATION
PROGRAM
Hospital-wide Committees
Hospital Executive Committee
Provides governance that can effectively address strategic and operational issues related to the provision of quality, cost-effective and safe healthcare services arising in MDH.
Medical Executive Committee
Administers, develops, coordinates, regulates and monitors the clinical services in MDH.
uality Management &
Patient Safety
ORIENTATION
PROGRAM
Hospital-wide Committees
Blood Utilization and
Tissue Review Committee
Ensures standardization of blood and blood products administration practices as recommended by the American Association of Blood Banks (AABB).
Monitors and investigates all pertinent cases in which clinical diagnoses (pre-operative and post operative) and pathological diagnoses do not agree.
Pharmacy & Therapeutics Committee
Acts as a policy recommending body to the Medical Staff, Pharmacy Department and Administration on all matters relating to the therapeutic use of drugs at MDH.
uality Management &
Patient Safety
ORIENTATION
PROGRAM
Hospital-wide Committees
Credentialing & Privileging
Committee
Defines hospital policies and procedures for credentialing and privileging of physicians, dentists and allied health professionals.
Morbidity and Mortality Committee
Provides critical analysis of the systems and processes leading to an adverse outcome of care (including death) in an open and ethical manner.
Develops recommendations to prevent similar adverse outcomes of care in the future.
uality Management &
Patient Safety
ORIENTATION
PROGRAM
Hospital-wide Committees
CPR Committee
Ensures implementation and monitoringof quality standards of cardio and/or pulmonary arrests based on the American Health Association (AHA) Resuscitation Guidelines and Saudi Heart Association.
OR Committee
Ensures proper utilization, safe surgical practice and high standard in communication with all involved disciplines in the Operating Room.
uality Management &
Patient Safety
ORIENTATION
PROGRAM
Hospital-wide Committees
Medical Records / MOI Committee
Oversees management of patient information: quality and maintenance, including filing, storage, access and release of confidential patient information.
Supports the Information Technology and Communication project decisions and ensures its alignment with the MDH Strategic Plan.
Patient Rights & Education Committee
Ensures that patient and family rights are protected, emphasizing on the involvement and participation of patients and families in the patient care.
Oversees the patient complaints process and outcomes.
Supports the clinical staff in developing their roles in patient education activities.
uality Management &
Patient Safety
ORIENTATION
PROGRAM
Hospital-wide Committees
Infection Control Committee
Ensures the implementation of the hospital-wide Infection Prevention and Control Program.
Effectively addresses infection control and prevention issues arising in MDH.
Hospital Safety Committee
Addresses general health and safety matters arising in MDH with particular reference to the requirements of the national and international standards regarding patient, staff, visitors and building safety.
uality Management &
Patient Safety
ORIENTATION
PROGRAM
1. Clinical
2. Managerial
3. International Patient
Safety Goals (IPSG)
“We cannot improve what
we cannot measure.”
Clinical Monitors
STANDARD INDICATOR NAMEDEFINITION
NUMERATOR AND DENOMENATOR
Clinical monitoring
include Patient
Assessment
Initial Patient
Assessment performed
after Admission by the
Physician within
acceptable time frame as
per P&P
Number of inpatients medical records with
completed Initial Physical Assessment
performed by the Physician within
acceptable time frame as per P&P /
Total audited Admitted Patient Medical
Records x100
Clinical monitoring
include Nursing
Assessment
Initial Nursing
Assessment performed
after Admission by the
Nursing within acceptable
time frame as per P&P
Number of inpatients medical records with
completed Initial Nursing Assessment
performed within acceptable time frame
as per P&P /
Total audited Admitted Patient Medical
Records
uality Management &
Patient Safety
ORIENTATION
PROGRAM
STANDARD INDICATOR NAMEDEFINITION;
NUMERATOR AND DENOMENATOR
Clinical monitoring include
these aspects of Lab
Services selected by the
leaders
Specimen Rejection
Rate
Number of Rejected Specimens /
Total Number of Lab samples collected
in the Same Month
Clinical monitoring include
these aspects of Lab
Services selected by the
leaders
Turnaround Time
Routine
No. of Selected Result Released within
2 Hours /
Total No. of Randomly Selected
Sample (500) X 100
Clinical monitoring include
these aspects of Lab
Services selected by the
leaders
Rate of Critical Values
Communicated
Total Number of Critical Values
Communicated / Total Number of
Critical Values Resultx100
Clinical monitoring include
these aspects of Lab
Services selected by the
leaders
Turnaround Time of
Critical Test Result
Troponin 1 (ER)
Total No. of Minutes result was
released / Total No. of Minutes the
request was made
uality Management &
Patient Safety
ORIENTATION
PROGRAM
Clinical Monitors
STANDARD INDICATOR NAMEDEFINITION;
NUMERATOR AND DENOMINATOR
Clinical monitoring
includes the use of blood
and blood products
In-Date Blood
Wastage
No. of In-Date Blood Units
Wastage / Total No. of Blood
Units Transfused+ Total No. of
In-Date Blood Units Wastage x
100
Clinical monitoring
includes the use of blood
and blood products
Rate of Blood
Transfusion
Reaction
Total No. of Blood Transfusion
Reactions / Total No. of Blood
Transfusions x 100
Clinical Monitors
uality Management &
Patient Safety
ORIENTATION
PROGRAM
STANDARD INDICATOR NAMEDEFINITION;
NUMERATOR AND DENOMINATOR
Clinical monitoring
includes surgical
procedures
Rate of unplanned
return to Operation
Theatre
Number of Unplanned return to
Operation Theatre during the same
admission / Total Surgeries
performed during the study period
Clinical monitoring
includes the use of
antibiotics and other
medications use selected
by the organization.
