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Management and Patient Safety New Hire Mary Kaye Tacuel, R.N. Quality Management Coordinator 23 November 2014 23 November 2014 / [email protected]
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uality Management and Patient Safety
New HireMary Kaye Tacuel, R.N.
Quality Management Coordinator23 November 2014
23 November 2014 / [email protected]
uality Management & Patient Safety ORIENTATION PROGRAM
STATEMENTThe mission of the Quality Management and Patient Safety Department of Mohammad Dossary Hospital is to improve performance through quality and patient safety culture, appropriate data management process, improvement approach (FOCUS-PDCA) and ongoing staff development and training.
uality Management & Patient Safety ORIENTATION PROGRAM
STATEMENTThe vision of the Quality Management and Patient Safety Department of Mohammad Dossary Hospital is to implement and maintain national and international quality and patient safety standards through the SCBAHI and JCI Accreditation.
• To ensure continuous improvement of the quality of services rendered to the MDH internal and external customers.
• To improve patient safety and reduce risk to patients.
uality Management & Patient Safety ORIENTATION PROGRAM
uality Management & Patient Safety ORIENTATION PROGRAM
Our FUNCTIONS:1. Performance Improvement2. Accreditation
3. Patient Safety4. Risk Management5. Utilization Management6. Audit
uality Management & Patient Safety ORIENTATION PROGRAM
FUNCTIONALOrganization
al Chart
Utilization Review & Clinical Audit Coordinator
(VACANT)
Ext. 674
Ext. 571
•Performance Improvement
•Accreditation•Patient Safety
•Risk Management
uality Management & Patient Safety ORIENTATION PROGRAM
FUNCTIONS
Implementation, monitoring and evaluation of Patient and Employee Satisfaction Survey.
Monitoring the Quality Improvement Guidelines. Reporting of Performance/Quality Indicators. Evaluation of evidenced-based practice (clinical
practice guidelines compliance monitoring). Compliance and validation audit. Identification, monitoring and evaluation of
high-risk, problem-prone and high-cost areas (high-risk medications, invasive procedures, high risk procedures and unusually expensive medications).
Data repository of all Quality Improvement, Patient Safety and Risk Management activities.
with HR & PFR
as per the QM Plan
by the Depts.
with the Medical Committees
with MOI
1. Performance Improvement
uality Management & Patient Safety ORIENTATION PROGRAM
FACILITATING… self-assessment of the accreditation standards. QI and Accreditation activities. the formulation, implementation, monitoring and
evaluation of the organization compliance . development of clinical guidelines and pathways .
INTEGRATING… data analysis results into opportunities for
improvement. quality findings into the policies and procedures. all accreditation standards into patient care
processes. Providing EDUCATION and TRAINING to all hospital staff
on the standards. Identifying areas of non-compliance with the
standards.2. AccreditationFUNCTIONS
uality Management & Patient Safety ORIENTATION PROGRAM
Ongoing assessment of patient safety-related occurrence and incidence.
Investigation of Sentinel/ Critical Event and Near Miss.
Implementation of Proactive Analysis and Root Cause Analysis (RCA).
Provide guidance in the formulation, implementation, monitoring and evaluation of the 6 International Patient Safety Goals.
Patient Safety Orientation, Training and Education Program.
Implementation of Patient Safety Culture Survey.
3. Patient Safety
Hospital-wide
December 2014
FUNCTIONS
uality Management & Patient Safety ORIENTATION PROGRAM
Monitoring the compliance for all Preventive Maintenance Program.
Monitoring and evaluation of Emergency and Disaster Guidelines.
Monitoring of Infection Control Program.
Sentinel Events and Near Miss investigation.
Risk Assessment, Risk identification thru OVR and Patient Complaints.
Analyzing Medical Record Review results.
Credentialing & Privileging Audit. Audit of Highly Critical, Problem Prone,
High Volume and High Cost Processes.4. Risk Management
Safety Com.
IC Com.
PFR Com.
MR/MOI Com.
for PI Project
FUNCTIONS
uality Management & Patient Safety ORIENTATION PROGRAM
Monitor the appropriate allocation of the hospital's resources by provision of quality patient care in the most cost effective manner.
Timely review of the medical necessity for admissions, continued stays and services rendered.
Monitor over utilization, underutilization, inefficient scheduling of resources.
Develop, formulate and monitor Utilization Review Guidelines.
Timely monitoring, review and evaluation leadership performance indicators related to the utilization of resources of the organization.
