following basic 6 sigma method

1. Saudi Ministry of Health
Mental Health Services
Quality Continuous Improvement
Program
Yellow Belt Six Sigma

2. Six Sigma Cycle
Define
Control Measure
Improve Analyze

3. Reducing the number of reports of
potentially harmful objects found
with patients in wards
Quality improvement program using
six sigma
Yellow belt level
By
Hatim banjar
Risk manager
Al – Amal Hospital-Jeddah

4. Define
ID Opportunity Process Map
Explain why & how Completes high-level,
your team detailed map and identify
selected this project? quick win opportunities.
Team Charter Effective Team VOC to CTQ
Develop charter to Assign role and Gather/Display data
include business case, responsibility to verifying customer
project opportunity, each team needs.
goals, scope, schedule member.
and team.

5. Project Title: Reducing the Number of Reports of Potentially Harmful
Objects Found with Patients in Wards
Business Case : Specific Problem Statement:
Through (OVRs) review from 10/2010 to What : High number of reports of harmful
3/2011 it was found that there were 52 cases objects found with hospitalized patients
of potentially harmful objects found with When: from 10/2010 until 3/2011
hospitalized patients in Al-Amal Hospital Where: Al-Amal Hospital Jeddah
wards, and that endangers the patients safety How: 9 reports/month
and security and may result in injuries or Specific Goal Statement:
even casualties (God forbids). By doing this Reduce the number of reports of harmful
project I hope to provide a safer environment objects found with hospitalized patients in
for the patients and staff of Al-Amal Hospital Al-Amal Hospital wards from 9 reports per
month to 3 reports per month by
10th/June/2011.
In Scope:
Project Scope Location of project: Al-Amal Hospital Jeddah
Business: Patient Safety - Quality Management
Process: Patient safety
Start Point: Patient admission
End Point: Patient discharge
Project Charter

6. Define
Project Title : Reducing the Number of Reports of Potentially
Harmful Objects Found with Patients in Wards
Resource Plan Review
Project Lead (YB): Review frequency :
Hatim Banjar (Patient Safety Officer) weekly meeting with
champion and team
Champion: members
Dr.Naji Alawed (Quality Manager)
Team Members: Review responsibility :
Dr.Naji Alawed (Quality Manager) Dr.Naji Alawed
Naif Al-Omari (Nursing Officer)
Eng.Turki Al-Ghamdi (Maintenance Officer)
Salim Al-Shumrani (Quality Officer) Project Charter Sign-off:
Team Leader:
Milestones Hatim Banjar
Stages Start Date End date Champion (HOD):
Dr. Naji Alawed
Define 10/3/2011 17/3/2011
Measure 17/3/2011 24/3/2011
Analyze 24/3/2011 1/4/2011
Improve 1/4/2011 10/6/2011
Control 10/6/2011 10/7/2011
Project Charter

7. SIPOC : Patient Search
Start Boundary : Arrival to Hospital
S I P O C
Supplier Input Process Output Customer
Security Entrance point Search Patient get
searched Admitted
Nurses Routine Search Body Search Patient
X - Ray Suspicions Abdominal X-Ray
Family
Social interaction Visitation
End Boundary : Patient in ward

8. SIPOC : Maintenance Order and response
Start Boundary : inform maintenance
S I P O C
Supplier Input Process Output Customer
Department s Find problem Call maintenance report
Reporting
receive department
maintenance Take complain report
workers maintenance
Fix problem Solve problem
End Boundary : report back

9. Patient search Functional Deployment Map
department Patient Security Psychiatry X Ray Nursing OPD Ward Internal activity Home ,work
nursing Pass and
referral
process
Admission
New Search and
Admission Chest x Ask P.T for Internal yes yes
admission metal properties
ray activity
to hospital detector Pass
no
Take no
P.T to
P.T returns
Search
Search activity
Internal from referral
Search or pass
Finish
activity
yes Suspicions
search No Receive
P.T in
Abdominal ward
Take P.T
x ray
to ward
Discharg
e
Give
P.T Take P.T
properties to OPD
leave Referral
Discharge
P.T = patient

