division / unit - quality management...

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King Khalid University Hospital

and King Abdul-Aziz University Hospital

QUALITY MANAGEMENT

PROGRAM

2009-2010

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Dr. Farheen Shaikh Prepared by: _____________________________ Date : ______________ Director of Quality Management

Department-University Hospitals

Dr. Ayman Abdo Authorization by: _____________________________ Date: _____________

Vice Dean for Quality & Development

Prof. Mussaad Al Salman

Approved by: _____________________________ Date : _____________ Dean of College

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Quality Management Program

Introduction

Goal & Objectives

Components

Scope of implementation

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Introduction

The QMP is in line with vision, mission, and values of KKUH & KAUH . It is

developed by the Quality Management Department (QMD) in collaboration

with KKUH & KAUH Executive Management and approved by the Chief

Executive Director (CEO) at the level of the quality council

QM Program has been developed to continually and systematically plans ,

measures and improves performance of hospital wide key functions and

processes.

QM Program for improvement is based on Canadian as well as CBAHI

Standards and Guidelines. The Program defines the responsibilities for

monitoring every aspect of quality and risk management.

Quality Management Program defines:

- Top management, key leaders’ and all staff role and responsibility in practicing

and promoting QM Philosophy in the facility.

- Quality definitions and statements of all terminologies and quality processes

that being done within the facility.

- Detailed information of QMP components and scope of implementation.

- Different levels of performance monitoring.

- Reporting quality improvement activities.

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Goal & Objectives of QM Program

In keeping with KKUH & KAUH mission, this program allows a systematic,

coordinated and continuous approach to improve quality in the facility.

Objectives

To incorporate quality planning throughout the facility

To provide a systematic mechanism for the facility’s individuals,

departments and professions to function collaboratively in their efforts

toward performance improvement

To ensure that the improvement processes are organization wide.

To report and communicate information to the Hospital Board, managers

and staff that is needed to fulfill their requirements as well as their

responsibilities for the quality of services, patient care and safety.

To contribute to cost containment efforts by assisting in developing

effective utilization programs.

To collaborate with Hospital Strategic Plan, Hospital Wide Risk

Management, Patient Safety Program.

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QM Program: Scope of implementation

QM Program requires quality in all aspect of the facility’s operations, starting

from developing a foundation /framework for quality structure, going to

processes being done right the first time and every time and ending with regular

monitoring to evaluate improvement and sustainability.

The scope of TQM Program includes:

1- Quality Management ( structural framework)

2- Continuous Quality Improvement ( CQI)

3- Quality Monitoring & Evaluation

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QM Program Implementation responsibility

Top Management (Quality Council)

With active participation, approval and support to QM Program, Top

Management also has an essential role of providing QM the visible support and

initiatives for all CQI activities.

Part of Top Management responsibilities toward successful implementation of

QM Program is regular review of all the reports related to quality submitted to

them at the level of Hospital Board

The reports that needed to be submitted to the Hospital Board for review and

critics are;

Progress on Accreditation process

Hospital teams performance

M&M Reviews

Sentinel Events

Risk Management

Key Services of the Departments

Patient and Staff Satisfaction

Quality Improvement Projects & Audits

KPIs and OCIs

Hospital Surveys for Standards Compliance

Efforts for Promoting Quality and safety Culture

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Directors / Head of Departments

All the efforts and work of QM Department wouldn’t be accomplished without

full cooperation of the departments: Clinical, Administrative and Nursing

The success of QMP implementation is nothing but the degree and the extent of

QM practices by the departments/ teams and individuals in the organization.

Director/ Head of Department should go through the activities in Departmental

QM plan and review it for specific requirements to apply quality principles in

their department.

Directors of the departments are required to do the following:

1. conduct monthly departmental management team meetings

2. The agenda should include items related opportunities for improvement

3. Report department performance by regular submission of departmental

monthly performance reports

4. Monitor department performance by using indicators

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Hospital Teams Leaders/chairpersons

The responsibilities of the leaders of the teams in KKUH & KAUH to do the

following:

To conduct meetings once per month

To function within the scope developed for each team

To ensure that all team members understand their roles and

responsibilities

To monitor the function of the team by evaluating team performance

using key process and outcome indicators.

