CBAHI Questions

2018
HGH
FOUZA AL JARREY
TQM
 Definition of quality

 It is a continuous improvement process

QUALITY
DOING THE RIGHT
THING
RIGHT FIRST TIME
RIGHT EVERYTIME
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 Quality and Patient Safety

 are the responsibility of all employees
 of a healthcare facility.
 Patient Safety:
 is defined as: the prevention of harm to patients
 Job Description:
 is a list that a person might use for general tasks, or
functions, and
 responsibilities of a position. It outlines the frame of
work which an employee should perform
 .
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 Privileges:
 are the rights of a clinician to provide specific diagnostic or
therapeutic
 services to patients. Clinical privileges are limited by the individual’s
 professional license, experience, and competence
 Policy & Procedures Guidelines (PPGs):
 Documents containing principles, rules, and guidelines formulated
 or adopted by an organization which describe an organization’s
policies
 for operation and the procedures necessary to fulfill the policies
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 Organizational Chart:
 A graphic representation of titles and reporting
relationships in an
 organization, sometimes referred to as an “organogram”
or “organization
 table.”
 Accreditation Survey:
 is a process in which a Healthcare Facility is assessed by
an
 accrediting body to determine if it meets a set of
standards designed to
 improve quality of care.
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 Standard:
 A statement that defines the performance
expectations, structures, or
 processes that must be in place for an organization to
provide safe and
 high-
 quality care, treatment, and service.
 Quality dimension

 Safe Avoiding preventable injuries, reducing medical errors

 Effective Providing services based on scientific
knowledge (clinical guidelines)
 Patient Centered Care that is respectful and
responsive to individuals
 Efficient Avoiding wasting time and other resources
 Timely Reducing wait times, improving the practice flow
 Equitable Consistent care regardless of patient
characteristics and demographics
 How many went through hospital orientation?

 A-I attend hospital orientation program when I start

working in this hospital and yearly I attend and
hospital doing this orientation program monthly for
any one like to attend
 Tell me what you did during the hospital
orientation?

 We have general hospital orientation and we take

hospital organization chart and principles about
infection control and safety ,patient family right
international patient safety goals and quality concept
then we take departmental orientation
 Then unit orientation if present same like icu or ccu
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 The hospital leaders make sure that staff understand

the flow of responsibilities and authority lines and
that there is a current list of name/s titles available
with the organizational chart to support good
communication between professionals
 The organizational structure(s) and the associated
processes used to carry out these responsibilities can
provide a single professional staff composed of
physicians, nurses, and others or separate medical
and nursing staff
Tell me about the structure of management in the
hospital

 organizational chart.
 Who do you report to?
 Accordingly
 Who does that person report to you?
 Accordingly
 Can someone tell me what the hospital
mission, vision, and values statement is for
the hospital?
 Mission:
Providing safety healthcare services, continuous
improvement to our customers and preventing the
risk and harm to reach them.
‫الرسالة‬
‫ ومنع األذى والمخاطر‬,‫تقديم خدمات صحية آمنه وتحسين مستمر لعمالئنا‬
.‫من الوصول لهم‬
 Q:What is the vision of your hospital?

VISION

To be the best healthcare services in KSA.

‫الرؤية‬
.‫أن تكون خدامتنا الصحية األفضل في المملكة العربية السعودية‬
 Q:What is the core value ?

OUR VALUES (TEAM)

‫القيم‬

 Teamwork
‫العمل كفريق‬
 Efficiency and Effectiveness
‫الفعالية والكفاءة‬
 Accountability
‫المسئولية‬
 Morality
‫األخالقيات‬
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 Mission: Purpose of the organization

 Vision: Desired future status
 Values: Beliefs and principles
 Goals: Proposed accomplishments
 What education programs do you attend at this
hospital?
 Staff must receive appropriate education and
training to remain effective and the
 Leadership must support this and provide the
necessary resources. This is a patient safety issue.
 Hospital must make sure there is adequate space,
human and material resources for effective
educational efforts.
 Weekly lecture for all hospital plus lectures in our
department
 Plus workshop on quality and infection control
 How often are you able to attend ongoing
educational events?
 Frequent
 Are you able to attend symposiums outside of the
hospital?
 Yes, we submit our request to administration and
administration will accept
 Give me an example of the last symposium or
conference you attended.
 How was this valuable to you personally and
professionally?
 Tell me what you know about the sentinel event

 A “Sentinel Event” is an unexpected occurrence involving

death or serious physical or psychological injury,
 Example ,
 Surgery on the wrong patient or body part
 Serious injury with loss of limb or function.
 Any unexpected death that is not the result of the patient’s
underlying condition
 Child Abduction or discharge to the wrong family
 Significant Hemolytic Blood Transfusion
 Suicidal Attempt
 Wrong patient identification
 Maternal death
 Significant Medication Error (overdose causing death
 How do you report this event?