10. Maintenance Order and Response Functional Deployment Map
department
process
Reporting department Maintenance
Call Answer and take complain t
Call maintenance
Report Ask for complaint details
Record complaint
Give complaint a job order and number
Record job order number, Give the caller the order number and end call
date and time
Process Give the job order to the appropriate
department
Give the job order to the technician
Take tools
Go to ward and chick problem
Repair Show the problem to
technician Report to complaining department charge
yes Chick wear house for parts
Need parts
Parts available
no no yes
Go back to ward
no
Fix problem
End yes
Sign job order by department
charge Give the job order to reporting department
charge
Report to department

11. Quick Win Analysis for Maintenance Order and Response
Potential Quick Easy to Fast to Cheap to Within the teams Easily Implement
win opportunity Implement Implement Implement control reversible (Yes/No)
Tools should Y Y Y Y Y Y
always be carried
in a tool box
A maintenance N Y Y Y Y N
supervisor should
go with the
technician and
supervise the work
Tool box should be Y Y Y N Y N
checked before
and after by
maintenance
supervisor on shift
Charge of Y Y Y Y Y Y
reporting
department must
check
maintenance sight
before signing job
order
Only tools that r N Y Y Y Y N
needed for that
specific task
should be taken in
the tool box

12. Quick Win Analysis for Patient Search
Potential Quick win Easy to Fast to Cheap to Within Easily Implement
opportunity Implement Implement Implement the reversible (Yes/No)
teams
control
Search PT every time he N Y N Y Y N
get out from OPD before
admission
Do abdominal X-Ray for all Y Y N N N N
admissions
Have portable metal N N N N N N
detecting machine
Activate pt transfer policy Y Y Y Y Y Y
for nursing correctly
Do not allow pt to get out Y Y Y Y Y Y
of nursing sight or mingle
with other PT after final
search in OPD

13. Quick Wins Opportunity for Harmful Objects
Found with Al-Amal Hospital Inpatients Program
Quick Win Opportunity Action When
Tools should always be carried Provide tool boxes One month from
in a tool box 1/4/11
Charge of reporting department Activate role of ro department One weak from
must check maintenance sight charge in maintenance 1/4/11
before signing job order
Do not allow pt to get out of Educate OPD nursing staff One month from
nursing sight or mingle with 1/4/11
other PT after final search in
OPD
Activate pt transfer policy for Monitor nursing behavior One month from
nursing correctly 1/4/11
Goal Accomplishment Current Actual (collect 2-4 weeks data)
3 reports/month 9 reports/month 7 reports/month
Did the quick wins meet the goal statement? Yes

14. Measure
Process Performance
ID Key Indicators
To identify the key IPO Display the data in graphic and
indicators that relate to project calculate current Process
goals. Sigma Capability.
Measure Plan MSA
Determine Operation Verify our
Definition, Data Operational
Collection Plan Definition and
measurement
system.

15. Measurement Plan for Reducing the Number of Reports of Potentially
Harmful Objects Found with Patients in Wards Project
Performance Operational Data Sample Who Will When to How to Other Data that
Measure Definition Source & Size Collect the Collect the Collect the Should be Collected
Location Data Data Data at the Same Time
Number of The number OVRs in 6mon Hatim 20/3/2011 Excel sheet Define the source of
harmful this incident TQM the object
10/2010-
Objects happen (internal/external/
3/2011
type )
Number of Incidents with OVRs in Dr.Naji 20/3/2011 Systematic Define the source of
Incident by source of the TQM review the object
Internal object from (internal/external/
Sources inside the type )
ward
Number of Incidents with OVRs in 52 Naif 20/3/2011 Systematic Define the source of
Incident by source of the TQM review the object
External object was (internal/external/
Sources from outside type )
the ward
Number of What is the OVRs in 52 Hatim 20/3/2011 Systematic
External source of the TQM review
Sources external
object
Number of What is the OVRs in 52 Dr.Naji 20/3/2011 Systematic
Internal source of the TQM review
Sources internal object

16. Sources of Harmful Objects Found
with Hospitalized atients
Sources No Sources Main Sources
No Sources Main Sourceo
N
External 31 External Smuggling 20 Internal Lights 10
Internal 21 External staff 2 Internal Furniture 2
External Barber 2 Internal WC 1
External Maintenance 6 Internal Frames 4
External catering 1 Internal Garden 3
Internal nursing 1

