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KKUH/KAUH HWQPP –004 DEPARTMENTAL MANUAL DEVELOPMENT

Department:

Unit:

Policy Number:

HWQPP - 004

Title:

DEPARTMENTAL MANUAL DEVELOPMENT

Issue Date: DEC 2009 Prepared/Revised by: Date: Quality Management Department

Revision Date Effective Date DEC 2009 Due for Revision on: DEC 2011

Reviewed by: Date: Dr. Farheen Shaikh Policy and Procedure Review Committee

Authorized by: Date: Dr. Badr Al Jabri KKUH – Medical Director

Authorized by: Date: Dr. Abdul Rahman Al Muammar KAUH – Medical Director

Authorized by: Date: Dr. Ayman Abdo Vice Dean for Quality

Authorized by: Date: Dr. Abdulaziz Al Saif Vice Dean for Hospitals

Approved by: Date: Prof. Mussaad Al Salman Dean of College

1. Condition:

It is the responsibility of all Chairman/Head of Departments/Division and Units to develop a Departmental/Division/Unit Manual.

2. Purpose: To ensure better organization of the Department and defining channels of reporting, communication and better provision of services and care.

3. Policy:

3.1. The guideline developed by the Quality management Department for developing a Departmental Manual has to be followed.

3.2. All the departments on fulfilling the requirements of developing departmental manual must send it to Quality Management Department for getting certification for completion.

4. Procedure:

4.1. The Department/Units will prepare a file labeled as Departmental Manual.

4.2. The Manual will be divided into three (3) sections (see attachment A).

4.3. On completion of the guideline for development of departmental manual, Chairman/Head of Department/Unit must send the manual to Quality Management Department for logging and completion certification.

4.4. The manual should be placed in an easy access to all department staff.

4.5. The Chairman/Head of the Department/Unit must ensure orientation and

implementation of the content of the manual.

4.6. The Chairman/Head of the Department/Unit must review and update the manual every two (2) years.

4.7. When modification is done, Quality Management Department must be

informed for the changes.

4.8. Quality Management Department will monitor:

King Khalid University Hospital King Abdulaziz University Hospital

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KKUH/KAUH HWQPP –004 DEPARTMENTAL MANUAL DEVELOPMENT

4.8.1. Availability of the manual in every department/unit. 4.8.2. Compliance of the content with the guideline. 4.8.3. Implementation 4.8.4. Revision and modification

4.9. Regular feedback will be given to the Chairman/Head of the Department/Units for the monitoring as part of their performance.

5. Attachments/Forms:

Departmental Manual Development Guidelines.

6. Reference:

Canadian Accreditation Standard, CBAHI Standards.

Guidelines for Department Manual

1 Prepare a file labeled as Departmental Manual., the manual will be developed for the department and all the units under this department

2 Divide the file into 3 sections.

Section 1: Administrative

This section will include the following:

1.1 Vision of the Department (See example attachment A)

- What do you want to become in the future or

- Where you want to see your department in the next 10 years or

- What is your dream of your department

1.2 Mission (See example attachment B)

- Write in a statement the functions of your department, by answering the following questions

- Who are you, where are you

- What do you do

- Who do you provide the care / service

- Through what

1.3 Values (See example attachment C)

Write down 3-5 values that ruled your department and you expect your staff to work

with these beliefs.

1.4 Scope of Service (See example attachment D)

1.4.1 Clinical Services

- The range of service: primary, secondary, tertiary - The age groups who receives care / services

- The major preventive, diagnostic or therapeutic methods

- High risk procedures

- Number of patients seen annually (in patients / out patients)

1.4.2 Administrative Services

- list all the major functions of the Department

1.5 Client & Supplier (See example attachment E)

- Based on scope of function/services define your client/customers

- identify all types of client/customers (direct & indirect)

-ask whom you are customer r to? That will answer who is your supplier

1.6 Goals and Objectives (See example attachment F)

Goals - what do you want to achieve through the services you are providing.