Percentage of
surgical patients
with antibiotic
administration within
60 minutes prior to
surgical incision
Number of selected surgical patients
whose prophylactic antibiotics were
initiated within 60 minutes prior to
surgical incision / Selected surgical
patients (exclusions listed)
Clinical monitoring
includes the use of
anesthesia
Pre-anesthesia
Assessment
Compliance Rate
Number of patients who have pre-
anesthesia assessment completed
prior to surgery / Total number of
patients who have anesthesia in the
same month
Clinical Monitors
uality Management &
Patient Safety
ORIENTATION
PROGRAM
STANDARD INDICATOR NAMEDEFINITION;
NUMERATOR AND DENOMINATOR
Clinical monitoring includes
infection control,
surveillance, and reporting
Urinary Catheter
Related (CAUTI)
Infection Rate
Total Number of UTI within study Period /
device (catheter) days multiplied by 1000
Clinical monitoring includes
infection control,
surveillance, and reporting
Catheter related BSI
Rate
Total Number of BSI within the study period
/ device (catheter) days multiplied by 1000
Clinical monitoring includes
infection control,
surveillance, and reporting
Health Care
Associated Infections
"HAIs" Rate
Total Number of HAIs within study Period /
Number of patient days multiplied by 1000
Clinical monitoring includes
infection control,
surveillance, and reporting
Surgical site infection
(SSI) Rate
Total Number of patients with surgical site
infection within the study period / Total
Number of patients with surgical site
infection within the study period x100
Clinical monitoring include
Nursing Assessment
Pressure Ulcer
Prevalence (Hospital-
Acquired) Rate
Patients that have at least one category/stage II
or greater hospital-acquired pressure ulcer(s)
on the day of the prevalence study / All patients
surveyed for the study who are > = 18 years.
Clinical Monitors
uality Management &
Patient Safety
ORIENTATION
PROGRAM
23 November 2014 / [email protected]
STANDARD INDICATOR NAME
DEFINITION;
NUMERATOR AND
DENOMINATOR
Clinical monitoring
include these
aspects of Radiology
Services selected by
the leaders
Rate of IV
contrast
complications
Number of patients
who had complication /
Total number of
patients who had IV
contrasts
Clinical monitoring
include these
aspects of Radiology
Services selected by
the leaders
Rate of
Ultrasound
Report
Issuance in 45
Minutes
Total No. of Delayed
Results/Total No. of
Patients for Ultrasound
uality Management &
Patient Safety
ORIENTATION
PROGRAM
Clinical Monitors
STANDARD INDICATOR NAMEDEFINITION;
NUMERATOR AND DENOMINATOR
Clinical monitoring
includes Labor &
Delivery Services
Rate of Accurate
Fetal Weight
Total No. of Error in Patient's Fetal Weight /
Total No. of Patients Delivered X 100
Clinical monitoring
includes Labor &
Delivery Services
Elective
Delivery
Patients with elective deliveries /
patients delivering newborns with >=
37 and < 39 weeks of gestation
completed
Clinical monitoring
includes Labor &
Delivery Services
Cesarean
Section
Patients with cesarean sections /
Nulliparous patients delivered of a live
term singleton newborn in vertex
presentation
Clinical Monitors
uality Management &
Patient Safety
ORIENTATION
PROGRAM
STANDARDINDICATOR
NAME
DEFINITION;
NUMERATOR AND
DENOMINATOR
Clinical monitoring
includes the
monitoring of
Medications Errors
and Near Miss.