17. Analyze
ID Potential Problems
Identify area to focus for the
improvement using Pareto
Update Data Collection
or SOV stratification
Plan
Modify data collection plan
and collect data to most
probable root causes Regression Analysis
Draw statistical and
practical conclusions
Analyze Potential Root on whether the X
Causes factors are
Identify potential root causes
using Fishbone diagram, 5- significant
Why’s, Cause & Effect Matrix Comparative Methods
or FMEA
Use hypothesis testing
to validate root cause

19. C & E DIAGRAM FOR SMUGGLING
Ishikawa Diagram (Cause and Effect Diagram)
Major Categories of Causes of Problem Statement
Machine (Generic Material (Generic Environment
Category) Category) (Generic Category)
no metal scaners
x-ray machine is not working no property window in gates a lot of hiding places in wards and OPD
no search rooms at ward doors
metal detectors are not set for low amount smugglers mostly smuggles lighters location of metal detectors
smuggling
smuglers use inter body cvities
smugglers use privet body parts
doctors are not always present in clinics smugglers cover things in tape
no clear searching PP for security
in wards A & B no punishment for smugglers smugglers use nilon wraping
security are not trained in searching methods
no united searching method searching is not always the final step in OPD
other PT praise smugglers
People (Generic Method (Generic
Category) Category)

20. C & E DIAGRAM FOR LIGHTS.
Ishikawa Diagram (Cause and Effect Diagram)
Major Categories of Causes of Problem Statement
Machine (Generic Material (Generic Environment
Category) Category) (Generic Category)
light switches are inside the rooms
light tubes are long lights are made of easley broken glass lights are not high enogh
lights covers are easily broken no barriers for lights protection
lights
brake by hand
nursing rounds are not done right use hard object
maintenance staff some times keep lights uncovered
patients donot fear elctricity
People (Generic Method (Generic
Category) Category)

21. C & E DIAGRAM FOR MAINTENANCE
Ishikawa Diagram (Cause and Effect Diagram)
Major Categories of Causes of Problem Statement
Machine (Generic Material (Generic Environment
Category) Category) (Generic Category)
tools are not counted no comunication between maintenance and house keeping
to many tools are taken to ward sometimes low quality tools are used high work load
maintenance
no policy for location cleaning
no policy for tool counting not always use tool box
maintenance staff are not safety orinted problem is not always cheiked before taking tools
no supervision
low number of staff for the job order
no policy for equipment supervision
Method (Generic
People (Generic Category)
Category)

22. C & E DIAGRAM FOR FRAMES
Ishikawa Diagram (Cause and Effect Diagram)
Major Categories of Causes of Problem Statement
Machine (Generic Material (Generic Environment
Category) Category) (Generic Category)
use of incorect scrwes
use of woden frames
some frames are rusty
some frames are easely broken
frames
maintenance staff are not safety orinted
some frames are not fixed properly
Method (Generic
People (Generic Category)
Category)

23. C & E DIAGRAM FOR GARDENS
Ishikawa Diagram (Cause and Effect Diagram)
Major Categories of Causes of Problem Statement
Machine (Generic Material (Generic Environment
Category) Category) (Generic Category)
leaves
durt
stiks
light stands stones
windows neting damged
gardens
sport equipments are left with no supervision
Method (Generic
People (Generic Category)
Category)

24. Cause & Effect Matrix For Smuggling
Smuglling Output Indicator
Input/Process Indicators 10 Importance
Location of metal detectors 0 0
X-Ray machine is not working 9
No metal scanners 0 0
Searching is not always the final step in OPD before admission 9 90
A lot of hiding places for restricted objects in wards and OPD 3 30
Metal detectors are not set for low amount 3 30
Security are not trained in searching method 9 90
No united searching method 3 30
Smugglers use privet body parts 0 0
Smugglers cover things in tape or nylon 0 0
Smugglers use inter body cavities 3 30
No search rooms at ward doors 0 0
3 30
No property window in gates
In wards A & B no punishment for smugglers lighters 0 0
Other PT praise smugglers 0 0
Smugglers mostly smuggles lighters 0 0