Objectives

- How you are going to achieve your goals

- Write down specific steps to achieve the goal

- Who will be doing them (responsibility)

1.7 Organizational Chart

Develop two (2) organizational charts for your department

1- with position

2- with names

1.8 Staffing plan (See example attachment G)

Write down how do you operate your department and utilize your staff effectively.

- Duration of coverage (24 hours / 7 days)

- Areas of coverage by the staff and their categories

- Staff schedule: no. Of or / no. Of clinics / no. Of on calls

- Weekend coverage

- Annual leave coverage

- Sick leave coverage

- Eid holidays

In addition for clinical areas:

- No. Of beds covered by each staff

- No. Of hours work / shift / day (ICU)

- Overtime

- How the Rota is developed

- How the shortage is covered

- Transferring responsibility from one staff to another

1.9 Communication and Reporting (See example attachment H)

1.9.1 Within the Department

- Daily morning meeting

- Weekly / monthly departmental meeting

- Who reports to whom

1.9.2 Communication with patients / family / community

- Patient / staff conference

- Meeting with community representative

- Clinical grand round

1.9.3 Communication with other Departments

- multidisciplinary team

How do you conduct these activities?

How do you document?

Where do you keep these documents (Arrange a file: Labeled: Departmental Meetings)

Section 2: Job Description

QM Department will be providing you a complete set of job description for all possible

positions in your department. Kindly:

2.1 Review these job descriptions. Do modification if needed.

2.2 Develop Job Description if the provided set does not include the position

2.3 Return back to Quality Management Department for final approval and logging.

2.4 Quality Management Department will send the Original to HRD and sent the relevant Department copy.

2.5 Attach copy of the new approved Job Description of your department in this section

2.6 Keep an updated CV of yourself (as chairman of the Department) and CV of all Head of the Units.

2.7 Certificate of Attendance to any Quality related topics either lecture / workshops have to be attached with the CV.

Section 3: Department Policies and Procedures

Quality Management Department is proud and honor to announce that he following IPPs will

be taking care of them and they will be sent to your department as organizational-wide IPPs in

a folder:

- (see attachment I)

3.1 Keep the folder next to the Department Manual file

3.2 Develop policies on how specific care/treatment/services are provided, basically it will

address how any patient/customer with specific disease/diagnose /need will be taken

care of.

3.3 The section will include how specific procedures are done

3.4 Any other processes / procedures that is not mentioned in organizational-wide policies.

ATTACHMENT A

VISION Medicine Department

Medicine Department in --------- Hospital will be recognized as a model for all Medicine Departments in the Kingdom of Saudi Arabia.

The vision of the Emergency Department

at -------------- Hospitals is to be recognized as the best integrated emergency service in the Kingdom of Saudi Arabia , in order to achieve patient trust and satisfaction

The vision of Oncology Department

To be a leader in patient-cancer care, training and research.

ATTACHMENT B

MISSION STATEMENT

DIVISION OF ENDOCRINOLOGY

In keeping with the mission of --------- Hospital, the Division of Endocrinology aims at providing the highest quality of care to the eligible patients and their families by highly

qualified staff. In addition, the department provides high standard medical education and training to under and post graduate candidates. Every member of the team in the Division

of Endocrinology is expected to do his or her best to ensure patients satisfaction and to participate fully in the continuing Medical Education Programs and Research.

ER Mission

The Emergency Department at -------------- HOSPITALS is the entrance to all emergencies and sick people to the medical care. The qualified Emergency Department team goal is to save patient’s life, limb, and organ and to preserve their function and to relief the patient

suffering.

Oncology Mission Statement

To provide high quality care for eligible patients, foster Education and Training, encourage and facilitate research in the field of Hematology and Oncology.

ATTACHMENT C

VALUES

All staff in Medicine Department

will provide high quality care

to eligible patients

in respectful, kind

and

confidential manner.

Values ER

Emergency Department team of ----------- Hospitals work with honesty, transparency and in a

professional manner in order to get the trust of patients and other hospital teams

Emergency Department team will always persuade the up-to-date in evidence based medicine.