To report quarterly for the progress and achievement of the team.

To conduct

i. Audits

ii. Quality Improvement Projects

.

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All the Staff of KKUH & KAUH

The front line and the processes owners of the organization the “STAFF” ,

have big responsibility in making QM Program capable for implementation ,

their understanding, practicing QM activities makes the positive change .

Therefore, it is very important to involve the processes owner in all quality

improvement activities as they can be the best who can identify the gaps,

problems and suggest the improvement.

Also QM Department will ensure that all the staff will have a chance to

participate in by becoming a member in hospital teams and get opportunities to

be trained for QM issues

QM Department

QM Department has a huge responsibility in implementing and facilitating

implementation of QM Program.

QM Department is fully responsible for successful implementation of QM

Program with its scope and elements by establishing the framework of quality

management going through continuous quality improvement activities and

ending by regular monitoring, trending and evaluation.

Good communication, reporting and liaison with departments/ teams as well as

with staff are the key for QM Program launching.

The responsibilities of QM Department for implementing QM Program are:

Integration of QM Program with QM Department Strategic Plan

Development of QM Operational Plan (TOP)

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Development of QM Training and Education Program which includes

the basics, principles and tools of Continuous Quality Improvement

(CQI)

Facilitating, selection and conduction of Quality Improvement Projects

at different departments/ teams level

Periodical and regular reinforcement for data collection and reviews

Maintaining data entries and efficient utilization of information

Regular trending and monitoring

Timely reporting and feedback

Celebrating success and maintaining sustainability through monitoring.

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A- Quality Management Program Structural Framework

Structural Framework

Documents:

1. Strategic Plan

2. Organizational Charts

3. Scope of Services

4. Job Description

5. Staffing plan

6. Staff Bylaws

7. Standards & Guidelines

8. Hospital Policy & Procedures

9. Hospital Manuals

10. Ethics & code of professional conduct

Quality Designees

a. Quality professionals

b. Quality Improvement Teams

c. QM Facilitators

d. Safety Officers

Processes

1- Q. Tools

2- Q. Techniques

3- QM Systems

3.1C.Q.I

3.2 Quality Education & Training

3.3 Accreditation

3.4 Follow up & Monitoring

3.5 Orientation

3.3

Documents

Quality Designees

Processes

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Quality Management: Structural framework

Introduction

QM Program seeks to integrate all organizational functions by distributing

roles and responsibilities along various lines of authorities and processes

owners, to make this possible, an organizational quality structure will be

develop to serves the following functions:

1. Producing organizational outputs and to achieve organizational quality

objectives.

2. Minimization or controlling the influence of individual variations on

organization functions and systems.

3. Facilitation decision making.

In order to develop QMP structure and foundation in our organization to

support and facilitate continuous quality improvement the following required:

1- Departmental and Hospital wide documents

2- Quality designees

3- Processes consist of tools, techniques and systems

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1- Documents

The following documents will be required to fulfill the requirements of QMP

structural framework; each document has been explained for its purpose and for the

lines of authorities and approval, each of these documents is respectively required at

QM Department level and /or hospital departments (clinical, administrative &

Nursing) and Hospital top management

1. Strategic Plan

2. Organizational Charts

3. Scope of Services

4. Job Description

5. Staffing plan

6. Staff Bylaws

7. Standards & Guidelines

8. Hospital Policy & Procedures

9. Hospital Manuals

10. Ethics & code of professional conduct

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Strategic Plan

Strategic plan is required to be developed at all levels , starting with Hospital Strategic

plan to be later use as a guideline and reference for all the department including QM

Department

Strategic plan will be developed for minimum of 3 years and has to be reviewed and

updated every year according to process and outcome indicators

The plan is guided by:

Organization vision and mission

SWOT analysis

Objectives and the key issues

Organizational Charts (OC’s)

In order to facilitate leadership directions, decision making, reporting and

liaison ship Organizational Charts have to developed at those levels: hospitals

and departments , also to enhance team work quality organizational chart will

be developed to show the quality committees

The chart exhibits the structure of the organization/ departments with position

(titles) and names of the Key Leaders.