 A: First to inform head department then he will

inform medical director and quality director will
inform hospital director who will ask for meeting for
sentinel events team within 24 hours and to do root
cause analysis within 10 working days and correction
action within 45 days formation of a team for
studying
 and is documented in minutes, reports, or other
 documents.
 What is Root Cause Analysis?

 It is an in-depth investigation; a process for

identifying the basic causal factors of an adverse
event and analyze them.
 Collecting, analyzing, integrating evidences and
establish causes, make recommendations and
drawing conclusions
 -what happen –how it is happened-how to prevent to
occurrence again
 5 whys method
 Would a Code Pink be a sentinel event?

 Yes (child abduction)

 Who is responsible for the implementation of this
Code?
 All staff

 All personnel/volunteers are responsible to be

familiar with the hospital infant Abduction Response
Plan as it applies to their area.
 What is your role in providing patient and
family education?
 Patient and family education provided by care givers
(giving appropriate information about illness and
possible complications, hand
 washing technique, treatment and possible surgical
procedures, use of equipment, pre-operative
 preparations and post-operative care, proper use of post-
operative
 medications, x-ray procedures,
 dietary restrictions, when to seek
 medical assistance, and follow up
 appointment).
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 Topics/teaching interventions may include but are

not limited to subjects such as:
 Patient's rights and responsibilities.
 Medical condition (diagnosis and treatment needs).
 How and when to take medications in a safe and effective manner
and (any specific precautions related to their needs.
 The safe and effective use of equipment(s) ordered for their use.
 Nutrition/potential food-drug interactions
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 Health maintenance and disease prevention

 Treatment plan: Providing an opportunity for the patient and/or
family to ask questions that allow them to make informed
decisions concerning their care and treatment.
 Directions on whom to contact and how to contact people (i.e.
physicians, outside agencies, etc.) for further information
regarding their care and treatment
 Pain management
 Personal care and hygiene
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 Discussed By Physician

 Nature of illness, complications
 Surgical Procedures- benefits, complication& outcome
 Pre-operative/procedure teaching
 Infection Control Practices
 Pain Education
 Patient Safety
 Diet
 Medications
 Use of Medical Equipment
 Provision of mental & emotional counseling
 Organ donation

 Discussed By Nurses

 Infection control
 Medication-Pain management
 Patient safety
 Preoperative/procedure teaching
 Where and how do you chart that?

 Patient education form

 Progress notes
 How do you assess the learning ability of the patient?
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 Factors for Assessment Needs include:


 Identification of designated learners to be involved in the educational process
 Primary language or mode of communication
 Patient's ability to read written materials
 Prior knowledge of identified topics
 Readiness to learn
 Barriers to learning
 The physical, cognitive, and cultural characteristics of patient served
 Cultural, spiritual or religious factors
 Desire and motivation to learn
 Age/developmental factors
 Individual learning preferences
 Availability of educational materials or the created materials is appropriate
and cost effective.
 Give me an example of some educational
information that you would give a patient
or family member

 Use of Nebulizer-insuline injection- pain

management –hand hygiene-
In discharge planning, what information is
important for the patient and family?
 Personal care: bathing, eating, dressing,
toileting
 Healthcare: medication management,
physician's appointments, physical therapy, wound
treatment, injections, medical equipment and
techniques
 Emotional care: activities, conversation.
 Write down a name and phone number of a person
 to call if you have questions.
 Tell me how patients are made aware of
their rights and responsibilities
when admitted
 On admission patients received booklet about
patient rights and responsibilities and patient
relation staff taking daily round for patients
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 organization educate patients and families so that

they have the knowledge and skills to participate in
the patient care processes and care decisions.
organization builds education into care processes
based upon its mission, services provided, and
patient population. Education is planned to ensure
that every patient is offered the education he or she
requires
 Who in the organization is responsible for this?