Medication
Errors Rate
Total number of Medication
Error / Total number of
Patient Days X 1000
Clinical monitoring
includes the
monitoring of
Medications Errors
and Near Miss.
Near Miss
Rate
Total number of Near miss
medication errors reported /
Total number of medication
errors reported x 100
Clinical Monitors
uality Management &
Patient Safety
ORIENTATION
PROGRAM
23 November 2014 / [email protected]
Managerial Monitors
STANDARD INDICATOR NAMEDEFINITION;
NUMERATOR AND DENOMINATOR
Managerial monitoring includes the
surveillance, control, and prevention of
events that jeopardize the safety of
patients, families, and staff
General Waste
Collection
(outsourced) Rate
Total Number of executed general
Waste collection jobs / Number of
planned general Waste collection jobs
Managerial monitoring includes the
surveillance, control, and prevention of
events that jeopardize the safety of
patients, families, and staff
Infectious Waste
Collection
(outsourced) Rate
Number of executed infectious waste
collection jobs / Number of planned
infectious Waste collection jobs x 100
Managerial monitoring includes the
surveillance, control, and prevention of
events that jeopardize the safety of
patients, families, and staff
Pest Control
(outsourced) Rate
Number of executed Pest Services
jobs / Number of planned Pest
Services jobs x100
Managerial monitoring includes the
surveillance, control, and prevention of
events that jeopardize the safety of
patients, families, and staff
Needle Stick Injuries
RateNumber of Needle stick injuries
uality Management &
Patient Safety
ORIENTATION
PROGRAM
STANDARD INDICATOR NAME
DEFINITION;
NUMERATOR AND
DENOMINATOR
Managerial
monitoring
includes reporting
of activities as
required by law &
regulation
Governmental
Reports
Submission
Compliance Rate
(eg.
Communicable
Diseases, Polio
Cases etc.)
Total number of
Governmental Mandatory
reports submitted as per
Laws & regulation /
Total number of requested
Governmental reports in the
same year x 100
Managerial Monitors
uality Management &
Patient Safety
ORIENTATION
PROGRAM
23 November 2014 / [email protected]
STANDARDINDICATOR
NAME
DEFINITION;
NUMERATOR AND
DENOMINATOR
Managerial monitoring
includes staff
expectations and
satisfaction
Employee
Satisfaction
Rate
Total Number of Staff Who were
generally satisfied/ Total Number
of surveyed Staff.
Managerial monitoring
includes patient and
family expectations and
satisfaction
Patient
Satisfaction
Survey
Total Number of Satisfied
Patient/Total Number of
surveyed Patients
Managerial monitoring
includes patient and
family expectations and
satisfaction
Monthly
Complaint
Rate
Total Number of Complaints
(cases*) in one month/ Number
of patients in same month
"inpatient & OPD".
Managerial Monitors
uality Management &
Patient Safety
ORIENTATION
PROGRAM
STANDARD INDICATOR NAMEDEFINITION;
NUMERATOR AND
DENOMINATOR
Managerial monitoring includes the
procurement of routinely required
supplies and medications essential to
meet patient needs
General Store
Items Availability
Rate
Total Number of Monthly
requested Items available in
General Store / Total Number of
Items requested in the same
month
Managerial monitoring includes the
procurement of routinely required
supplies and medications essential to
meet patient needs
Purchasing
Response Time
Compliance Rate
Total Number of purchase
request processed within time
frame (26 days) in one month /
Total number of purchase
requests received in the same
month.