It will the responsibility of top management to exhibit and finalized the

organization chart of the facility and to approve the authorized OCs of the

departments

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Scope of Service

Scope of service will be written for the hospital as well as for each

department. The scope of service is part of strategic plan and of each

Department Policy Manual. To make it public, scope of service is part of

hospital/ patient information booklet.

Scope of Service of the hospital includes the following:

Range of service: medical, surgical, preventive, and diagnostic

or as level of care: primary, secondary, tertiary or general and

specialized care.

The age group who receive care

Number of patient seen annually

Major diagnostic or therapeutic method used

Job Description (JD)

At King Saud University Hospitals, all categories of staff will have a clearly

written job description which will be reviewed at least every three (3) years

or as needed.

Leadership team will be responsible to develop and finalize JDs of top

management and each Director/ Chairman of the department will be

responsible to develop JD of each position in the department, QM

Department along with HR department will facilitate development of all these

JDs.

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Staffing Plan

To ensure customer satisfaction and for better healthcare outcomes, the

facility requires appropriate variety of skilled, qualified staff to fulfill its

mission, and this best accomplished by having hospital wide staffing plan.

Staffing plan has to be carried out at two levels, departmental and facility

wide.

Facility Staffing Plan

This plan should be written as a part of Human Resource Department

(HRD) policies and has to be developed in collaboration with clinical and

managerial leaders.

Departmental Staffing Plan

This is applicable to all departments; the staffing plan in here explains staff

coverage, schedule, weekend coverage, and transferring of responsibilities.

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Staff Bylaws

KKUH & KAUH leadership will be responsible to develop set of documents

that describe the medical, administrative as well as Nursing Bylaws, the

documents contain the following:

Organizational structure of the hospital with divisions and units and

reporting relationship

Job responsibilities of the top management

The membership categories (full time, part time, locum, visitor, etc.)

Promotion, appointment and re-appointment

Disciplinary process and corrective actions and appeals

Credentialing and privilege processes

Standards and Guidelines

Canadian standards and guidelines have been chosen to provide the

framework for the facility by its leaders with a commitment to provide

quality in patient care, safety and the services.

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Hospital Policy and Procedures

Internal Policy &Procedure is a written document which outlines the rules,

regulation and expected performance of staff within the organization.

For that, the facility as well as each department/ division/ unit are subject for

having clearly written IPPs.

The IPPs should be:

Consistent with organization mission

Able to guide performing and decision making

Capable for implementation

Written for owned processes with defined responsibilities

Recorded in Departmental IPPs

Signed, dated and subject for review

Development of IPPs is a responsibility of each Director/ Head of

Department (or for whom he/ she will delegate).

All IPPs developed in consistence with AC and/or other applicable standards

could be adopted as needed.

All IPPs will be written on a specific format and must be authorized and

approved

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Hospital Wide Manuals

Hospital Wide Policy & Procedure Manual

Hospital Safety plan

Disaster Management Plan

Leadership manual

Hospital Wide Policy & Procedure Manual

The manual will be applicable organizational wide, designed to be flexible so it

can be implemented as the policy states or to be as a guideline or reference for

developing specific IPPs.

The manual will include only those HPPS which will be developed by different

disciplines but involve significant organizational wide issues, mandatory rules

by the hospital or local authorities and/ or requirement for QMP /Risk

Management Program.

The manual will be divided in following sections according to the area of

issues:

Clinical HWPP

Quality HWPP

Administrative HWPP

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Hospital Safety Manual

Hospital Fire & Safety Department with coordination with Fire & Safety

team has to develop this manual in consistence with Canadian, CBAHI

Standard, Local Body’s policies and other International rules and regulations

as required.

The purpose of the program is to ensure that:

The facility, occupants and environment is safe from fire and smoke

No smoking policy implementation

Hazardous Material and Waste Management System is intact

Medical Equipment are maintained

Evacuation Plan in place

Major Disaster Management Plan

The Major Disaster Management team must this plan so the facility as well as

the staff will be able to respond to possible community emergencies,

epidemics, natural or internal disaster.

The plan should be tested and reviewed annually and as necessary, and staff

must be trained and oriented by conducting at least one drill annually.