 Patient relation
 Is a booklet or written material provided to the
patient/family?
 Yes
 How is cost of treatment handled in this
organization?
 Through elag beagr
 PATIENT COMPLAINT PROCESS
The complaint
Patient complaint is received The person who receives involves
the complaint medical or
refers it to the PRO clinical issues

No Yes

The unit head involved completes the investigation The PRO contacts the department
and communicates the results and the actions to involved and requests
the PRO verbally first and In writing within 24hours for investigation and action

The Clinical Review Analyst

The Chief of Medical staff requests
performs The PRO refers the case to
a clinical review of the case from
the review and refers the chief of medical staff
the clinical review Analyst
the case to the Chief of Medical staff

The Chief of Medical Staff The Chief of Medical Staff The Chief of Medical Staff
and the department head informs the patient of the informs the PRO of the
( if appropriate) outcome of the complaint outcome of the complaint
take the necessary actions management management

The PRO enters the data in The Chief of Medical Staff If needed the he Chief of Medical Staff
preparation for a files the complaint form in the refers the case for discussion to
trend report TQM office the appropriate medical staff committee

Approved by: Dr. Emad Kotb Aldin, QM Director

 How are complaints handled in this hospital?

 Patient complaints received by any staff in HGH are forwarded

to the first responsible personnel.
 If solving the complaint is within the capacity of the first
responsible personnel then they would immediately take a
corrective action, fill the complaint management form and
send it to the Head of Patient relations Department.
 Written complaints in the complaints boxes is collected and
managed through the Head of Patient relations Department.
 Potential complaint is recorded and undergoes
analysis and trending
 Who is responsible for handling the
complaints?
 Patient relation section
 What documentation is required for this process?
 Patient complaint form
 What do you do with generated data to improve
services and /or patient
 outcomes?
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 Data will be aggregated and analysis and to be

discussed in patient care committee for
improvement action plan if medical cases discussed
in mortality and morbidity committee
 What is your policy on a patient with life
threatening condition that is not
able to pay for services?
 hospital implements the MOH policy regarding
provision emergency care when needed regardless
of inability to pay.
 How are the leaders trained in quality
concepts ?

 1-lectures in hospital by quality director

 2-symposium
 3-Workshop
 4-Training
 How to analyze data.
 LD.36.2 How to use an improvement cycle (PDCA) or
other method to make improvements.
 LD.36.3 How to work in teams.
 LD.36.4 How to perform root cause analysis
 How to develop indicators.
What training have you had on quality concepts?

 We share in improvement project FOCUS PDCA

 We attend training in quality tools and usage of
software (statistical analysis)
 What criteria do you use in selecting a
quality improvement project?
 High volume : Those that are performed frequently or
affect large number of people .
 High risk :Those that expose the customer to a greater risk
of adverse outcomes because of the nature of the disease or
the case management process
 Problem prone: Those that are producing repeated
problems for the organization and or customers .
 High cost service :
 High impact: Those that are producing significant
influence that will continue beyond the timeframe of the
project or beyond the region where the project is situated
How the leaders are are involved in Quality
Improvement?

 identifies clear goals that define expected outcomes of

the overall QI effort
 Is fact-based using indicators to measure progress if
not meet the target leader will start quality
improvement project
 Includes systematic cycles of planning, execution, and
evaluation
 Concentrates on key processes as the route to better
results
 Focuses on patients and other stakeholders
 What methodology do you use for Quality
Improvement?
 FOCUS PDCA
 F
 Find an Opportunity to Improve:

 O
 Organize a Team:

 C
 Clarify the Current Process:

 U
 Understand the Root Cause:

 S
 Select the Improvement Process:

 P
 Plan the improvement:

 D
 Do the improvement to the process:

 C
 Check the results:

 A
 Act to hold the gain and continue to improve the process:


How have you personally been involved in
improving the quality of
service in you department or the whole
organization?
 Accordingly
 What quality projects are in place in your department
or organization?
 Accordingly
 Give some example of projects done over the past year?
or what were
 some of the accomplishments in the past year?
 How do you choose the members for you quality
improvement projects?