Values Oncology

Caring

Collaboration & Integrity

Communication

Continuous Improvement

Dignity & Trust

Respect

ATTACHMENT D

Scope of Services

Emergency Department

provides emergency service around the clock with trained physicians and

nurses for all patients to save their lives, limbs and function.

The services include :

o Emergency medical intervention and resuscitation o Assessment, diagnosis, treatment planning, o Liaise with other medical and surgical departments for patient

admission and follow up o The Emergency Department will be the entrance to the mass

casualties to the hospital in Disasters situation.

Oncology

Scope of service

1. Patient care:

Management of benign hematological disorders.

Management of neoplstic hematological and lymphoid disorders.

Management of Solid tumors.

Palliative and supportive care (medical and psychological). Patient and family education.

2. Training of medical and paramedical staff. 3. Research.

The division will provide its services in the following locations:

1. Emergency Room. 2. Out Patient Department. 3. In Patient. 4. Oncology Day Care Unit. 5. Consultations in other department.

The Hematology/Oncology Department will provide its services through:

A) EMERGENCY ROOMS CONSULTATIONS will be provided to patients 24 hours a day, 7 days a week by the on-call teams in hematology/oncology department, as will as Internal Medicine Department.

B) IN-PATIENT CARE: the staff in hematology/oncology as will as Internal Medicine

Departments will provide high quality care to admitted patients.

C) CARE FOR OUT PATIENTS:

1. Out Patient Clinics: a. Hematology clinic:

i. Location: Clinic 2, in the 1st floor: ii. Time: Saturday: 8Am-12Pm.

Sunday: 1-5 Pm.

Monday 8Am-12Pm

b. Oncology clinic: i. Location: Oncology Department, in the ground.

ii. Time: Saturday: Am Sunday: Am

Monday Am

Tuesday: Pm

Wednesday: Am

2. Outpatient Chemotherapy: will be provided in Oncology Day Care Unit daily, Saturday to Wednesday (8 am to 5 pm).

3. Radiotherapy will be provided in radiotherapy unit. 4. Transfusion support will be provided in Oncology Day Care Unit

Saturday to Wednesday (8am-5pm)

5. Bone Marrow biopsy will be done in Oncology Day Care Unit on Wednesday 9am-12pm.

6. Lumber Puncture and Intrathecal Chemotherapy will be provided in Oncology Day Care Unit on Wednesday 9am-12pm.

The Medicine Department aims at providing high quality care by highly qualified medical staff to

eligible patients in ---- Hospital, PSH and Rehab. The Department will provide its OPD services in

Clinic 2 for Internal Medicine, Endocrinology, Gastroenterology, Hematology, Pulmonology,

Rheumatology, and Infectious Diseases and Neurology in Clinic.

Medicine Department

The service will be provided through:

D) EMERGENCY ROOMS CONSULTATIONS will be provided to patients 24 hours a day 7 days a

week by the on-call teams in Medicine Department.

E) IN-PATIENT CARE the highly qualified staff in Medicine Department will provide high quality care to admitted patients.

F) CARE FOR OUT PATIENTS Medicine Department will provide care to out-patients from Saturday to Wednesday (8 am to 5 pm) through General Medicine and its sub specialty clinics.

2.2 MEDICAL EDUCATION:

As the Department of Medicine is recognize as a training center by the Saudi Council of Medical

Specialties, the department will provide high standard continuous medical education to both

under and post graduates by highly qualified medical staff.

2.3 RESEARCH ACTIVITIES:

The Medicine Department will be committed to active participation in research activities. All

staff will be encouraged to publish and participate in all Educational Activities related to

research.

2.4 PUBLIC EDUCATION:

Medicine Department will be committed to participate in public activities to raise awareness of commonly seen medical problems (ex. International Diabetes Day, AIDS Awareness …etc).