Leadership Manual Administrative: Leadership responsibilities, Standards of patient services,

culture of safety and quality, leadership support to quality improvement ,

administrative on call, budget process, confidentiality of information,

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community need assessment , IM Plan, release of information to media Dress

Code, inappropriate behavior

Ethics: research, end of life issues, sexual harassment t, conflict of interest

Medical Staff Bylaws: 18 articles : hiring, appointment evaluation of medical

staff, clinical privileges, promotion, meetings, CME, leave coverage

- Patient Safety plan

Clinical Risk Management is an approach to improve Patient safety in

healthcare by emphasizing on identifying the circumstances which put

patients at risk of harm, and then acting to prevent or control these risks.

Patient safety plan will be developed to help the organization to implement,

assess and to improve patient safety activities through defined safety

indicators.

The plan works as resource to assist in development and improvement of

patient safety issues. The plan is an attempt to identify and define critical

elements, activities, ROPs , principles and functions of an effective patient

safety environment..

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Ethics and Code of Professional Conduct

Code of Professional Conduct is a document that describes the standards

by which staff may determine the propriety of his/ her conduct in relation

to patient, colleagues, and members of organization and with public.

Code of conduct provides guidance to ensure that all hospital activities,

functions and services are conducted in legal manner.

Code of conduct must be developed in accordance with Islamic, Medical

,Country cultural values.

The document will be prepared by Ethics team/committee and should

explains in detail the policy and procedure to implement and monitor code

of conduct and how to the deal with ethical issues as related to staff and

patient care.

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2- Quality Designee

To fulfill the requirements of QM structural framework that is needed to establish QM

Program in the facility, following staff, teams and personnel should be assigned in

each facility according to facility complexity and services provided.

1. Quality Professionals

2. Quality Facilitators

3. Safety officers

4. Hospital Teams

Q Professionals

To ensure implementation of QM Program at all levels of the

organization, each facility King Saud University Hospitals will have QM

professionals, who report to Voice Dean of Quality Affairs , and are

responsible for development, implementation , improvement and

continuous monitoring for QM activities.

QM Professionals will be also representing in all hospital and

departments quality improvement teams

Q Facilitators

To fulfill the requirement of QM Program, at least two volunteers

(according to the size of the department and its complexity) will be

selected in every department to follow and implement QM Department

instructions and plans

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Those volunteers will be known as TQM Facilitator, and will be

assigned by QM Department staff and /or Director of the department

recommendation.

The facilitator will go through extensive QM Training and will be

consider as an extension of QM Department in his/her respective

department.

Patient Safety Officer

To ensure patient safety, a safety officer will be assigned to discuss,

report, identify, review, investigate and advise on safety issues related to

patients

The safety officer is a full time staff working at QM Department and or

a part time staff working as coordinator for safety such as in ICU,

Radiology, OR and at inpatient floors.

Patient safety officer should be a trained staff who can to carry out all the

responsibilities as related to audits, surveys and staff training for safety

issues.

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3- Process

TQM is a method by which management and employees are involved to bring positive

and continuous change in the facility, to fulfill these requirements of TQM following

processes and systems will be established and adopted in the facility.

1. QM Tools

2. QM Techniques

3. QM Systems

QM Systems

QM Department will be organized in a manner to facilitate systematic

approach to all the quality activities that will be carried out in the facility

to ensure quality control, continuous improvement and staff development.

It is a responsibility of QM Department to facilitate implementation of

those systems and have effective monitoring for their compliance.

The systems are:

1- Follow up and Monitoring

The system monitor and do follow up of all type of documents and

activities related to documentation process. The system also looks at

appropriateness of reporting and on time performance.

The system comprises the following:

1- Control of Documents and Documentation

2- Review and Amendments

3- Authorization and Approval

4- Environmental Control

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5- Standing Teams Meeting

6- Reporting Channels

7- Development of New Documents

2- Continuous Quality Improvement

The system is mainly concerned with continuous improvement in all

processes, from high level of strategic planning and decision making, to

detailed steps of work elements at every levels of care.

The system is based on using the quality improvement model, quality

tools and techniques by individuals or through team approach.

