This is a brief introduction, to essential elements for implementing health care quality improvement, The responsibility taken by the health care providers, should stimulate them to find out better way , to be applied specifically and appropriately, to reach better than expected for the patient and family

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Health Care,Health Care,
Not only qualityNot only quality
But also improvementBut also improvement
Rule # OneRule # One
No Blame But RewardNo Blame But Reward

2. 08/01/13 Prepared By: Dr Gamal Soliman
Health Care Quality ManagementHealth Care Quality Management
Introduction And PrinciplesIntroduction And Principles

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Today’s AgendaToday’s Agenda
24-05-201024-05-2010

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1.1. Criteria for Performance Excellence.Criteria for Performance Excellence.
2.2. Eight Disciplines Problem Solving.Eight Disciplines Problem Solving.
3. Accreditation Decisions.
4.4. Ten Survey Strategies to Remember.Ten Survey Strategies to Remember.
5.5. Quality Management StandardsQuality Management Standards
Flow of informationFlow of information
5-1 Plan For Implementation.5-1 Plan For Implementation.
5-2 Patient Safety Initiative.
5-3 Internet Resources

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Part1Part1
Criteria for Performance ExcellenceCriteria for Performance Excellence
 To help improve organizationalTo help improve organizational
performance practices, capabilities andperformance practices, capabilities and
resultsresults
 To facilitate communication and sharing ofTo facilitate communication and sharing of
information on best practices.information on best practices.
 A working tool for, understanding,A working tool for, understanding,
managing performance, for guidingmanaging performance, for guiding
planning and opportunities for learningplanning and opportunities for learning

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The seven categories of the CriteriaThe seven categories of the Criteria
areare
1. Leadership1. Leadership
2. Strategic Planning2. Strategic Planning
3. Customer Focus3. Customer Focus
4. Knowledge Management4. Knowledge Management
5. Workforce Focus5. Workforce Focus
6. Process Management6. Process Management
7. Results7. Results

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Results to be achieved:Results to be achieved:
 delivery of ever-improving value todelivery of ever-improving value to
patients& owners, contributing topatients& owners, contributing to
organizational sustainabilityorganizational sustainability
 improvement of overallimprovement of overall
organizational effectiveness andorganizational effectiveness and
capabilitiescapabilities
 organizational and personal learningorganizational and personal learning

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Part2Part2
Eight Disciplines Problem SolvingEight Disciplines Problem Solving

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1-Define the Problem1-Define the Problem
2-Use a Team2-Use a Team
3-3- Implement and verify InterimImplement and verify Interim
ActionsActions
4-4- Identify and Verify Root CausesIdentify and Verify Root Causes
5- Choose and verify Permanent5- Choose and verify Permanent
Corrective Actions (PCAs)Corrective Actions (PCAs)::

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6-Implement and validate PCAs6-Implement and validate PCAs
7-Prevent recurrence7-Prevent recurrence: Modify the: Modify the
management systems, operationmanagement systems, operation
systems, practices and proceduressystems, practices and procedures
to prevent recurrence of this and allto prevent recurrence of this and all
similar problems.similar problems.
8-Congratulate your Team8-Congratulate your Team

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Part3
Accreditation Decisions

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  Accredited
  Provisional Accreditation
  Conditional Accreditation
  Preliminary Denial of
Accreditation
  Denial of Accreditation
  Preliminary Accreditation

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Part4Part4
Ten Survey Strategies to RememberTen Survey Strategies to Remember

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 1. Be confident - you are the expert not
the survey team!
 2. Anticipating the survey is more
stressful than the actual survey
 3. You will pass by meeting regulatory
requirements,
 4. Preparation for the survey includes
documentation, organization - effectively
communicating what you know.

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 5. Show the surveyors completed risk
assessments, “RCA’s” and :FOCUS
 6. First impressions are extremely
important;
 7. “Closing the loop” on identified
problems can be more important than the
problem itself!
 8. Facts not documented, don’t exist!