5. Utilization Management
Committees
FUNCTIONS
uality Management & Patient Safety ORIENTATION PROGRAM
Identify High Risks, High Volume, Problem-Prone and High Cost Processes.
Development of a flexible Annual Audit Guidelines.
Implement the annual Audit Guidelines. Conduct clinical and compliance audits. Maintain teams, staff with sufficient
knowledge, skills and experience in auditing. Keep the executive team informed of
emerging trends. Provide audit recommendation.
6. Audit
Presently done by the departments in collaboration with the QM&PS.
FUNCTIONS
uality Management & Patient Safety ORIENTATION PROGRAM
SN Name of Committee1 Hospital Executive Management Committee2 Medical Executive Committee3 Blood Utilization and Tissue Review Committee4 Morbidity and Mortality Committee5 Medical Records Review and Hospital Formats / MOI Committee6 Quality Improvement and Patient Safety Committee7 Operating Room and Surgical Case Review Committee8 Medical Credentialing and Privileging Committee9 Pharmacy and Therapeutic Committee10 CPR Committee11 Patient and Family Rights Committee12 Infection Control Committee13 Hospital Safety Committee
Hospital-wide Committees
uality Management & Patient Safety ORIENTATION PROGRAM
Hospital-wide Committees
Quality Improvement and Patient Safety Committee
Multidisciplinary
Provides coordination and oversight for the implementation of the hospital-wide quality, performance improvement, risk management and patient safety programs.
Ensures that high standards of care provided are adequate, and that appropriate governance structures and controls are in place throughout MDH.
uality Management & Patient Safety ORIENTATION PROGRAM
Hospital-wide Committees
Hospital Executive Committee
Provides governance that can effectively address strategic and operational issues related to the provision of quality, cost-effective and safe healthcare services arising in MDH.
Medical Executive Committee Administers, develops,
coordinates, regulates and monitors the clinical services in MDH.
uality Management & Patient Safety ORIENTATION PROGRAM
Hospital-wide Committees
Blood Utilization and Tissue Review Committee
Ensures standardization of blood and blood products administration practices as recommended by the American Association of Blood Banks (AABB).
Monitors and investigates all pertinent cases in which clinical diagnoses (pre-operative and post operative) and pathological diagnoses do not agree.
Pharmacy & Therapeutics Committee Acts as a policy recommending body to
the Medical Staff, Pharmacy Department and Administration on all matters relating to the therapeutic use of drugs at MDH.
uality Management & Patient Safety ORIENTATION PROGRAM
Hospital-wide Committees
Credentialing & Privileging Committee
Defines hospital policies and procedures for credentialing and privileging of physicians, dentists and allied health professionals.
Morbidity and Mortality Committee Provides critical analysis of the systems and
processes leading to an adverse outcome of care (including death) in an open and ethical manner.
Develops recommendations to prevent similar adverse outcomes of care in the future.
uality Management & Patient Safety ORIENTATION PROGRAM
Hospital-wide Committees
CPR Committee Ensures implementation and
monitoring of quality standards of cardio and/or pulmonary arrests based on the American Health Association (AHA) Resuscitation Guidelines and Saudi Heart Association.
OR Committee Ensures proper utilization, safe
surgical practice and high standard in communication with all involved disciplines in the Operating Room.
uality Management & Patient Safety ORIENTATION PROGRAM
Hospital-wide Committees
Medical Records / MOI Committee Oversees management of patient information:
quality and maintenance, including filing, storage, access and release of confidential patient information.
Supports the Information Technology and Communication project decisions and ensures its alignment with the MDH Strategic Plan.
Patient Rights & Education Committee Ensures that patient and family rights are protected,
emphasizing on the involvement and participation of patients and families in the patient care.
Oversees the patient complaints process and outcomes. Supports the clinical staff in developing their roles in
patient education activities.
uality Management & Patient Safety ORIENTATION PROGRAM
Hospital-wide Committees
Infection Control Committee Ensures the implementation of the hospital-wide
Infection Prevention and Control Program.
Effectively addresses infection control and prevention issues arising in MDH.
Hospital Safety Committee Addresses general health and safety matters
arising in MDH with particular reference to the requirements of the national and international standards regarding patient, staff, visitors and building safety.
uality Management & Patient Safety ORIENTATION PROGRAM
Categories of KPIs:
1. Clinical2. Managerial3. International
Patient Safety Goals (IPSG)
“We cannot improve what we
cannot measure.”