Quality Models, Tools and Techniques

Although that there are various models adopted by different organizations for

implementing QM to fulfill the requirement of accreditation considering the

continuous change and the culture.

QM Department will be adopting the model of improvement that is FOCUS

PDCA.

The model is simple and easy to implement and should be repeatedly

implemented in upward spiral that moves toward the ultimate goal of CQI.

While implementing the improvement model, different quality tools will be

used for issues/ problems identification, prioritization, solving, decision

making and implementation.

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The recommended Quality Tools to be used in the facility are:

1. Brainstorming

2. Fish Bone Analysis (Cause – Effect Diagram)

3. Pareto Chart

4. Histogram

5. Control Chart

6. Run Chart

7. Prioritization Matrix

8. Affinity Diagram

9. Failure Mode and Effect Analysis (FMEA)

10. Indicators

The team can also use the following techniques & methods:

Audit

Surveys ( Hospitals, customers)

Reviews

Development/ Identification of Indicators

Hospital Information System (HIS)

Patient Medical Record

The areas for implementation include and not limited to:

1-Performance Improvement

2-Quality Improvement

3-Risk Management

4-Utilization Management

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3- Quality Training & Education

The system demands plans & program for quality education and training

of the staff concern to the general requirements of the organization as

related to quality.

Education and Training as related to QM concepts and implementation is

very important for all the employees to be highly productive.

Key leaders and managers are responsible for implementing QM within

their areas and departments by coaching, educating and training their staff

on how to use and develop IPPs, guidelines, forms and other documents

and how to conduct continuous improvement activities.

Training of the employees required skills, knowledge, ability to observe

and absorb, the thinking of creativity and out of the box ideas.

4- Orientation

The system deals with putting plans for orientation both organizational wide

and at departmental level, it’s also deals with quality publications, news letters

and marketing for Quality management Department.

5- Accreditation

In recent years, accreditation bodies have changed their accreditation

policies and standards shifting from focusing on availability of documents

and compliance with the standards to incorporating of CQI approach in all

activities, by that, looking more and more to data collection, analysis,

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trending and improving the outcomes along with patient safety

applications.

Keeping this in mind, QM Department, with the approval of top

management and higher authorities will be calling for accreditation and to

maintain the certification by focusing on continuous quality improvement

activities such as more and more audits, quality improvement projects and

the outcome management.

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B- Continuous Quality Improvement (CQI)

One of the objectives of QM Program is to ensure that there is continuous

improvement applied organizational wide throughout all activities and

functions and manifested in a fundamental and shared belief in Quality

Management.

Everyone in the organization, from the directors, hospital administrators,

physicians, other professionals and employees must adopt the concept of

continuous quality improvement (CQI) principles and embrace the philosophy

and culture where quality is the key for every process.

The following section briefly indicates the specific activities and elements

needed for continuous improvement.

It is a responsibility of all directors/ team leaders to implement those activities

accordingly as and applicable to their scope of service.

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1- Quality Improvement Plans

These plans should be targeting specific areas for improvement. Project topics

are determined through the use of data collection and analysis and include both

clinical and non-clinical topics.

Plans are considered complete when a year of sustainable improvement has

been demonstrated.

Conducting these plans is a responsibility of team leader in the organization.

The plan should be based or criteria and all projects must be conducted using

PDCA model of improvement

2- Quality Reviews

As a part of overall quality improvement system, all staff as appropriate and as

directed by their team leaders or head of department should conduct the

following reviews and not limited to:

Case-Specific Review

Peer Review

Medical Record Review

Surgical and Procedure Case Review

Medication Usage

Blood and Blood Products Use

Morbidity & Mortality Reviews

Utilization Review

Code Blue Review

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Sentinel Events

Annual Performance Review

A review could be done retrospective and concurrent. Each review has its own

methodology and frequency as designed by TQM Department.

3- Audits

Quality Audit is an assessment to determine whether agreed requirements

are being met. It is associated with formal examinations, checking and

reviewing the performance against standards or criteria.

Audits should be initiated upon instructions from the team leader/ director

of specific area depending on certain criteria.