25. Cause & Effect Matrix for ward lights problem
Pareto Output Indicator
Input/Process Indicators 10 Importance
light switches are inside the rooms 0 0
light tubes are long 3 30
lights covers are easily broken 9 90
nursing rounds are not done right 9 90
maintenance staff some times keep lights uncovered 9 90
patients do not fear electricity 0 0
Patients have easy access to lights 9 90
lights are not high enough 3 30
brake by hands 0 0
use hard object 0 0

26. Cause & Effect Matrix For Maintenance Problem
Pareto Output Indicator
Input/Process Indicators 10 Importance
High work load 0 0
sometimes low quality tools are used 3 30
no policy for tool counting 3 30
maintenance staff are not safety oriented 9 90
Maintenance locations are not always cleaned after job is done 9 90
no communication between maintenance and house keeping 3 30
not always use tool box 9 90
to many tools are taken to ward 3 30
problem is not always checked before taking tools 0 0
no supervision 3 30
low number of staff for the job order 3 30
Equipments used by maintenance are not will supervised 9 90

27. Cause & Effect Matrix For Frames Problem
Pareto Output Indicator
Input/Process Indicators 10 Importance
some frames are rusty 9 90
maintenance staff are not safety oriented 9 90
use of incorrect screws 9 90
use of wooden frame 3 30
some frames are easily broken 9 90
some frames are not fixed properly 9 90

28. Cause & Effect Matrix For Gardens Problem
Pareto Output Indicator
Input/Process Indicators 10 Importance
Light stands 9 90
Sport equipments are left with no supervision 9 90
Windows netting damaged 9 90
Garden components 9 90

29. 5 Why Root Cause Analysis For Smuggling Problem
Validated Root Why1 Why2 Why3 Why4 Why5 Actionable
Cause
x-ray machine maintenance No spare parts Can not buy Manufacturer Very old Change machine
is not working parts model
searching is not Doctors are not Seeing in Only one doctor Fix number of 2
always the final always present in patents in A and N shift internist /shift
step in OPD clinic
before
admission
security are not Searching is not No clear P&P No clear job Put clear job
trained in included in description description and P&P
searching training program for security
method
no property There is no There is no There is no Make a window and
window in gates window opening property policy in policy for property
made in the gates declaration at the security for declaration before
gates before properties entering
detectors declaration
before detectors
a lot of hiding the toilets, sealing They are not In purchasing Set a policy for
places for and furniture are customized for toilets and consulting with
restricted used for hiding an addiction furniture nursing and doctors
objects in objects hospital doctors and before buying
wards and OPD nursing were not
consulted

30. 5 Why Root Cause Analysis For Maintenance Problem
Validated Root Why1 Why2 Why3 Why4 Why5 Actionable
Cause
maintenance No training on No safety Not part of No clear P&P Educate and train
staff are not PT safety education safety 1st line
safety oriented program education maintenance staff
program
Maintenance no policy for Put clear policy
locations are not location for location
always cleaned cleaning cleaning
after job is done
not always use No clear policy Put clear policy
tool box for using tool stating use of tool
box box
Equipments no policy for Put clear policy
used by equipment that tools and
maintenance are supervision equipments must
not will be supervised all
supervised the time

31. 5 Why Root Cause Analysis For Ward Lights Problem
Validated Root Why1 Why2 Why3 Why4 Why5 Actionable
Cause
nursing rounds Nurses are not They don’t Non Educate and train
are not done right interested understand the experienced nursing
importance
lights covers are Light covers are Change light
easily broken made of soft covers material
plastic
maintenance staff Maintenance staff Not trained nor No education No education Make policy to
some times keep do not educated in PT plan policy educate
lights uncovered understand the safety maintenance
dangers
Patients have no barriers for Put a steal net on
easy access to lights lights
lights protection

32. 5 Why Root Cause Analysis For Frames Problem
Validated Root Why1 Why2 Why3 Why4 Why5 Actionable
Cause
some frames are Old frames Do regular rounds
rusty and change rusty
frames
maintenance No training on No safety Not part of No clear P&P Make policy to
staff are not PT safety education safety for educate and train
safety oriented program education maintenance 1st line
program staff on PT maintenance staff
safety training
use of incorrect Some screws Use screws that
screws that are used are not easily
easily removed removed by
patents
some frames are Maintenance maintenance Chick after fixating
not fixed properlystaff do not chick staff are not and educate
will after fixating safety oriented maintenance staff
some frames are Some frames Cheap material Chick material 1st
easily broken are made of bad
material