 Membership of the quality improvement teams is

determined by the leadership (Hospital Director, Medical
Director, Administrative Director, Nursing Director).
 QM.30.2 The teams include staff who have working
knowledge of the process.
 QM.30.3 The teams include a facilitator.
 QM.30.4 The teams include a designated ‘team leader’
who is an identified leader within the organization.
 QM.30.5 The teams use a learning cycle (PDCA or other)
for process improvement.
 QM.30.6 The teams use CQI tools (Pareto charts,
brainstorming, affinity diagrams, fishbone charts,
multivote
 What quality tools used for that projects?

 Statistical data presentation

 1-histogram
 2-bar chart
 3-pie chart
 4-run chart
 5-Control chart
 6-cheeck sheet
 Cause analysis tool

 -RCA
 -Fishbone diagram
 -pareto chart

 Idea creation:
 1-Brainstorming
 2-Affinity diagram
 3-Benchmarking
 Project planning

 Focus pdca
 Gantt chart
 How do you deal with all near misses and
incidents (sample of incident/OVR
reports)?give an example
 We will deal with near miss as it happen
 Definitions:
 A. Incident (minor): An unplanned event that interrupts
the completion of an activity that includes minor, non-life
threatening personal injury/illness and/or minor damage to
property or the environment.
 B. Near Miss (minor): a potential for harm or error that
is intercepted prior to the completion of the incident/event
resulting in no harm to the patient.
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 Evaluation of near misses provides the organization

with many opportunities for improvement and staff
report near misses more than they report OVA”s
because no harm occurred to the patient.
 Root cause analysis is performed when appropriate.
 MS.11.2 Emphasis is placed on improving systems.
 MS.11.3 The “Actions taken” are documented
 What are your roles/ responsibility in the
implementation of hospital
management information plan?
 Participating in defining the terminology related to
management of information including data,
information, aggregated data, correlated data,
confidentiality, integrity and security.
 LD.37.2 Approving the Hospital wide Management
of Information (MOI) plan.
 LD.37.3 Providing the necessary resources to
implement the hospital wide information plan
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 There must be a strategic plan for the management of

information based on the information needs related to
the mission, scope of service, and internal and external
customer.
 Information is generated and used during patient care
and for managing a safe and effective organization. The
ability to capture and provide information requires
effective planning. Planning incorporates input from a
variety of sources.
 The care providers;
 The organization’s managers and leaders; and
 Those outside the organization who need or require data
or information about the organization’s operation and
care processes
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 What education you had in data management?

 Lectures
 Workshop about software MINITAB
 How does the organization protect
online patient information?

 Unique IDs and passwords

 Firewalls and encryption on computer, software, and router
 Anti-virus and anti-spyware
 Backup and recovery
 All files have been set to restrict access only to authorized
 individuals.
 Computers are protected from environmental hazards.
 Wireless networks use appropriate encryption
 Computers contain no peer-to-peer applications.
 Computers are free of unnecessary software and data files
 Did the leaders participate in selecting
information management technology

 Yes
 Can you provide an example.
 What data (indicators) do you collect?

 Indicator is a is a quantitative measurable variable or

characteristic used to monitor performance by assessing the
degree of discrepancy between the actual and expected
performance

 What you can not measure you can not improve

 Choosing indicators must be
 S :specific
 M:Measurable
 A:achivable
 R:Realistic
 T:Timelines
-High risk-High volume-High cost-Problem prone
 Data Collection
: Before beginning to collect data, you should consider the
following questions:
WHY are we collecting this data?
WHAT exactly are we collecting?
WHERE are we going to collect it?
WHEN are we going to collect it and for how long?
WHO is going to collect it?
HOW will it be collected and displayed
 The Data Pyramid
Value
Wisdom How can we improve it ?
(Knowledge + experience)

Knowledge We passed
Volume
(Information + rules)

Information 80% our result in CBAHI

(Data + context)

Data 80%
When To Use Data Collection
To define or identify a problem
To measure current functioning
To monitor progress
To measure the effects of change Data Collection Tools:
Data Sheet or Work Sheet
Check sheet
Survey
Interview or Focus Group;
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Every indicator requires identification of, but not

limited to, the following elements: data collection
tools, methodology, source of information,
frequency, analysis, data abstractor, data receiver.
Collection of data will create a data base that should
be aggregated and trended over time and used for
quality and strategic planning
indicators based on the mission and scope of services
 Types of indicators