The audit like other quality improvement activities has to be authorized,

conducted by scientific methods, documented and reported with especial

consideration to professional conduct, ethics and liability issues. Audit can

be chosen for any organization functions and services.

4- Surveys

Surveys are considered as a powerful technique as well as tool to

determine the level of compliance or performance.

As part of continuous improvement, regular surveys should be conducted

to identify areas for improvement and to determine the sustainable areas.

As instructed by TQM/ MSD, all MHS has to conduct an internal survey

(self-assessment) every 2-3 years, and customer satisfaction survey (both

for patients as well as for staff) at least once per year.

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The results should be reviewed and reported to the top management to

review the findings and develop action plans and follow-up plan as well.

5- Promoting Quality and Patient Safety Culture

QM to be successful, quality and patient safety culture should be

embedded in the organization.

Every organization in the world has its own culture and characteristic, built

by their leaders and managers into the employees. QM culture to be built

up high and strong, continuous commitment from top management and

key leaders towards QM philosophy and principles is required.

There are methodologies and culture build up activities needed to be

practiced by the leaders and to be shared with the staff to make the culture

on-going. Such activities are not limited to:

Owning the Vision

Participative Leadership

Customer Focus

Value Added Processes

Process Owner Concept

Continuous TQM Training & Education

Rewarding (Quality Day)

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Patient safety culture will be spread through implementation of patient safety

standards and Required Organizational Practices (ROPSs)

6- Evidence – Based Quality Management (EBQM)

The aim of EBQM is to improve patient outcome and to improve work

processes and systems of care, and this could be possible by promoting the

collaboration between quality management and clinical research as well as

with health service research.

Quality Management also promotes Evidence – Based Practice (EBP)

where multiple disciplines are involved in providing patient health care,

which is possible through following guidelines:

Clinical Practice Guideline

Patient Care Protocol

Clinical Pathway

Care Management

Case Management

Peer Review

Case Specific Review

Disease Management

Demand Management

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7- Grand Rounds (Safety, QM, Clinical)

Safety Rounds

To promote safe environment in the facility, Environmental Health and

Safety Department should conduct regular rounds on monthly basis in the

whole facility, using specific checklist to look at:

Safety of the Building (Physical)

Collection, storage and disposal of waste

Safety of the Department

Hazardous Materials: handling, collection, storage,

labeling

Radioactive Waste Management

Sharp Collection

Chemical, Pathological and Pharmaceutical waste

OPD and ER Safety

Facility Walkthrough Safety Round

Patient Safety

The result of those rounds has to be discussed in the monthly meeting of

Hospital Safety Team. The data must be trended and close observation for

safety issue must be done with immediate reporting and pro-active actions.

QM Rounds

To promote QM Culture, better communication and develop close

relationship with the staff, the Director of QM along with Key /Top

Management will be doing regular rounds to the facility on monthly basis.

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During the rounds, staff will be asked for their perception and benefits from

QM and how QM Department can help and facilitate to improve the work

and their satisfaction.

Clinical Grand Rounds

This has to be conducted in every Clinical Departments. The round should

be at least once a month.

All the members of the department should be participating. The aim is to

promote high quality, integrated and collaborative healthcare to the patient.

The rounds’ findings should be documented and to be reviewed by the

Director of the Department for better outcome of patient care and to be

utilized as a guideline for further patient management.

Head of the department is responsible for assuring that clinical grand

rounds are done .

8- Utilization Management

To serve the purpose of cost-effective care provision, and by looking at the

dimensions of quality improvement, utilization management team had

developed different programs and plans for effective and efficient

utilization of:

Bed

Supplies

Equipments

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Space

Radiology Service Utilization

Laboratory Service Utilization

Medication

Human Resource

An ad-hoc team has to be developed to look at each area to ensure proper

utilization and recommend for better utilization.

9- Performance Appraisal

To ensure staff active involvement in quality improvement activities, the

new system of performance evaluation of the staff along with credentialing

(promotion) process has included the staff performance towards improving

the quality. The activities include:

Being leader of any Hospital Team

Being member of any Hospital Teams

Active presence and participation in teams’ activities

Incident Reporting

Morbidity Reporting

Completion of Medical Record

Appropriate patient discharging plan (LOS/ diagnosis)

Involvement in any Quality Improvement Projects

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C- Quality Monitoring and Evaluation

The main purpose of monitoring in QM is to evaluate the improvement and to

check the stability and sustainability of the improvement over time.

