Content 1. Introduction to KFHU 11
UOD president Message
12
KFHU Director General Message
15
Objectives, Vision, Mission, Value
13 16 17 18 19 21
About KFHU
Bed distribution
Organizational Chart Staffing
Patients (Hospital Statistics at a Glance) Developments
2. Clinical Departments 26
Internal Medicine
42
General surgery
39 49 53 56 63 65 68 70 74 76 78 81 83
Dental
Urology
Obstetrics & Gynaecology Pediatrics
Neurosurgery Orthopedics
Ophthalmology ENT
Neurology
Dermatology Psychiatry
Anesthesia
Family & Community Medicine
3. Special Services 88
Intensive Care Units
91
Coronary Care Unit
94
Day Care Unit
92 95 97 99
101 103
Operating Room
Physiotherapy Unit Radiology
Interventional Radiology & Vascular Catheter Unit Outpatient Department Emergency Room
4. Specialized Clinics 110
Employees Health Service
113
Royal Clinic
112 114
Primary Healthcare Clinic UOD Clinic
5. Auxiliary Departments 113
Nursing
127
Pharmacy
123 130
Laboratory Medicine & Blood Bank Electronic Health service and information systems • Health information department • Information technology
135
Patient Rights & Relations
138
Social medical service section
137 141 143
Central sterilization and supply Dietary
Infection control
6. Supportive Services Department 150
Maintenance and Operating Section
152
Security
150 152 154 154 154
Cleaning, Laundry and Medical Waste Biomedical Engineering Central Section
Landscaping Section
Safety facilities and Occupational
7. Administrative Departments 162
Transportation
163
Arabic transcription
163 164 164 165 166 166 167 169
Administrative Communication Monitoring & Follow-up Human Resource Finance
Purchasing
Warehouse
Medical Supplies and Medical Equipment Housing
8. Academic Affairs and Training & Medical Library 172 173 177 180 181
Academic Affairs and Training
Continuous Professional Development Unit External Training Unit Internal Training Unit Audio-visual Unit
184
Medical Photography Unit
185
Translation Unit
185 185 187 190 191
Design Unit
Health Education unit
Life Support Programs
Evidence Based Medicine Program
Medical Library
9. Directorate of Quality & Safety 200
Accreditation Unit
201
Decision Support Unit
204 214 215 216 220
Credentialing & Privileging Unit Documents Control Unit
Environmental & Safety Unit Risk Management Unit
Performance Measurement Unit
1
Custodian of the Two Holy Mosques
King Salman bin Abdul Aziz Al Saud King of Saudi Arabia
2
KFHU Annual Report 1435 - 2014
3
His Royal Highness
Muhammad bin Naif bin Abdulaziz Al Saud Crown Prince, Deputy Prime Minister and Minister of Interior
4
KFHU Annual Report 1435 - 2014
His Royal Highness
Mohammad bin Salman Al Saud Deputy Crown Prince and Minister of Defense
5
His Royal Highness
Saud bin Naif bin Abdulaziz Al Saud Governor of the Eastern Province
6
KFHU Annual Report 1435 - 2014
His Excellency
Dr. Azzam bin Mohammed Al-Dakhil Minister of Education
7
Introduction to KFHU
8
KFHU Annual Report 1435 - 2014
1.Introduction to KFHU
Introduction to KFHU
UOD president Message
KFHU Director General Message Introduction to KFHU
Objectives, Vision, Mission, Values Bed distribution
Organizational Chart Staffing
Patients (Hospital Statistics at a Glance) Achievements
9
Introduction to KFHU
| MESSAGE OF HIS EXCELLENCY, PRESIDENT OF UNIVERSITY OF DAMMAM, SUPERVISOR GENERAL OF KING FAHD HOSPITAL OF THE UNIVERSITY (KFHU)
King Fahd Hospital of the University (KFHU) operates under the auspices of the University of a a an f fi a t f n t ff a f a an nt g at at a f the Eastern Province, trains the university’s medical college constituents and hosts strategic research in biotechnology and healthcare services. Since KFHU is one of Saudi Arabia›s largest academic healthcare clusters, we have a talented pool of doctors, nurses, allied health professionals and administrators who provide quality healthcare services. Our specialists in over 38 departments and clinics are constantly at the four front of cutting edge medicine, harnessing the synergies of clinical research and medical education. In 2014, we have seen more than 376116 patient visits. Taking into consideration the growing role of KFHU in serving the people of the Eastern Region, we are always very concerned with the provision of better healthcare through continuous improvement of services received by patients and other stakeholders. To create an optimal healthcare environment much effort and resources have been put into infrastructure and human resources› development. State-of-the-art technology has been utilized to the maximum and will continue to be a focus of our future. We have successfully completed the major requirements of the hospital accreditation and the actual accreditation survey is expected to be conducted by the Joint Commission International (JCI) in September 2015. Fruitful cooperation with the counterpart healthcare organizations and the effective community partnership have resulted in the treatment of several serious and critical cases admitted in