33. 5 Why Root Cause Analysis For Gardens Problem
Validated Root Cause Why1 Why2 Why3 Why4 Why5 Actionable
light stands PT climbs them up To brake top glass To use glass or wires Remove light stands
and use high sealing
lights
sport equipments are Sport therapist do Sport therapy Make clear policy for
left with no not remove them department have no sport therapist to be
supervision clear P&P for that responsible for
equipment
windows netting Easy to cut netting Netting is rusty No regular Do regular
damaged maintenance maintenance
Garden components Patents use garden Cover all gardens with
components for harm floor tiles

34. Generate Solutions Conduct Screen DOE
Generate alternative Use DOE and
solutions to root response surface
causes of problems optimization to
quantify relationships
Improve
Piloting Process Change Management
Rank and Select Solutions
To rank and select Pilot the solution Develop and
solutions by considering on a small scale deploy
expected impact, ROI and evaluate the a plan for how to
and timeline result respond to
process changes

35. Possible solutions for smuggling problem
Root Cause Possible Solutions
x-ray machine is a very old model buy new x-ray machine
search for spear parts in other hospitals
buy portable x-ray machine
only one internist in A and N shift 2 internists / shift
In patients to be examined in OPD clinic
higher more internists
No clear job description for security Put clear job description for security
put clear search P&P for security
train security personnel on P.T search
There is no policy in security for properties Make a window before the metal detectors
declaration before detectors Make a policy for property declaration before
entering
Set the metal detectors on the highest sensitivity
In purchasing toilets and furniture Set a policy for consulting with nursing and
doctors and nursing were not consulted doctors before buying
Bring samples
Consult with nursing manager and head of
psychiatric department before purchasing

36. Possible solutions for maintenance problem
Root Cause Possible Solutions
No clear P&P for maintenance education in PT Set policy for maintenance education in PT safety
safety Set training program for 1st line maintenance staff
Monitor maintenance safety issues
no policy for location cleaning after maintenance Set clear policy for location cleaning
Corporation between maintenance and housekeeping
Monitor maintenance activity
no policy for equipment supervision Set clear policy that tools and equipments must be
supervised all the time
Count tools before and after maintenance order
Maintenance supervisor must chick every
maintenance sight
No clear policy for using tool box Set clear policy stating use of tool box
Prevent any tool movement from warehouse with out
tool box
Ask maintenance company to provide tool boxes

37. Possible solutions for ward lights problem
Root Cause Possible Solutions
Non experienced nursing Educate and train nursing
Monitor nursing staff performance
Security rounds in wards
Light covers are made of soft plastic Change light covers material
Chick material strength before purchasing
Consult with nursing before purchasing
No education policy for maintenance on PT Set policy to educate maintenance PT safety
safety Set policy to follow safety measures in
maintenance order
Set education program for maintenance
no barriers for lights protection Put a steal net on lights
Change type of wards lights

38. Possible solutions for frames problem
Root Cause Possible Solutions
Old frames Do regular rounds and change rusty frames
Change all wards frames regularly
Change frames when they are broken
No clear P&P for maintenance staff on PT safety Make policy to educate maintenance staff on PT
training safety
Train maintenance staff on PT safety
Monitor all maintenance activities all the time
Some screws that are used are easily removed Use screws that not easily removed by patents
Prohibit the use of any other type
some frames are easily broken
Use strong materials
Ask nursing opinion before purchasing

39. Possible solutions for gardens problem
Root Cause Possible Solutions
Patients brake lamps to use glass or wires Remove light stands
Use high sealing lights
Use wall lamps
Sport therapy department have no clear P&P for Make clear policy for sport therapist to be
removal of equipments after use responsible for equipment
Educate sport therapist on PT safety
Remove movable sport equipments from garden
No regular maintenance for windows netting Do regular maintenance
Nursing chick netting daily
Maintenance supervisor chick netting daily
Patents use garden components for harm Cover all gardens with floor tiles
Use artificial plants
Keep a nursing staff in gardens at all times