Clinical Monitors
STANDARD INDICATOR NAME DEFINITION NUMERATOR AND DENOMENATOR
Clinical monitoring include Patient Assessment
Initial Patient Assessment performed after Admission by the Physician within acceptable time frame as per P&P
Number of inpatients medical records with completed Initial Physical Assessment performed by the Physician within acceptable time frame as per P&P /Total audited Admitted Patient Medical Records x100
Clinical monitoring include Nursing Assessment
Initial Nursing Assessment performed after Admission by the Nursing within acceptable time frame as per P&P
Number of inpatients medical records with
completed Initial Nursing Assessment performed within acceptable time frame as per P&P /Total audited Admitted Patient Medical Records
uality Management & Patient Safety ORIENTATION PROGRAM
STANDARD INDICATOR NAME DEFINITION; NUMERATOR AND DENOMENATOR
Clinical monitoring include these aspects of Lab Services selected by the leaders
Specimen Rejection Rate
Number of Rejected Specimens /Total Number of Lab samples collected in the Same Month
Clinical monitoring include these aspects of Lab Services selected by the leaders
Turnaround Time Routine
No. of Selected Result Released within 2 Hours /Total No. of Randomly Selected Sample (500) X 100
Clinical monitoring include these aspects of Lab Services selected by the leaders
Rate of Critical Values Communicated
Total Number of Critical Values Communicated / Total Number of Critical Values Resultx100
Clinical monitoring include these aspects of Lab Services selected by the leaders
Turnaround Time of Critical Test Result Troponin 1 (ER)
Total No. of Minutes result was released / Total No. of Minutes the request was made
uality Management & Patient Safety ORIENTATION PROGRAM
Clinical Monitors
STANDARD INDICATOR NAME DEFINITION; NUMERATOR AND DENOMINATOR
Clinical monitoring includes the use of blood and blood products
In-Date Blood Wastage
No. of In-Date Blood Units Wastage / Total No. of Blood Units Transfused+ Total No. of In-Date Blood Units Wastage x 100
Clinical monitoring includes the use of blood and blood products
Rate of Blood Transfusion
Reaction
Total No. of Blood Transfusion Reactions / Total No. of Blood Transfusions x 100
Clinical Monitors
uality Management & Patient Safety ORIENTATION PROGRAM
STANDARD INDICATOR NAME DEFINITION; NUMERATOR AND DENOMINATOR
Clinical monitoring includes surgical procedures
Rate of unplanned return to Operation Theatre
Number of Unplanned return to Operation Theatre during the same admission / Total Surgeries performed during the study period
Clinical monitoring includes the use of antibiotics and other medications use selected by the organization.
Percentage of surgical patients with antibiotic administration within 60 minutes prior to surgical incision
Number of selected surgical patients whose prophylactic antibiotics were initiated within 60 minutes prior to surgical incision / Selected surgical patients (exclusions listed)
Clinical monitoring includes the use of anesthesia
Pre-anesthesia Assessment Compliance Rate
Number of patients who have pre-anesthesia assessment completed prior to surgery / Total number of patients who have anesthesia in the same month
Clinical Monitors
uality Management & Patient Safety ORIENTATION PROGRAM
23 November 2014 / [email protected]
STANDARD INDICATOR NAME DEFINITION; NUMERATOR AND DENOMINATOR
Clinical monitoring includes infection control, surveillance, and reporting
Urinary Catheter Related (CAUTI) Infection Rate
Total Number of UTI within study Period / device (catheter) days multiplied by 1000
Clinical monitoring includes infection control, surveillance, and reporting
Catheter related BSI Rate
Total Number of BSI within the study period / device (catheter) days multiplied by 1000
Clinical monitoring includes infection control, surveillance, and reporting
Health Care Associated Infections "HAIs" Rate
Total Number of HAIs within study Period / Number of patient days multiplied by 1000
Clinical monitoring includes infection control, surveillance, and reporting
Surgical site infection (SSI) Rate
Total Number of patients with surgical site infection within the study period / Total Number of patients with surgical site infection within the study period x100
Clinical monitoring include Nursing Assessment
Pressure Ulcer Prevalence (Hospital-Acquired) Rate
Patients that have at least one category/stage II or greater hospital-acquired pressure ulcer(s) on the day of the prevalence study / All patients surveyed for the study who are > = 18 years.