ATTACHMENT E

Client & Supplier

Surgery Department

Client/customers

-Patients

-Other departments and physicians (for consultation)

Supplier

-IT

-Medical Supply

-Other departments ( provide consultation)

-clinical Supportive Services( Lab, Radiology, Pharmacy)

Social Service Department

Client/customers

- Physician

- Patients

- Families

Supplier

- Medical Supply

- Community Volunteer Services

- Government Agencies

ATTACHMENT F

The goals of the Intensive Care Unit are to:

- Provide multidisciplinary patient care on a concentrated and continuous basis.

- Provide an environment conductive to the continuous quality improvement of the medical, nursing and other healthcare professional staff.

- Ensure that standards for professional practice, as defined by International societies , State regulatory codes and are implemented, evaluated and monitored.

- Provide an environment conducive to the educational needs of the medical, nursing and other healthcare professional staff, students from healthcare institutions, patients and families.

- Provide for and participate in relevant research that investigates problems and provides opportunities to improve patient care.

Objectives:

- Written guidelines of patient care that are reviewed on an annual basis and enforced by all staff. Such standards are kept current by annual review.

- Written policies and procedures that is standardized and is available to the staff as a reference. They are updated by annual review.

- A planned, on-going system of monitoring and evaluation of medical, nursing, patient care quality will be performed through the continuous Improving Organizational Performance Program.

- Job descriptions are kept current. Staff performance is evaluated on an annual basis and mutual goals for continued development will be set to maintain competency.

- Recertification are kept updated as required and records are kept in the unit.

Basic Life Support (BLS)

Advanced Cardiac Life support (ACLS)

- Multidisciplinary consultations for patients are instituted, as appropriate, by the medical and nursing staff.

- Continuing education is provided through a collaborative, effort between ICU, Staff Education and Medical Staff. Educational topics are provided by the staff and through performance evaluations and self-assessment.

- Students of accredited healthcare institutions are directly supervised by appropriate staff members.

- Research protocols are always available in the unit.

- Selected staff members participate in community educational and research programs through the Hospital and/or community professional organizations.

ATTACHMENT G

STAFFING PLAN Cath Lab

1. During vacation time the consultant on vacation; his duties are carried by other

consultants. 2. In our department only one consultant can go on vacation at a time.

3. If any registrar goes on leave his duties are being covered by other registrar.

4. For Cath Lab we have 24 hours on call team available.

Pharmacy

Is staffed by

- registered Pharmacists - trained Technicians - clerical assistants in a manner consistent with quality patient care and professional expectations from the medical

and nursing staff.

- At least one (1) registered Pharmacist is available, or is on call in the Department 24 hours daily, seven (7) days a week.

- Additional Pharmacists are scheduled during peak hours of workload, Saturday through Friday.

- Pharmacy Technicians staff the Department 24 hours a day, seven (7) days a week.

- Additional Technicians are scheduled during peak hours of operation Saturday through Friday.

- Unit-Dose clerks are employed seven (7) days a week in an adequate numbers to ensure the filling of the Unit-Dose Cassettes and other associated duties.

- Other support personnel are employed five (5) days a week to ensure proper accounting procedures and necessary clerical work.

Radiology

- On- Call schedule is prepared monthly by the Department Head/designee and it can be seen from the system. (Intranet-On-Call Schedule)

o Radiologist-On-Call is available for emergency call through Bleep o System or mobile after 4:30 P.M. onwards when the Radiology

Department is closed for routine work.

o Only the Radiologist-On-Call is In-Charged to contact the CT Tech. and o MRI Tech.- On-Call.

o They must respond to a call or bleep within 30 minutes.

o The Radiology Nurse could be called after normal working hours if needed, according to the discretion of the RADIOLOGIST-On-Call.

- Rota - Rota refers to different modalities such as Nuclear Medicine, MRI, CT

Scan, Ultrasound, Angiography/Special Procedures/ Flouroscopy, and General X-ray.

- Rota schedule is prepared monthly by the Department Head/designee and copies are distributed to Medical Staff and E.R. Department.

- All Radiologists has his own assignment for each modality and they can be contacted on this rota during the normal working hour between 8 a.m. to p.m.