Monitoring helps reducing risk and error. It also facilitates in monitoring safe

environment for patient, staff and the facility. It is the responsibility of the

leader and directors to set priority on what they want to monitor and have

frequency on evaluating staff as well as the processes of care/ services and

outcomes.

On the other hand, facility Top Management needed to support the activity by

providing all necessary technologies and develop motivational strategies for

active staff involvement in the process.

QM Department will monitor all the activities with the help of the Directors of

Departments through submission of regular reports.

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Clinical Performance Monitoring

Along with Directors of Clinical and Paramedical Departments, QM

Department will also be in close monitoring of the following:

Laboratory Quality Control Program

Radiology Quality Control Program

Surgical Procedures

High Risk Procedures

High Risk and High Cost Medication

Invasive Procedures

High Risk Services

Utilization: Antibiotics, Blood and Blood Products

Morbidity and Mortality Review

Clinical Documentation

Infection Control

Clinical Guidelines and Pathways

Length of Stay

Sentinel Events

EMS Performance

Managerial Performance Monitoring

Completion of Medical Records

Major Disaster Management

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Fire Management

Utilization: Supplies, Equipments

Hospital Staffing Plan

Incidents related to safety

Patient Registration

PPM Program

Utility System

Monitoring Environmental and Patient Safety

Facility safety

Waste Management

Hazardous Material Management

Radiology Safety Program

Laboratory Safety Program

ER and OPD Safety

Monitoring Documentation

IPPs Compliance

Forms

Quality Records

Job Descriptions

Cross Functional Agreements

Departments and Teams Meetings

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Monitoring Key Services and Organizational Functions

Key Services of the facility

Cardiac Science Service

Clinical Laboratory Services

Diagnostic Radiology Services

Pharmaceutical Services

Oncology Services

Emergency Services

Nuclear Medicine

Nursing Services

Nutritional Care

Social Services and Discharge Policy

Rehabilitation Services

Organizational Functions include:

Patient/ Family Rights

Code of Professional Conduct

Patient/ Family Education

Leadership Performance

Human Resource

Staff Credentialing

Reporting

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Patient/ Family and Staff Satisfaction and rights

Staff Performance (Staff Responsibilities)

Staff Development Activities

Orientation Program

Reporting QM Activities

For QM Program to be implemented successfully, reporting of all QM/ CQI

related activities is very essential. Reporting is required at following levels:

Departmental Reporting

Teams Reporting

Staff Reporting

QM Department Reporting

All Departments/ Teams/ Individuals in King Saud University Hospitals are

subject to report to QM Department.

Departmental Reporting

Department Meeting Minutes

Departmental Monthly Performance Reports

Morbidity & Mortality Reviews(clinical)

documentation:

PPGs

Job Description

Forms

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Quality Improvement Activities

Opportunities for improvement

Compliance to CBAHI/Canadian Standards

Staff Orientation

Customers Satisfaction

Teams Reporting

All Hospital Teams are subject to report to TQM Department except Quality

Council

The teams are required to meet at least once a month and report to QM

Department through minutes of the meetings attached with meeting agenda and

attendance of the members with their signature.

Teams are also required to submit quarterly reports on their progress and

achievements to QM Department. The report should be based on Key Process

Indicators (KPIs) and Key Outcome Indicators (KOIs).

Staff Reporting

Department Directors/ Head and Area Administrators must encourage staff to

report:

Incidents

Morbidities ( clinical departments)

The reporting can be direct or indirect (through head of the department) to QM

Department.

QM Department also welcomes any suggestions or out of box ideas for

improvement by any staff steps in QM Department.

Issue No: 1

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QM Department Reporting

QM Department on receiving all the previous reports from departments, teams

and individuals will review them, aggregate the data and develop reports of

performance.

Feedback Reports will be submitted on quarterly and annual basis to top

management and for respective departments and teams for review, action plan

and follow-up