Clinical Monitors
uality Management & Patient Safety ORIENTATION PROGRAM
STANDARD INDICATOR NAME
DEFINITION;
NUMERATOR AND DENOMINATOR
Clinical monitoring include these aspects of Radiology Services selected by the leaders
Rate of IV contrast
complications
Number of patients who had complication / Total number of patients who had IV contrasts
Clinical monitoring include these aspects of Radiology Services selected by the leaders
Rate of Ultrasound
Report Issuance in 45
Minutes
Total No. of Delayed Results/Total No. of Patients for Ultrasound
uality Management & Patient Safety ORIENTATION PROGRAM
Clinical Monitors
STANDARD INDICATOR NAME DEFINITION; NUMERATOR AND DENOMINATOR
Clinical monitoring includes Labor & Delivery Services
Rate of Accurate Fetal Weight
Total No. of Error in Patient's Fetal Weight / Total No. of Patients Delivered X 100
Clinical monitoring includes Labor & Delivery Services
Elective Delivery
Patients with elective deliveries / patients delivering newborns with >= 37 and < 39 weeks of gestation completed
Clinical monitoring includes Labor & Delivery Services
Cesarean Section
Patients with cesarean sections / Nulliparous patients delivered of a live term singleton newborn in vertex presentation
Clinical Monitors
uality Management & Patient Safety ORIENTATION PROGRAM
23 November 2014 / [email protected]
STANDARD INDICATOR NAME
DEFINITION; NUMERATOR AND
DENOMINATOR
Clinical monitoring includes the monitoring of Medications Errors and Near Miss.
Medication Errors Rate
Total number of Medication Error / Total number of Patient Days X 1000
Clinical monitoring includes the monitoring of Medications Errors and Near Miss.
Near Miss Rate
Total number of Near miss medication errors reported / Total number of medication errors reported x 100
Clinical Monitors
uality Management & Patient Safety ORIENTATION PROGRAM
Managerial Monitors
STANDARD INDICATOR NAME DEFINITION; NUMERATOR AND DENOMINATOR
Managerial monitoring includes the surveillance, control, and prevention of events that jeopardize the safety of patients, families, and staff
General Waste Collection
(outsourced) Rate
Total Number of executed general Waste collection jobs / Number of planned general Waste collection jobs
Managerial monitoring includes the surveillance, control, and prevention of events that jeopardize the safety of patients, families, and staff
Infectious Waste Collection
(outsourced) Rate
Number of executed infectious waste collection jobs / Number of planned infectious Waste collection jobs x 100
Managerial monitoring includes the surveillance, control, and prevention of events that jeopardize the safety of patients, families, and staff
Pest Control (outsourced) Rate
Number of executed Pest Services jobs / Number of planned Pest Services jobs x100
Managerial monitoring includes the surveillance, control, and prevention of events that jeopardize the safety of patients, families, and staff
Needle Stick Injuries Rate Number of Needle stick injuries
uality Management & Patient Safety ORIENTATION PROGRAM
23 November 2014 / [email protected]
STANDARD INDICATOR NAMEDEFINITION;
NUMERATOR AND DENOMINATOR
Managerial monitoring includes reporting of activities as required by law & regulation
Governmental Reports
Submission Compliance Rate
(eg. Communicable Diseases, Polio
Cases etc.)
Total number of Governmental Mandatory
reports submitted as per Laws & regulation /
Total number of requested Governmental reports in the
same year x 100
Managerial Monitors
uality Management & Patient Safety ORIENTATION PROGRAM
STANDARD INDICATOR NAME
DEFINITION; NUMERATOR AND
DENOMINATORManagerial monitoring includes staff expectations and satisfaction
Employee Satisfaction
Rate
Total Number of Staff Who were generally satisfied/ Total Number of surveyed Staff.
Managerial monitoring includes patient and family expectations and satisfaction
Patient Satisfaction
Survey
Total Number of Satisfied Patient/Total Number of surveyed Patients
Managerial monitoring includes patient and family expectations and satisfaction
Monthly Complaint
Rate
Total Number of Complaints (cases*) in one month/ Number of patients in same month "inpatient & OPD".
Managerial Monitors
uality Management & Patient Safety ORIENTATION PROGRAM
STANDARD INDICATOR NAMEDEFINITION;
NUMERATOR AND DENOMINATOR
Managerial monitoring includes the procurement of routinely required supplies and medications essential to meet patient needs
General Store Items Availability
Rate
Total Number of Monthly requested Items available in General Store / Total Number of Items requested in the same month
Managerial monitoring includes the procurement of routinely required supplies and medications essential to meet patient needs
Purchasing Response Time
Compliance Rate
Total Number of purchase request processed within time frame (26 days) in one month / Total number of purchase requests received in the same month.