- In case, the Radiologist or Technician is not available or any problem arises during odd working hours, then the Duty Officer of the hospital can be contacted to sort out the matter.

Neurosurgery

The Head of the Division or his deputy will arrange the on-call schedule on a draft paper,

the n the secretary will type it on monthly basis.

1. The On-Call schedule will contains :

i. The 1st on-call usually an intern if available. ii. The 2nd on-call usually resident or registrar)

iii. The consultant on-call iv. At the bottom of the schedule, the names of all staff involved in the rota

with their bleep number and home telephone numbers will be typed.

2. The number of call each staff should do depend on the total numbers of staff present on board.

3. For senior staff, the maximum calls is 1 in 3, but occasionally this can not be achieved in same department as the total numbers is one or two maximum in which case, the consultant will do 1 in 2 (in busy department) and to be available (by mobile telephone whenever needed)

4. In case if the needed consultant is not available 5. For Junior staff the maximum calls is 1 in 3.

6. For Head of the Division, he will share the on-call regarding the weekends, but for Saturdays Wednesdays, he will share if the total numbers of staff on board is less than four.

7. Any changes in the on-call after being typed and approved by the Head of Division should be by agreement between those who wants to change, and to inform the secretary to change the rota.

8. Whenever a patient attends E.R. Department, or in case if there is a consultation for in-patient from other department, the 1st or 2nd on-call will assess the case, (unless it is life threatening or major trauma cases, then the consultant will be called to assess the case), and inform the consultant to take his advice about management.

9. In case of accepting a patients from other hospital, please see Organizational Wide IPP Manual .

10. For locum neurosurgeon, the on-call system will follow the same as in item 2 above, except when the period of the locum is short i.e. 2 weeks or less then the locum should cover his specialty everyday.

11. Ay any time one consultant should be on board.

12. During Eid and Hajj Holidays, arrangements will be in rotation between Consultants and

13. the Juniors; a record will be kept in the division head office.\Junior staff should be enough to cover the daily work and emergency cases.

14. Expect for Emergency Leave, should be arranged and discussed and approved by the Head of the Division in advance at lease 3 months prior to starting day of leave.

15. In case of overlapping of leave such as in a summer, then the whole members of the department should meet and discuss the situation and come to agreement.

16. Emergency leave will be approved by the Head of the Division, if he is convinced, then the applier should arrange his On-call and his OPD clinic with his colleague to cover him.

ATTACHMENT H

Communication

Radiotherapy

It is the policy of the Radiotherapy Department to provide best and latest care to patients to

discuss with all personnel working in the department on a regular basis about provided care

and all problems encountered, aiming to improve service.

1. Regular department meeting is conducted at the Oncology Department, chair by the Head of Oncology Department or the assigned person.

2. The chair of Oncology Department should give a notice of meeting day, date and venue. The notice will also include agenda of the points to be discussed.

3. In the meeting, all points suggested in the agenda will be discussed. Further points will be added as suggested from members of the meeting, for further discussion in the future.

4. Plan for suggested action to sort out problems and improve quality will be suggested and duties will be assigned.

5. Summary of the minutes of the meeting, suggested plan and assign duties will be completed to be included in the appropriate logbook.

6. Recording. All such meetings will be recorded in the appropriate logbook.

It is the policy of Radiology Department to work

as a team with E.R. Department.

1. ER Physician can request CT brain for recent strokes and recent head injury (refer to Clinical Guidelines for CT Brain in ER).

2. ER Physician should fill the CT Radiology request form including full clinical details, sign and stamp the request.

3. ER Physician should call 3328 or 3329, for reservation, after hours on-call, radiologist will be contacted, then the patient will be sent to Radiology Department, according to their approved time.

4. During (day duty), the immediate handwriting Radiology report will be submitted to ER. 5. During on-call duty, Consultants, Neurologist or Neurosurgeon may see the CT and manage

the case. Radiology report will be ready next morning. If any problem cases, Radiologist on-call can be contacted for reporting.

6. Other than CT brain should be approved by the relevant Consultant.