KFHU. As part of our efforts to deliver a quality healthcare and to achieve all stakeholders› satisfaction, the hospital has been providing a continuous medical education programs to medical students, staffs, patients and patient relatives. The hospital complies with and participates in the development plans of our wise government under the leadership of His Majesty the Custodian of the Two Holy Mosques King Salman bin Abdul-Aziz Al-Saud (May Almighty Allah guard him), the Crown Prince His Highness Royal Emir Miqrin bin Abdul-Aziz Al-Saud, and His Highness the Royal Prince and Second Deputy Prime Minister Emir Mohammed bin Nayef bin Abdul-Aziz Al-Saud. His Royal Highness Emir Saud bin Nayef bin Abdul-Aziz Al-Saud, Emir of the Eastern Region has honored us with their faithful support. None of the progress at UOD and KFHU could have taken place without his leadership. On Behalf of the entire hospital family I express my deep gratitude to him. A successful trust is the product of the hard work of so many different groups of dedicated people, whether it be our Physicians, Nurses and all other staffs, I would like to thank them all for their many contributions and support over the last year. On behalf of the entire team of UOD and KFHU, I would like to thank you for taking the time to study this report. We hope you enjoy it and trust that it will help decision makers at every level to make the plans they need to enhance and upgrade the services of KFHU which is an academic healthcare center. 10
KFHU Annual Report 1435 - 2014
Introduction to KFHU
| MESSAGE OF HIS EXCELLENCY, DIRECTOR GENERAL OF KING FAHD HOSPITAL OF THE UNIVERSITY (KFHU), VICE DEAN OF COLLEGE OF MEDICINE FOR KFHU AFFAIRS
Praised be to Allah, the Lord of the World, and Peace be Upon our Prophet Mohammed, his family and all his companions. Our Kingdom is propelled to a prestigious position. Thanks to the grace of Almighty Allah, then to the care and attention paid by our wise government under the leadership of the Custodian of the Two Holy Mosques, the service sectors, including the two sectors of health and education. a a t nt t ann a t f t t a t n gn fi ant statistical data about the activities of and the services provided by KFHU to the citizens and residents of the Eastern Region. It also shows the research and training opportunities availed to the medical doctors, researchers and students of the relevant medical colleges and institutions. All activities and health services provided by KFHU are recorded in details to enable the higher administration under the chairmanship of H. E. the President of the University of Dammam, Professor Abdullah Al-Rubaish to make sound decisions. The KFHU report will also enable the higher administration to devise the required plans for the development of performance in the various departments of the hospital. These development plans will be supported by data from the local, regional and international organizations. t t a ag t a n t fi f a t an research, as well as the studies of therapeutic and preventive health indicators.
nt fi
Dr. Khalid bin Matar Al Otaibi Director General, KFHU
11
Introduction to KFHU
12
KFHU Annual Report 1435 - 2014
Introduction to KFHU
|  Overview a ffi a na g at nt 1 t f aa 1 1 n ng t a 1 1 81 then Minister of Health, H.E. Dr. Husein Al Jazairy. At that time it was called Khobar Teaching Hospital. In 1404H, it was called King Fahad Hospital. In 1405H, the late Custodian of the Two Holy Mosques King Fahd visited Dammam and held a meeting with the employees of UOD; and at t t ng t ffi a f ng a a n t a ng a t affi at ng a Hospital to KFU instead of the Ministry of Health. King Fahd responded positively to the request, and the hospital became part of KFHU. Then when Dammam branch of KFHU was upgraded to a full-pledged university in 2010, the hospital became part of it. The story of KFHU began almost 33 years ago as a small teaching hospital. Today we stand tall and proud as one of the most respected academic health science hospital of the university in Saudi Arabia. Over the years we have consistently expressed our commitment to excellence, compassion and improving the quality of the health care in Saudi Arabia. By continuing to provide excellent patient care, while driving new breakthroughs in medical research, we are committed wholeheartedly in research; and delivering the best medical services to the community.
| KFHU Objectives The major objectives of the hospital are as follows: 1. Teaching and training 2. Healthcare 3. Research
13
Introduction to KFHU
First: Teaching and Training a
ng an t a n ng t nt a a a t 1. n g a at a n ng an at t a t nt 2. Interns. 3. Postgraduates in different medical specializations. 4. In-service paramedicals. 5. Trainees from other hospitals and medical institutions. In addition to that there are some academic activities represented in didactic lectures and tutorials, morning reports, journal clubs, grand round, mortality meeting‌.etc.