Managerial monitoring includes the
procurement of routinely required
supplies and medications essential to
meet patient needs
Out of stock
Medication rate
Total Number of items that hit
zero stock / Total number of line
items in stock
Managerial Monitors
uality Management &
Patient Safety
ORIENTATION
PROGRAM
STANDARD INDICATOR NAMEDEFINITION;
NUMERATOR AND DENOMINATOR
Managerial monitoring
includes utilization
managementNICU Utilization
Total Number of admission which fulfill
admission criteria over a certain time / Total
no. of babies admitted over the same time
Managerial monitoring
includes utilization
managementICU Readmission Rate
Readmission to the ICU within 24 hrs of
transfer / Total Number of Patients Manage in
ICU in a Given Time Frame X 100
Managerial monitoring
includes utilization
managementICU Length of Stay
Total Occupied Bed Days / Total Number of
Patients in a Given Time Frame X 100
Managerial monitoring
includes utilization
management
Unplanned
Readmission To the
hospital within 3 days
after discharge
Unplanned Readmission To the hospital within
3 days after discharge during the study period
/ Total number of discharges during study
period X 100
Managerial monitoring
includes utilization
management
Overall Hospital
Length of Stay
Total number of patient days / Total
Admissions
Managerial Monitors
uality Management &
Patient Safety
ORIENTATION
PROGRAM
STANDARD INDICATOR NAMEDEFINITION;
NUMERATOR AND DENOMINATOR
Managerial monitoring
includes risk managementOVR Reports
Total Number of OVR Reports / Total
patient days 1000
Managerial monitoring
includes risk management
Sentinel event
RatioTotal Number of Sentinel events / Total
no. of Patients Days X 1000
Managerial monitoring
includes risk management
Overall CPR
Survival Rate
Total Number of CPR Survival / Total
Number of CPR Call-out X 100
Managerial monitoring
includes risk management
Total Number of
Still Birth
Total Number of Still Birth / Total no. of
deliveries X 100
Managerial monitoring
includes risk management
Neonatal Mortality
Rate
Total no. of neonatal deaths / Total no. of
inpatient admissions X 100
Managerial monitoring
includes risk management
Pediatric Mortality
RateTotal Number of Pediatrics Deaths / Total
Number of Pediatric Admissions X 100
Managerial monitoring
includes risk management
Overall inpatient
mortality rate
Total no. of inpatient deaths / Total no. of
inpatient admissions X 100
Managerial Monitors
uality Management &
Patient Safety
ORIENTATION
PROGRAM
STANDARD INDICATOR NAME
DEFINITION;
NUMERATOR AND
DENOMINATOR
Managerial monitoring
includes patient
demographic and
diagnoses
Top 5 Medical
Diagnosis
Highest Number of
Medical Diagnosis/Month
Managerial monitoring
includes patient
demographic and
diagnoses
Top 5 Surgeries
Highest Number of
Surgery Procedure /
Month
Managerial Monitors
uality Management &
Patient Safety
ORIENTATION
PROGRAM
International PatientSafety Goals Measurements
STANDARD INDICATOR NAME
IPSG.1
Identify Patients
Correctly.
Use of two (2) patient
identifiers when
laboratory staff collect specimens.
DEFINITION –
NUMERATOR AND
DENOMENATOR
Use of two (2) patient
identifiers when
laboratory staff collect
specimens /
Total Number of Staff
observed
uality Management &
Patient Safety
ORIENTATION
PROGRAM
The leaders of the institution
identify the key measures
for each of the International
Patient Safety Goals (IPSG).
STANDARD INDICATOR NAME
IPSG.1
Identify
Patients
Correctly.
Use of two (2) patient identifiers when
• when admitting patients. -Nursing
• when administering medications. - Nursing
• when giving treatment. –RT, PT
• when performing diagnostic imaging. –RD
• when directing patients to clinics. – OPD Nurses
uality Management &
Patient Safety
ORIENTATION
PROGRAM
IPSG Monitors
STANDARD INDICATOR NAME
IPSG.1
Identify
Patients
Correctly
Time-Out Compliance
Rate
(OR and Dental)
DEFINITION - NUMERATOR AND
DENOMENATOR
No. of Time Out
Practices as per P & P /
Total No. of Surgery
conducted in same
period.
IPSG Monitors
uality Management &
Patient Safety
ORIENTATION
PROGRAM
STANDARD INDICATOR NAME
IPSG.2
Improve
Effective
Communication.
Use of
Unapproved
Abbreviations
Rate
(MS & Medical
Records)
DEFINITION –
NUMERATOR AND
DENOMENATOR
Total Number of unapproved
abbreviations used by
medical staff in medical
record documentation
/ Total Number of Medical
Records Reviewed
IPSG Monitors
uality Management &
Patient Safety
ORIENTATION
PROGRAM
23 November 2014 / [email protected]
STANDARD INDICATOR NAME
IPSG.3
Improve the
Safety of
High-Alert
Medications.
Medication errors due
to look-alike/sound-
alike (LASA) drugs
(Pharmacy)
DEFINITION:
NUMERATOR AND DENOMENATOR
Total Number of medication
errors due to look-alike /
sound-alike (LASA) drugs
IPSG Monitors
uality Management &
Patient Safety
ORIENTATION
PROGRAM
STANDARD INDICATOR NAME
IPSG.3
Improve the
Safety of
High-Alert
Medications.