 1-Structure
 Availability of essential supplies and equipment.
 QM.23.2 Availability of medical records.
 QM.23.3 Availability of blood and blood products.
 2-Process
 The timing and use of antibiotics prior to surgery.
 QM.24.2 Blood and blood products administration.
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 3-Outcome:
 Mortality rates.
 QM.25.2 Nosocomial Infection rates.
 QM.25.3 Staff satisfaction.
 QM.25.4 Patient satisfaction
 How did you use that data for
improvement or to monitor
improvement?
 Quality improvement is based on an available
measurement system that identifies opportunities of
improvement. A measurement (monitoring) system
should be based on leadership needs. The organization
should select a mixture of indicators, clinical &
managerial that focus on activities that are risky in
nature to patients or staff, occurring in high volume or
associated with problems and high cost. The mixture of
indicators used could measure the outcomes, processes
or required inputs (structure) for important aspects of
care or a dimension of performance.
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 All indicators should be valid, reliable, measurable,

clear and realistic. Every indicator requires
identification of, but not limited to, the following
elements: data collection tools, methodology, source
of information, frequency, analysis, data abstractor,
data receiver. Collection of data will create a data
base that should be aggregated and trended over
time and used for quality and strategic planning
 strategic planning or quality
improvement?

 1-Completion of medical record

 2-Hand hygiene compliance
 3-Usage of antibiotics
 4-Blood culture contaminated rate
 5-Incomplete prescriptions
 6-Number of circumcision done under general
anesthesia
 sources are available of decision
making?

 The 24-hour inpatient census.

 MOI.12.2 The dietary requests for patients.
 MOI.12.3 The laboratory values including ‘panic’
reports.
 MOI.12.4 X-ray reports including ‘panic’ reports.
 strategic planning or quality
improvement?

 1-Hand hygiene compliance

 2-usage of prophylactic antibiotic
 3-Increase number of emergency ultrasound from
OPD
 4-Writing prohibited abbreviations
 How information needed by staff to
do their jobs is provided to them

The organization collects and analyzes aggregate data to

support patient care and organization management.
Aggregate data provides a profile of the organization over
time and allows the comparison of the organization’s
performance with other organizations. Thus, aggregate data
are an important part of the organization’s performance
improvement activities. In particular, aggregate data from
risk management, utility system management, infection
control, and utilization review can help the organization
understand its current performance and identify
opportunities for improvement.
 Are you involved in nursing
recruitment? (Nursing director)

 Yes
 Requesting staff depending on identified
departmental needs.‫حسب احتياجات االقسام‬
 NR.16.2 Checking the nurses’ credentials and licenses’
by Kingdom rules
 ‫مراجعة شهادات الممرضات حسب اللوائح والقوانين‬.
 NR.16.3 Ensuring that the references are checked from
previous employment.
 ‫اذا كان قد عمل سابقا بمكان اخر التأكد من عمله من المكان السابق‬
 NR.16.4 Checking the time frames of past
employment.
 ‫مراجعة الوقت الزمنى للعمل السابق‬
 How many contracts does the hospital
have?

 3
 Kitchen-Maintenance-Waste management
 What are those subcontracted services?
 No
 How the hospital leadership does ensure that the
contract is fulfilled?
 Contracts could be monitored regularly from different
aspects. Besides monitoring the technical components of
the contract, other aspects should be considered as, but
not limited to, safety, confidentiality, timeliness of
contacted service, contractor's employees orientation, job
description and health program as appropriate
 How does the leadership receive
reports about the subcontracted
operations?
 We don’t have subcontract
 What is strategic plan

 Strategic or long-range planning

 The process of planning for Quality in
 Healthcare is divided into tow components:-
 1-Strategic Planning
 2-Operational Planning
 Planning starts at the strategic level & is spread to
the operational level & ends at
intervention/implementation level
In SP the level of involvement is higher
in the organizational hierarchy
Where initial decisions & board
policies are made for the proper
implementation of HCQ
It involves:
Top management's commitment
Securing additional support (financial
& technical)
The organization of structural support
for Q implementation
 What is a mission

 A Mission Statement
 is a short paragraph of 3-5 sentences in length which describes the scope
and functions of an organization/service/department/unit and should
answer questions like:
 Who we are?
 Why we exist? What our main purpose as an organization is?
 What are the services provided by the organization?
 Whom we are serving? (target population)
 What their needs are?
 How to meet those needs ( please see the mission statement of your
hospital as example) Providing safety healthcare services, continuous
improvement to our customers and preventing the risk and harm to
reach them.