Managerial monitoring includes the procurement of routinely required supplies and medications essential to meet patient needs
Out of stock Medication rate
Total Number of items that hit zero stock / Total number of line items in stock
Managerial Monitors
uality Management & Patient Safety ORIENTATION PROGRAM
STANDARD INDICATOR NAME DEFINITION; NUMERATOR AND DENOMINATOR
Managerial monitoring includes utilization management
NICU UtilizationTotal Number of admission which fulfill admission criteria over a certain time / Total no. of babies admitted over the same time
Managerial monitoring includes utilization management
ICU Readmission RateReadmission to the ICU within 24 hrs of transfer / Total Number of Patients Manage in ICU in a Given Time Frame X 100
Managerial monitoring includes utilization management
ICU Length of Stay Total Occupied Bed Days / Total Number of Patients in a Given Time Frame X 100
Managerial monitoring includes utilization management
Unplanned Readmission To the
hospital within 3 days after discharge
Unplanned Readmission To the hospital within 3 days after discharge during the study period / Total number of discharges during study period X 100
Managerial monitoring includes utilization management
Overall Hospital Length of Stay
Total number of patient days / Total Admissions
Managerial Monitors
uality Management & Patient Safety ORIENTATION PROGRAM
STANDARD INDICATOR NAME DEFINITION; NUMERATOR AND DENOMINATOR
Managerial monitoring includes risk management OVR Reports Total Number of OVR Reports / Total
patient days 1000
Managerial monitoring includes risk management
Sentinel event Ratio
Total Number of Sentinel events / Total no. of Patients Days X 1000
Managerial monitoring includes risk management
Overall CPR Survival Rate
Total Number of CPR Survival / Total Number of CPR Call-out X 100
Managerial monitoring includes risk management
Total Number of Still Birth
Total Number of Still Birth / Total no. of deliveries X 100
Managerial monitoring includes risk management
Neonatal Mortality Rate
Total no. of neonatal deaths / Total no. of inpatient admissions X 100
Managerial monitoring includes risk management
Pediatric Mortality Rate
Total Number of Pediatrics Deaths / Total Number of Pediatric Admissions X 100
Managerial monitoring includes risk management
Overall inpatient mortality rate
Total no. of inpatient deaths / Total no. of inpatient admissions X 100
Managerial Monitors
uality Management & Patient Safety ORIENTATION PROGRAM
STANDARD INDICATOR NAMEDEFINITION;
NUMERATOR AND DENOMINATOR
Managerial monitoring includes patient demographic and diagnoses
Top 5 Medical Diagnosis
Highest Number of Medical Diagnosis/Month
Managerial monitoring includes patient demographic and diagnoses
Top 5 SurgeriesHighest Number of Surgery Procedure / Month
Managerial Monitors
uality Management & Patient Safety ORIENTATION PROGRAM
International PatientSafety Goals Measurements
STANDARD INDICATOR NAME
IPSG.1 Identify Patients Correctly.
Use of two (2) patient identifiers when
laboratory staff collect specimens.
DEFINITION –NUMERATOR AND
DENOMENATOR
Use of two (2) patient identifiers when laboratory staff collect specimens /Total Number of Staff observed
uality Management & Patient Safety ORIENTATION PROGRAM
The leaders of the institution identify the key measures for each of the International Patient Safety Goals (IPSG).
STANDARD INDICATOR NAME
IPSG.1 Identify Patients Correctly.
Use of two (2) patient identifiers when
• when admitting patients. -Nursing• when administering medications. - Nursing• when giving treatment. –RT, PT • when performing diagnostic imaging. –RD• when directing patients to clinics. – OPD
Nurses
uality Management & Patient Safety ORIENTATION PROGRAM
IPSG Monitors
STANDARD INDICATOR NAME
IPSG.1 Identify Patients Correctly
Time-Out Compliance Rate
(OR and Dental)
DEFINITION - NUMERATOR AND
DENOMENATOR
No. of Time Out Practices as per P & P / Total No. of Surgery conducted in same period.
IPSG Monitors
uality Management & Patient Safety ORIENTATION PROGRAM
23 November 2014 / [email protected]
STANDARD INDICATOR NAME
IPSG.2 Improve Effective Communication.