Second: Health Care
KFHU is a referral hospital for the entire Eastern Region. It provides integrated health and
medical care services to the community. More than 200 outpatient clinics were weekly conducted n
1
n
a
t fift
seen daily by doctors in these clinics. g n
at
nt n
at
ffi
an
nt an
at
t an
t
t
an n
8 at nt a
ng
functioning 24 hours a day, 7 days a week. In 2014, the Emergency department received more
than 186,690 patients with an average of 511 patients per day. Meanwhile the hospital admitted about 11,240 patients.
In addition, a considerable number of patients were received at the special service units of KFHU such as Burn Unit, Neonatal Intensive Care Unit, Endoscopy Unit, Pediatric Cardiac Lab, Adult
Cardiac Lab, Diagnostic Labs, Physiotherapy, Lithotripsy, MRI, CT scan, PICU and the Peritoneal Dialysis Unit.
It is worth mentioning that all these units are equipped with advanced devices and equipment. KFHU has many other services, including Medical Library, Audio-visuals, Day Care Unit, and
Pharmacy Services. The tests carried out by the Diagnostic Labs in 2014, reached more than 2, 521, 320.
To manage the patient medical documents and records properly, the hospital used an advanced t
Arabia.
t
an
t
a
n
a t
fi t f t t
n Sa
KFHU has special disaster plan. This plan was applied during the Gulf war in 1991 and when an explosion occurred at Khobar housing in 1996. The plan was regularly implemented by a mock implementation and was updated to encounter any emergency.
Third: Research
University of Dammam with KFHU, its strong commitment to social values and the Medical Research dream to create a world class research facility. Research is only carried out after being approved by the concerned boards so as to make sure that it falls in line with the fundamentals and ethics of research. It usually covers diagnostic and therapy areas as well as family and community medicine. 14
KFHU Annual Report 1435 - 2014
Introduction to KFHU
| Vision
a a ng n t ta n a t according to the international standards.
a
n
at n an
nt fi
a
| Mission
To provide high quality healthcare education and training for healthcare professionals and t nt fi a
| Values •
Honest
•
Mutual Respect
•
Teamwork
•
Transparency
•
Responsibility
•
Commitment
15
Introduction to KFHU
|窶ィed distribution a
1
t
t n f
Units/Wards 1A 1A 1A 1B 1C 1D 2E 2A 2BN 2B 2C 2D 3A 3B 3C 3D 3E 4A 4B 4C 4D 4E 5A 5B
a
ng t t
nt
Unit In-Patient Services MICU (Medical Intensive Care Unit) SICU (Surgical Intensive Care Unit) PICU (Pediatric Intensive Care Unit) Burn Unit Step Down Unit Female Surgical / Medical Word CCU (Coronary Care Unit) Delivery Room NICU (Neonatal Intensive Care Unit) WBN (Well Born Nursery) (OB/GYN Ward) (OB/GYN Ward) (Male ENT / Neurosurgery / Ophtha Word) (Male Ortho Ward) (Male Medical Ward) (Male Medical Ward) (Male Sergical Ward) (Padiatric Surgical Ward) (Padiatric Medical Ward) (Female Medical Ward) (Female Surgical Ward) (Female Surgical) (Male Psychiatry Ward) (Female Psychiatry Ward) Hemodialysis Endoscopy Male Medical / Surgical Female Medical / Surgical Total Bed Capacity
N0. of beds 18 12 5 12 5 20 10 7 40 40 21 21 20 20 21 21 19 20 24 21 21 19 18 18 35 10 24 24 550
Beds for daily use A total of around 300 beds are using for daily use of OPD, ER and all other services.
16
KFHU Annual Report 1435 - 2014
n a
عيادات الموظفين E.H.S. Clinics
O.P.D. & E.R. Reception
Director of OPD & Patient Services
a
ng ffi
C.S.S.D.
Out Patient Services
In patient Services
Director of Nursing Services
nt
Social Service
Dietary
Respiratory Therapy
Physical Therapy
Laboratory and Blood Bank
Patient Relations & Rights
Pharmcy
Radiology
O.R.