 What is a vision

 Vision statement
 Somewhat futuristic (visionary) and should answer the
question of what the organization strives to be in the future
(3,5, or 10 yrs) / what you want to become in the future?(
please see your hospital vision)
 To be the best healthcare services in KSA.
 What is Operational Planning

 More specific & more elaborate in design, process & activities

 Involves detailed planning for every activity during
implementation of HCQ
 The right individuals are actively forecasting proper resource
allocations, training requirements, employee participation,
projects to be performed, all at the intervention level.
 Requires much more time & detail.
 Essential step before proper implementation of any process.
 What is A scope of service

 provides you with a good overview of:

 Range of services provided to the patient
 Who you provide the service to (age group, types of diseases,
etc) (Target population)
 What you provide the service with: (technology, diagnostics
used) (Methods/equipment)
 When you provide the service (24 hours every day of the
week, or 8am to 5pm on weekdays, etc) (Working hours)
Leadership
Leadership commitment is the Key and without true leadership
in Ql, success may not be attained and maintained.
Commitment
Active & participatory commitment is required
Leaders: verbal & active commitment
Leaders: involved in decision-making aspect of Ql.
If top management's commitment is not there, the success of
implementing quality is jeopardized.
“if you can’t come, then send no one”
System component
|System components : Structure (input) , Process , Outcome
(output)
 Dimensions of Quality

 Appropriateness : The degree to which the

care/intervention is relevant to the patient's clinical
needs, given the current state of knowledge.
 Availability :The degree to which appropriate
care/intervention is obtainable to meet the patient's
needs.
 Competency : The practitioner's ability to produce
both the health and satisfaction of customers. The
degree to which the practitioner adheres to
professional and/or organizational standards of care
and practice.(Not a JCAHO dimension
Continuity : The coordination of needed healthcare services
for a patient or specified population among all practitioners and
across all involved organizations over time.
Effectiveness : The degree to which care is provided in the
correct manner, given the current state of knowledge, to achieve
the desired or projected outcome(s) for the individual,
Efficacy :The potential, capacity, or capability to produce the
desired effect or outcome, as already shown, e.g., through
scientific research (evidence-based) findings.
Efficiency : The relationship between the outcomes (results
of care) and the resources used to deliver care.
Respect and Caring : The degree to which those
providing services do so with sensitivity for the individual's
needs, expectations, and individual differences, and the
degree to which the individual or a designee is involved in his
or her own care decisions.
Safety : The degree to which the risk of an intervention ...
and risk in the care environment are reduced for a patient
and other persons including health care practitioners.
Timeliness :The degree to which needed care
and services are "provided to the patient at
the most beneficial or necessary time.
 Quality Planning: Quality Control: Quality Improvement:

■
■ Identification of opportunities
Quality Assurance ■ Developing
■ Prioritization of opportunities ■
include ■ indicators /
planning, measures Defining the improvement opportunity•
setting of Monitoring • Team building ■
standards compliance
Analysis of the improvement ■
and opportunity
communication Measuring ■
Selection of the intervention ■
of standards variance ■
Implementation of the intervention ■
 Patient Safety
 Patent safety can be defined as freedom from accidental
injury due to medical care, or medical errors. It can be
defined also as the prevention of healthcare errors,. It is
considered as one of the quality dimensions .Hospital
should support patient safety by:
 Development of Quality Management and Patent Safety
plan . International Patient Safety goals (IPSGs) should
be defined in the plan and implemented hospital wide.
 Establishing a Patient Safety Committee with
representation from medical, nursing, and pharmacy and
safety departments. The presence of Patient Safety officer
is also essential to have required infrastructure for
patient safety.
Establishing good reporting system that include
Incident report and Sentinel event policy. These
reports should be discussed in safety committee to
study the problem, understand the cause and prevent
future occurrence. It is mandatory that each sentinel
event followed by formation of a team for studying the
causes of the event (Root Cause Analysis) and this RCA
must be performed within 10 working days with
development of an action plan and review systems for
improvement. RCA can be also used to understand the
root causes of any incident or process for improvement
( as in FOCUS PDCA)
 international Patient Safety goals (IPSGs)