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 9. Prepare for the survey by
organizing the required planning
documents, practicing interview and
pre-planning the building tour
 10. If you disagree with a surveyor,
tactfully uncover their perspective,
- - - - - -------Relax!
Resource: www.ahrq.org

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5-1 Quality Management Standards5-1 Quality Management Standards
Plan For ImplementationPlan For Implementation

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 1-A sufficient staff to QM1-A sufficient staff to QM
committee,committee,
 2-QM2-QM
Mission, Vision, Value, scope ofMission, Vision, Value, scope of
services, Organizational Chart andservices, Organizational Chart and
job descriptions Templatesjob descriptions Templates
MethodMethod: This week templates of: This week templates of
designs for each department,designs for each department,

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3-Define high problem prone areas.3-Define high problem prone areas.
 3- 1 Invasive procedures.3- 1 Invasive procedures.
 3-2 High risk procedures.3-2 High risk procedures.
 3-3 unusually expensive3-3 unusually expensive
medications.medications.
 3-4 All high risk medications.3-4 All high risk medications.

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 MethodMethod: Flow of information to head: Flow of information to head
departments,departments,
Print and give high problem pronePrint and give high problem prone
areas PFR-16 teaching file,areas PFR-16 teaching file,
To be modified accordingly.To be modified accordingly.

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5-2 Patient Safety Initiative

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 Assign individuals (team)
 Scope of program activities
 Safety culture
Focus to improve patient safety processes, No
blame No punishment against staff making errors
But correct them and reward the competent
 Components of program
Description of how Al-Rashid Hospital integrates
safety elements into wide effort

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 Adverse Events (medical errors) Plan provides for:
Procedures for immediate response.
1- Care of the affected patients
2- Containment of risk to others
3- Preservation of information for subsequent analysis
 Definition of the systems in place for internal and
external reporting of information
 Definition of mechanisms in place for responding to
unexpected clinical events including sentinel events-SE,
root cause analysis-RCA, Plan Do Check Act-PDCA and
FOCUS

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 Measurement and analysis
 Corrective actions for high-risk processes
 Resourced allocation
1-A good design of adequate parameters
2-Assignment of competent personnel
3-Provision of information systems and data
management process
4-Leadership assessment

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5-5-Barriers and solutions to:
 Effective communication,
 Analysis of major adverse events
 Knowledge-based systems

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6- Information analysis on:
A-Confirmed transfusion reactions
B-Significant adverse drug reactions
C-Significant medication errors and
hazardous conditions
D-Major discrepancies between pre- and
postoperative diagnosis
E-Adverse events associated with anesthesia

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7-Identification of staff roles and7-Identification of staff roles and
responsibilities.responsibilities.
8-Quality concepts and Risk8-Quality concepts and Risk
Management.Management.
9-Problem identification, information9-Problem identification, information
gathering, implementing actions, andgathering, implementing actions, and
evaluation.evaluation.

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10- Data measurements, analysis and10- Data measurements, analysis and
implementation evaluationimplementation evaluation
11- Quality improvement projects11- Quality improvement projects
prioritization, teams reports and flowprioritization, teams reports and flow
of information to all staffof information to all staff
12- Quality plans approval by the QM12- Quality plans approval by the QM
and the Hospital Directorand the Hospital Director
13- Annual plans’ revisions by GM13- Annual plans’ revisions by GM

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MethodMethod
QM supplies hard and soft P&P thisQM supplies hard and soft P&P this
week to all committees of the next:week to all committees of the next:

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 Checklist for Patient SafetyChecklist for Patient Safety
 Template for Developing Your Quality ManagemTemplate for Developing Your Quality Managem
 The Focus: PDCA MethodologyThe Focus: PDCA Methodology
 Action Minutes TemplateAction Minutes Template
 Indicator & PDCA WorksheetIndicator & PDCA Worksheet
 Organizational QI PlanOrganizational QI Plan
 Application Form For PDCA ProjectsApplication Form For PDCA Projects
 Quality Management PlanQuality Management Plan

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6-3 Internet Resources:6-3 Internet Resources:
www.cbahi.orgwww.cbahi.org
www.jointcommissioninternational.orgwww.jointcommissioninternational.org
www.ahrq.orgwww.ahrq.org
www.apic.orgwww.apic.org

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ENDEND
Primo Non NocerePrimo Non Nocere
==
Before All No ObstaclesBefore All No Obstacles