40. Solution matrix
Sigma Level Time to Implement Cost/Benefit Other <<<< Criteria
10 8 5 0 <<<<<<<<Importance
----- Possible Solutions ----- --------- Ratings --------- --------- Total ---------
Remove light stands from gardens 10
8 9 209
Use high sealing lights in gardens
9 8 8 209
Use wall lamps in gardens 5 6 5 123
Make clear policy for sport therapist to be responsible for
equipment
9 7 9 191
Educate sport therapist on PT safety
9 9 9 207
Remove movable sport equipments from garden
8 8 8 184
Do regular maintenance for windows neting
8 8 7 179
Nursing chick windows netting daily
5 7 7 141
Maintenance supervisor chick windows netting
daily 8 7 9 181
Do regular rounds and change rusty frames 9 8 9 199
Change all wards frames regularly 8 3 1 109
Change frames when they are broken 5 5 9 135
Make policy to educate maintenance staff on PT
safety 8 7 9 181
Train maintenance staff on PT safety 8 7 5 161
Monitor all maintenance activities all the time 5 4 7 117
Use screws that not easily removed by patents 7 7 8 166
Use strong materials for frames 8 6 6 158
Ask nursing opinion before purchasing materials
for frames 7 4 9 147
Educate and train nursing on PT safety 9 4 7 157
Monitor nursing staff performance on PT safety 9 7 9 191
Security rounds in wards 5 3 8 114

41. Sigma Level Time to Implement Cost/Benefit Other <<<< Criteria
10 8 5 0 <<<<<<<<Importance
----- Possible Solutions ----- --------- Ratings --------- --------- Total ---------
Change light covers material 9 6 6 168
Chick light covers material strength before purchasing 8 8 9 189
Consult with nursing before purchasing 7 4 9 147
Set policy to follow safety measures in maintenance order
9 9 9 207
Put a steal net on lights 9 6 7 173
Change type of wards lights 7 4 5 127
buy new x-ray machine 10 3 2 134
search for spear parts in other hospitals 9 5 9 175
buy portable x-ray machine 10 4 4 152
2 internists / shift 9 7 5 171
in patients to be examined in OPD clinic 3 6 9 123
Put clear job description for security 8 8 8 184
put clear search P&P for security 9 8 8 194
train security personnel on P.T search 9 7 8 186
Make a window before the metal detectors 7 5 5 135
Make a policy for property declaration before entering 9 8 9 199
Set the metal detectors on the highest sensitivity 8 8 9 189
Set a policy for consulting with nursing and doctors before
buying furniture 9 8 9 199
provide samples of furniture before purchasing 9 7 9 191
Corporation between maintenance and housekeeping
9 8 9 199
set clear policy for maintenance sight cleaning after order
complited 9 8 9 199
Set clear policy that tools and equipments must be
supervised all the time 9 8 9 199
Count tools before and after maintenance order 9 8 9 199
Maintenance supervisor must chick every maintenance
sight 8 7 6 166
Set clear policy stating use of tool box 9 8 9 199
Ask maintenance company to provide tool boxes 9 7 9 191
Prevent any tool movement from warehouse with out tool
box 9 8 10 204
Monitor maintenance activity 6 5 7 135
Cover all gardens with floor tiles 10 7 5 181
Use artificial plants 0 9 4 92
Keep a nursing staff in gardens at all times 5 5 5 115

42. Filtering Solutions
• After ranking the solutions it was found that
the highest ranking was at 209 and the lowest
was at 92 and the total number was 52
solutions and after the 1st filtering the team
chose the solutions that ranked above 150
and it was found to be 35 solutions.

43. Final Choice Of Solutions
• Set policies
• Gardens renovations
• Repair frames and widows netting
• Training programs
• Training of employees
• Monitoring number of incidences
• Provide X-Ray machine

44. Plan and Implement Key Learning
Process Integration
Solution &Closure
•Integrate permanent
•Document results solution into appropriate
To develop a plan to make •Identify potential future
improvements permanent Quality System
projects •Identify replication
•Hand off to process owner and/or standardization
•Reward the team opportunities to expend
ROI
Control
Process Control Systems Monitoring Evaluating Results
Monitor the process Recalculate process
•Control KPIV and KPOV using control charts to capability, and
•To prevent mistakes or ensure process stays financial results based
errors in stable on improvements