 Goal #1 : Identify patients correctly (please see patient

identification policy for details)
 Goal #2 : Improve effective communication ( please see verbal
and telephone orders
 policy for details)
 Goal #3 : Improve the Safety of High- alert Medications
 Goal #4 ; Eliminate wrong site, wrong patents, wrong
procedures surgery ( please see the
 policy for details)
 Goal #5 : Reduce the risk of Healthcare-acquired infections
 Goal #6 : Reduce the risk of patient harm resulting from fall
 Incidents reporting ( occurrence variance
report).
 Important definitions:
 An Occurrence: any occurrence that is not consistent
with the routine operation which happens at the
premises, unusual or unexpected response by a patient to
standard treatment or medical intervention, any routine
operation that adversely affects or threatens the health or
life of patient, visitor, employee, trainee or volunteer; or
which involves loss or damage to personal or Hospital
property. An occurrence also includes any event might
result in any other adverse situation that violates the
code of conduct or a claim against the organization
Adverse Event: are unexpected incidents, therapeutic
misadventures, iatrogenic injuries or other adverse occurrences
directly associated with care or services provided.
Near Miss: Is an event or situation that could have resulted in
an accident, injury or illness, but did not, either by chance or
through timely intervention. An example of a Near Miss would
be: surgical or other procedure almost performed on the wrong
patient due to lapses in verification of patient identification but
caught at the last minute by chance. Near
misses will receive the same level of analysis as Adverse Events
that result in actual injury, and for learning purposes.( see
incident report policy and form for more details) from each 600
near miss it will happen one death or sever injury
 Sentinel Event

 Sentinel Event: A “Sentinel Event” is an unexpected

occurrence involving death or serious physical or
psychological injury, or the risk thereof, not related
to the natural course of a patient’s illness or
underlying condition
 The following events are considered Sentinel Events
even if the outcome is not death or major permanent
loss of function:
 Root Cause Analysis (RCA)

 RCA is a process for identifying basic or

contributing causes of an Adverse
Event or any unexpected occurrence.
This process focuses on systems and
processes rather than individuals and
identifies proposed changes and
preventive strategies.
 RCA Goals

Find out:
– What happened?
– Why did it happen?
– What do you do to prevent it from happening again?
– How do we know we made a difference?
The hospital leaders should appoint a team who will
conduct a root cause analysis especially in response to a
sentinel event occurrence. Objectives of the root cause
analysis are: to identify those causative issues, systems or
processes that represent core reasons for occurrence of
the event; to develop an action plan that will prevent
future recurrence of the event; and to implement the plan
To conduct RCA, the hospital should assign a team,
which ideally should be between 3- 5 individuals. The
team should have an appointed lead investigator. This
team will perform the following tasks:
1-Describe event( sequence of the event and steps of
process can be described by flowchart)
2-Identify immediate (proximate) cause(s) - human
factors
Identify contributing factors- latent errors - systems
and processes
3-Analyze the causal factors.
4-Complete the root cause matrix.
5-Provide a complete report and create action plan for
the SYSTEM to prevent future occurrence ( please see
conducting RCA policy for more details)
 FMEA(Failure Mode and Effect Analysis)

 is a systematic method of identifying and preventing

product and process problems before they occur.
 Steps in the process
 Failure modes (What could go wrong?)
 Failure causes (Why would the failure happen?)
 Failure effects (What would be the consequences of each
failure?)

1-Analyze the current process and evaluate the
potential impact of changes under consideration
 2-Track improvement over time
 Team building

 Team : A high-performing task group whose members

are interdependent and share common performance
objectives.”
 Team Building is The process of deliberately creating
an effective team Successful teams
 Team members speak freely
 Support each other
 Effectively group problem solve
 Have a clear sense of direction
 Have adequate information
 Have adequate resources
 Trust each other
 Accomplish their goals
 How to handle patient complaints

 The hospital has an effective structure to handle

patient complaints that includes the following:
 Patient complaints policy
 Specific unit or person responsible for complaints
management
 Committee that oversee the complaints process and
the outcomes
 Evidence of trending the reports and take necessary
corrective actions
 Patient rights and responsibilities

 Hospital leaders are involved in supporting and

protecting patient and family rights by:
 Development of Patient Rights and Responsibility
statement
 Development of Patient Rights and Responsibility
policy
 Formation of Patient Rights/advocacy committee
 Discussing aspects of patient rights in selected
workshops and or meetings