Adverse Drug Events
(ADEs) related to
Anticoagulant per
100 Admissions with
Anticoagulant
Administered(ICU)
DEFINITION -NUMERATOR AND
DENOMENATOR
Total number of ADEs in the
sample related to an
anticoagulant
/ Total number of admissions in
the sample in which the patient
was administered at least one
dose of an anticoagulant X 100
IPSG Monitors
uality Management &
Patient Safety
ORIENTATION
PROGRAM
23 November 2014 / [email protected]
STANDARDINDICATOR
NAME
IPSG.4 Ensure Correct-Site,
Correct-Procedure,
Correct-Patient
Surgery.
Surgical site
correctly marked
with patient
involvement and
prior to start of
surgical
procedure(Surgery; OR)
DEFINITION –
NUMERATOR AND
DENOMENATOR
Surgical site correctly
marked with patient
involvement and prior to
start of surgical procedure/
Total No. of Operations at
the Same Period of Time x
100
IPSG Monitors
uality Management &
Patient Safety
ORIENTATION
PROGRAM
STANDARDINDICATOR
NAME
IPSG.4 Ensure Correct-
Site, Correct-
Procedure, Correct-
Patient Surgery
Surgical Safety
Checklist
Compliance
Rates(OR; Dental)
DEFINITION –
NUMERATOR AND DENOMENATOR
Total No. of Surgeries with
Complete (all of three
phases) Surgical Checklist
at Given Period / Total No.
of Operations at the Same
Period of Time x 100
IPSG Monitors
uality Management &
Patient Safety
ORIENTATION
PROGRAM
STANDARDINDICATOR
NAME
IPSG. 5Reduce the Risk
of Health Care–
Associated
Infections
Hand Hygiene
Compliance
Rate
(IC; LiNCs)
DEFINITION –
NUMERATOR AND DENOMENATOR
Total Number of staff who
comply with hand hygiene
instructions / Total Number of
Staff X 100
IPSG Monitors
uality Management &
Patient Safety
ORIENTATION
PROGRAM
STANDARDINDICATOR
NAME
IPSG. 6 Reduce the Risk
of Patient Harm
Resulting from
Falls
Patient Falls
(Nursing)
DEFINITION –
NUMERATOR AND DENOMENATOR
Total number of patient falls (with
or without injury to the patient)
during the calendar month /
Patient days by Type of Unit
during the calendar month.
IPSG Monitors
uality Management &
Patient Safety
ORIENTATION
PROGRAM
STANDARD INDICATOR NAME
IPSG.6
Reduce the
Risk of Patient
Harm Resulting
from Falls
Patient Falls
with Injury
(Nursing)
DEFINITION -NUMERATOR AND
DENOMENATOR
Number of patient falls with an
injury level of minor or greater
during the calendar month /
Patient days by Type of Unit
during the calendar month
IPSG Monitors
uality Management &
Patient Safety
ORIENTATION
PROGRAM
STANDARD INDICATOR NAME
IPSG.6
Reduce the
Risk of Patient
Harm Resulting
from Falls
Fall Risk
Assessment
Rate
(Nursing)
DEFINITION -NUMERATOR AND
DENOMENATOR
No. of Patient Assessment
on Fall Risk At Admission /
Total No. Admissions during
the Study Period
IPSG Monitors
uality Management &
Patient Safety
ORIENTATION
PROGRAM
QM&PS Education Program
uality Management &
Patient Safety
ORIENTATION
PROGRAM
Quality Concepts,
Dimensions and
Principles
Fundamentals of Patient
Safety
Quality Cycle
Use of Quality
Improvement Tools
Improvement
Methodologies
OV Reporting System
Handling Critical and
Sentinel Events
Medication Errors &
Adverse Drug Reaction
Reporting
Conduct of Proactive
and Root Cause
Analysis
Data Management
Introduction to Quality
Culture and Patient
Safety
Effective
Communication &
Customer Services
Teamwork and Team
Building
Structure, Process and
Outcome Audits
QM, PS and RM Lectures:
QM&PS Education Program
uality Management &
Patient Safety
ORIENTATION
PROGRAM
23 November 2014 / [email protected]
![Orientation program 2014[1]](https://img.pdfslide.net/doc/110x75/568c56431a28ab4916c5f0bd/orientation-program-20141.jpg)
