Quality Improvement& Patient Safety

(QPS)

You must be acquainted with the content of Hospital Mission and Vision.

Must know Paediatric department Scope of Services and the department Objectives.

Clinical guidelines/ Clinical Pathways:

• Aim to standardize patient care of certain diagnoses and reduces variation, ensure patient safety, reduce length of patient stay.

Criteria for Selecting:

• High volume diagnosis or procedures

• High risk diagnosis or procedures

• High cost diagnosis or procedures

• Problem prone diagnosis or procedures

• Cause impact on the facility

key Performance Indictors (KPI)

• Developed to reduce variation, improve the safety of high-risk procedures/treatments, improve patient satisfaction, or improve efficiency.

• Criteria for KPI selecting is the same for selection Clinical guidelines/ Clinical Pathways.

• KPI can be selected from JCI International library of measures.

• Our department is collecting data for indicator :Systemic Corticosteroids for Inpatient Asthma, to prove its superior efficacy to gain control of acute asthma exacerbation.

Sentinel Events:

• Unanticipated occurrence involving death or serious physical or psychological injury.

• Serious physical injury specifically includes loss of limb or function

• Death that is unrelated to the natural course of the patient’s illness/underlying condition

• Death of a full-term infant. - Suicide.

• Major permanent loss of function unrelated to the patient’s natural course of illness or underlying condition.

• Wrong-site, wrong-procedure, wrong-patient surgery.

• Transmission of a chronic or fatal disease or illness as a result of infusing blood or blood products or transplanting contaminated organs or tissues.

• Infant abduction or an infant sent home with the wrong parents

• Rape. - Workplace violence such as assault.

Near Miss:

• is a sentinel event that almost happened or circumstances happened but didn’t reach the patient.

Root cause analysis (RCA):

• is a systematic method that uses problem solving tools that tries to identify the real cause of a problem.

• CQI&PS will create RCA Team as indicated

What you will do when an Incident occurred:

• Primary focus is for the patient

• Get help• Immediate mitigation for the

harm • Disclosure of the error• All employees are required to

report all incidents that jeopardize patient safety even if the incident almost happen or if it occurred but didn’t reach the patient.

Reporting of incidents must be done through one of the following:

• Online PSMMC incident reporting system (You may be asked to demonstrate how you can access the system and report an incident)

• Manual via completing an incident reporting form.

• Calling CQI&PS extension # 25637

Which Incidents to be Reported:

• All Sentinel Events, Near Miss.

• - All serious adverse drug events,

• All medication errors. - All confirmed transfusion reactions.

• All In-patient falls.

• All major discrepancies between preoperative and postoperative diagnoses

• Adverse events or patterns of adverse events during moderate or deep sedation and anesthesia use.

• Other adverse events; for example, health care–associated infections and infectious disease outbreaks.

Hospital wide and Departmental Policies & Procedures and Forms:

• Policies and procedures go hand-in-hand to clarify what your organisation wants to do and how to do it.

Policies:

• Policies are clear, simple statements of how your organisation intends to conduct its services, actions or business. They provide a set of guiding principles to help with decision making.

Procedures:

• Procedures describe how each policy will be put into action in your organisation. Each procedure must outline:

• Who will do what• What steps they need to take• Which forms or documents

to use.• Procedures sometimes they

work well as forms, checklists, instructions or flowcharts.

• Policies and their accompanying Procedures will vary between departments/services because they reflect the values, approaches and commitments of each department/services, but they share the same role in guiding the organisation.

• You may be asked to demonstrate how you can access any of the Hospital Wide and departmental Policies & Procedures and Forms, using the hospital ego-portal.

• It is important to train yourself for easy access of the policies site.

Staff, Qualification and Education

(SQE)

You will may be asked for the following to match clinical staff knowledge, skills, and competency with patient care and

needs:

• Your hospital ID Badge (Hang it in a place everyone can see) as all providers of patient care must be identified and other trained in cardiac life support are identified

• What is your qualifications?

• Did you received the desired level of training requirements, where and when?

• Are you registered from Saudi Commission for Health Specialties and must possess a valid license (up-to-date)?

In case your license is outdated ?

• - Renew of your license as soon as possible.

• - Failure to renew will result in suspension of contract renewal and you will be subject for withdrawal of your clinical privileges.

- How you will conduct your daily work?

• Healthcare providers that don’t have a valid and updated license must work under supervision until their license is renewed.

• Did you receive CPR training and what is its level (Mandatory BLS) for all staff.

• Job Description of the staff member - when applicable (For Head of Divisions).

• Did you receive ongoing in-service and other education and training to maintain or to advance your skills and knowledge?

• JCI Team will look for evidence.

• What in-service education attended by the staff member?

• What is your clinical privileges, (be aware of its contents).

• How did you obtain them, either by providing evidence of training or receiving in-service treating?

• Did you see your Annual Staff Evaluation, and if was discussed with you, as indicated.

• For New clinical and trainees staff members: Did you received orientation to the hospital, to the department or unit to which you are assigned, and to your job responsibilities and any specific assignments.

• Are you aware of staff vaccination and immunization hospital program? Did you receive any vaccination?

Are you aware of all necessary requirements to work/practice in PSMMC?

• All healthcare providers are required to ensure that their employee file is completed and updated to include the following:

• Copy of their CV• Copy of their certificates• Copy of their Saudi license• Copy of their BLS & other advance

live support• Copy of work history• Copy of job description/ clinical

privileges• Copy of evaluation• Copy of in-service training

Are you aware what is your evaluation process as medical staff work in PSMMC?

• Medical staff evaluation in PSMMC is data driven.

• - Medical staff are evaluated for their • behaviours,• professional growth commitments

and• clinical results/outcome related to

their scope of clinical privileges.– Behaviours: committed to hospital

code of ethics– Professional Growth: actively

participated in continuous medical education activities and updates such as grand rounds, symposiums, forums.

• Clinical Results: patient care outcomes based on clinical privileges

You may asked how do you participate in the hospital’s quality improvement activities:

• The Minimum Participation is:

• Attending the Monthly Paediatric Management Team Meeting.

• Attending the Monthly paediatric Mortality& Morbidity meetings.

• Reporting any occurred incidents.

• Attending CQI&PS Lectures, Workshops, Symposia, etc.

The Ideal Participation is:

• Started or jointed in any of the Quality Improvement Projects in the department or hospital wide.

• Conducted any departmental or Hospital wide education sessions.

• Joined in any hospital /public health education companies.

• Member in any of the hospital CQI&PS Committees.

• Obtained any education degree in CQI&PS

• This is Not an inclusive list of common questions & explanation, as you cannot read the JCI Survey Assessor Mind.

• But for more detailed information,• Please refer to the lectures

conducted by the Paediatrics JCI Trainers.

• They are available in the hospital-ego-portal and to access them is as follow:

• 1- Go to All departments. 2- Select Continuous Quality Improvement and Patient Safety (CQI&PS)

• 3- Press on Quality training program (yellow colour).

• 4- Select JCI training the trainer workshop.

• Also the Joint Commission International (JCI) Standards 5th Edition is available on the site.

• Thank You For Your Continuous Cooperation In The CQI&PS Process In Our Department

Good Luck

Dr Amal MostafaConsultant neonatology