Use of Unapproved
Abbreviations Rate
(MS & Medical Records)
DEFINITION – NUMERATOR AND DENOMENATOR
Total Number of unapproved abbreviations used by medical staff in medical record documentation/ Total Number of Medical Records Reviewed
IPSG Monitors
uality Management & Patient Safety ORIENTATION PROGRAM
STANDARD INDICATOR NAME
IPSG.3 Improve the Safety of High-Alert Medications.
Medication errors due to look-alike/sound-alike (LASA) drugs
(Pharmacy)
DEFINITION:NUMERATOR AND DENOMENATOR
Total Number of medication errors due to look-alike / sound-alike (LASA) drugs
IPSG Monitors
uality Management & Patient Safety ORIENTATION PROGRAM
23 November 2014 / [email protected]
STANDARD INDICATOR NAME
IPSG.3 Improve the Safety of High-Alert Medications.
Adverse Drug Events (ADEs) related to Anticoagulant per
100 Admissions with Anticoagulant Administered
(ICU)
DEFINITION -NUMERATOR AND DENOMENATOR
Total number of ADEs in the sample related to an anticoagulant/ Total number of admissions in the sample in which the patient was administered at least one dose of an anticoagulant X 100
IPSG Monitors
uality Management & Patient Safety ORIENTATION PROGRAM
STANDARD INDICATOR NAME
IPSG.4 Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery.
Surgical site correctly marked
with patient involvement and prior to start of
surgical procedure
(Surgery; OR)
DEFINITION – NUMERATOR AND
DENOMENATOR
Surgical site correctly marked with patient involvement and prior to start of surgical procedure/Total No. of Operations at the Same Period of Time x 100
IPSG Monitors
uality Management & Patient Safety ORIENTATION PROGRAM
STANDARD INDICATOR NAME
IPSG.4 Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery
Surgical Safety Checklist
Compliance Rates
(OR; Dental)
DEFINITION – NUMERATOR AND DENOMENATOR
Total No. of Surgeries with Complete (all of three
phases) Surgical Checklist at Given Period / Total No. of Operations at the Same
Period of Time x 100
IPSG Monitors
uality Management & Patient Safety ORIENTATION PROGRAM
STANDARD INDICATOR NAME
IPSG. 5 Reduce the Riskof Health Care–Associated Infections
Hand Hygiene Compliance
Rate(IC; LiNCs)
DEFINITION –NUMERATOR AND DENOMENATOR
Total Number of staff who comply with hand hygiene
instructions / Total Number of Staff X 100
IPSG Monitors
uality Management & Patient Safety ORIENTATION PROGRAM
STANDARD INDICATOR NAME
IPSG. 6 Reduce the Risk of Patient Harm Resulting from Falls
Patient Falls(Nursing)
DEFINITION –NUMERATOR AND DENOMENATOR
Total number of patient falls (with or without injury to the patient)
during the calendar month / Patient days by Type of Unit during the calendar month.
IPSG Monitors
uality Management & Patient Safety ORIENTATION PROGRAM
STANDARD INDICATOR NAME
IPSG.6Reduce the Risk of Patient Harm Resulting from Falls
Patient Falls with Injury(Nursing)
DEFINITION -NUMERATOR AND DENOMENATOR
Number of patient falls with an injury level of minor or greater during the calendar month / Patient days by Type of Unit during the calendar month
IPSG Monitors
uality Management & Patient Safety ORIENTATION PROGRAM
STANDARD INDICATOR NAME
IPSG.6 Reduce the Risk of Patient Harm Resulting from Falls
Fall Risk Assessment
Rate(Nursing)
DEFINITION -NUMERATOR AND DENOMENATOR
No. of Patient Assessment on Fall Risk At Admission /
Total No. Admissions during the Study Period
IPSG Monitors
uality Management & Patient Safety ORIENTATION PROGRAM
QM&PS Education Program
uality Management & Patient Safety ORIENTATION PROGRAM
Quality Concepts, Dimensions and Principles
Fundamentals of Patient Safety
Quality Cycle Use of Quality
Improvement Tools Improvement
Methodologies OV Reporting System Handling Critical and
Sentinel Events Medication Errors &
Adverse Drug Reaction Reporting Conduct of Proactive
and Root Cause Analysis
Data Management Introduction to Quality
Culture and Patient Safety
Effective Communication & Customer Services
Teamwork and Team Building
Structure, Process and Outcome Audits
QM, PS and RM Lectures: Quality
improvement is a
continuous and dynamic process.
23 November 2014 / [email protected] QM&PS Education
Program
uality Management & Patient Safety ORIENTATION PROGRAM