45. Implementation Schedule
Reducing the number of reports of potentially harmful
Process: objects found with patients in ward
Location: Al-amal Hospital in Jeddah
Responsibil Complete
Tasks Activities ity Start Date Date
Prepare needed policies for
maintenance, sport therapy,
security, nursing Quality
Set policies departments department 5/4/2011 5/5/2011
Support
Cover gardens with floor
services
tiles, remove light stands,
Gardens renovations install sealing lights Eng, Turki 10/4/2011 30/4/2011
Do round and chick all
wards frames and window Wards
Repair frames and netting and ask maintenance safety
widows netting to repair damaged ones officers 7/4/2011 10/4/2011

46. Reducing the number of reports of potentially harmful objects
Process: found with patients in ward
Location: Al-amal Hospital in Jeddah
Quality
department
Hatim
banjar
Nursing
Prepare training program
education
for maintenance, nursing
and security departments in naïf
Training programs patient safety alomari 15/4/2011 10/5/2011
Education
department
Training of Implement training Majed
employees programs sahafi 30/5/2011 30/7/2011
Quality
department
Monitoring number of Keep track of incident hatim
incidences reports on daily bases banjar 1/4/2011

47. Reducing the number of reports of potentially harmful objects
Process: found with patients in ward
Location: Al-amal Hospital in Jeddah
Support
services
department
eng. fawaz
Finance
department
Provide x-ray Get a portable x-ray Ibrahim
machine machine asiry 1/4/2011 1/10/2011
Quality
department
Compare number of
incidents/month with the Hatim
Verify Results expected goal banjar 1/4/2011

48. Verification of Implementation
The implementation of the quick wins started in the
2nd quarter of 1342 and the final implementation of
the program started in the 3rd quarter of 1432 and
the result was that after implementing the quick wins
the numbers of reports dropped from 9 / month in
the 1st quarter to 7/month in the 2nd quarter and after
the full implementation of the program the number of
reports dropped to 4/month and the goal of the
project was not fully met and that is because not all
chosen solutions were implemented due to financial
and legal issues.

49. Verification of Implementation
Year Month No of Harmful Objects
2010 Oct 10
2010 Nov 7
2010 Dec 8
2011 Jan 12
2011 Feb 9
2011 Mar 6
2011 Apr 9
2011 May 8
2011 Jun 4
2011 Jul 6
2011 Aug 4
2011 Sep 2

50. Control
Verification of Implementation
Before ( Oct 2010- After ( June—Aug
Mar 2011) 2011
No of 9 4
Harmful
Objects
/mth

51. Verification of Implementation
Trend Chart ( No of Harmful Objects)
No of Harmful Objects Per
10 9
7
8 No of Harmful
6 Objects per mth
Mth
4
4 Target
3 3 3
2
0
Before ( Quick After (
Oct 2010- Wins ( July- Aug)
Mar 2011) Mar-June
2011)
Phases

52. Control
Process Control Systems
Hold the Gains
Process Description: CAF activation Process Customer: Ext Cust Critical Customer Requirements: Outcome Indicator(s):
Process Flow Chart Checking
Position Input-Process- Control Checking Item Frequ Responsi Contingency Plan
Outcome Indicators Limits ency bility
Charts and Graph Specs/Tar What to Check When Who Action Req’d for
Type gets to Checks Exception
Step/or Time Critical Process Step Check
harmfull objects harmfull objects 1 no of incedents week hatim Corrective ACTION

53. CORRECTIVE ACTION REQUEST
TO: Eng. Turki Al-Ghamdi
DEPARTMENT:
Support services
FROM: Hatim Banjar
DEPARTMENT:
Quality Management
PROBLEM DESCRIPTION:
What: Dangerous object ( wire cuter )
Where: Ward B
When:20 July 2011
Who: in patient
How: 1
ROOT CAUSE: Took from maintenance location in ward – maintenance staff didn’t have
tool box
CORRECTIVE ACTION:
ACTION WHO COMPLETION
DATE
Enforce caring tools in tool box Eng. fawaz 23July 2011
VERIFIED:
ACTION: DONE/ NOT DONE
RECEIVER SIGN: Eng. Turki Al-Ghamdi
ORIGINATOR SIGN: Hatim Banjar