I. C. U.
Clinical Sections
Emergency
Central
Bio medical Engineering
Bio medical Engineering
Security
Cleaning & laundry & medical waste
Operations & Maintenance
Support Services
Follow-up and monitoring
Inventory Control
Administrative Communications
Housing
Warehouses
Procurement
Finance
Human Resources
Director of Admin & Finance
Primary Care Centers
Directorate of Information Technology and Health Electronic Records
Safety Facilities and Occupational
Director of Medical Services
S
Directorate of Academic Affairs for Training
ft
Medical Supplies and Medical Equipment
Director ofAllied Med.
Director General & Vice Dean for Hospital Affairs
ffi
Public Relations
Transporations
Infection Control
Directorate of Quality & Safety
Supervisor General
University of Dammam President
University of Dammam Council
Introduction to KFHU
| Organizational Chart
17
Introduction to KFHU
| KFHU Staffing
a fi f na t n an an a n t at manpower consists of Saudi and non-Saudi nationals. f
ng ta
Hospital manpower
n t at
Category
t
Male
Physicians
t
t n f
Saudi
285
Nurses
Specialist (Medical)
182
Supportive Staffs Laborers
Specialist (Non-Medical) Administrative staffs Total
ng n
ta
an
Non-Saudi
Female
Male
Female
102
74
505
9
0
177
19
a
135
Total
30
627
106
588
673
162
108
120
52
23
16
211
20
0
0
0
20
23
0
52
7
701
500
0
322
0
657
32 59
2180
Source: Decision Support Unit, DQS, KFHU.
Figure.1: Staffing (As of 31st December 2014) Physicians Nurses Total 2180
Specialist (Medical) Specialist (Non -Medical) Specialist (Non -Medical)
18
KFHU Annual Report 1435 - 2014
Introduction to KFHU
|窶ォospital Statistics at a Glance Key Figures, 2014 at KFHU 11,240 Admissions
186,714 Out-Patients
186,690 Emergency Patients
6,111 Surgical Procedures
13,233 Dental Procedures
1,221 Deliveries
85,914 Radiology Procedures
17,161 Primary care services
69,641 Physiotherapy treatment
2,521,320 Laboratory diagnostics
11,164 EHS Patients
630 ICU Patients
947,396 Pharmcy walk in
233,497 Respiratory Therapy 1,119,148 CSSD Services
19
Introduction to KFHU
Table 3: Service Statistics Services
Description
Total Numbers
Daily Average
OPD
Patient
186714
788 (4.3%)
ER
Patient
186690
511 (18.5%)
Inpatients
Patient
11240
31 (10.8%)
Dental
Patient
13233
55 (57%)
EHS
Patient
11164
47 (17.5%)
Physiotherapy
Procedure
69641
290 (30.6%)
Respiratory Theraphy
Procedure
233497
640 (59%)
Hemodialysis
Procedure
10426
36 (12.5%)
Lithotripsy
Procedure
1227
5
Operations
Procedure
6111
17 (41.6%)
FAMCO
Patient
17161
72 (38.5%)
Day Surgery
Operation
947
4
Deleveries
Case
1221
3
Mortality
Case
416
1
Pharmacy
Item
947396
2596 (13.7%)
Radiology
Procedure
85914
235 (2.2%)
Procedure
2521320
Cardiac Lab.
Procedure
7743
21
Neuro-diagnostic Lab
Procedure
1452
6 (20%)
Endoscopy
Procedure
1640
7
Pedia Cardiac Lab
Procedure
882
4
Diagnostic Laboratories
Average length of stay Average dayes Bed Occupancy Rate
Percentage
Source: Decision Support Unit, DQS, KFHU. Increasing as compared with 2013 Same as compared with 2013
20
KFHU Annual Report 1435 - 2014
6908 (20.5%)
9.0 84%
Introduction to KFHU
| Achievements
There were many developments that were achieved during the year 2014, namely a New clinic in ER for Urgent emergency patients and ICU & Endoscopy new building.
New ER clinic for Urgent Clinic Unit
The UCU project was initiated for the purpose of decompressing the crowding in the hospital emergency department, limiting the time of waiting and in order to optimize the care of more critical patients & serious injuries was implemented on the 5th of April 2014. During the following 2 weeks; 41 covered shifts were rescheduled from the ED schedule, a 100 UCU shifts were covered by ED physicians (a total of 800 working hours); 59 of which were part time totaling to 472 hours. Of the 59 part time shifts 33 (56%) were covered by specialists, and 31 (53%) were covered by the g n a an ng t fi t a t ta f 1 at nt t t f had been seen in the UCU.The total number of patients seen on the afternoon shifts was 1070, 612 of these patients were seen in the UCU (57% of patients visiting during the afternoon shifts) The estimated waiting time for patients to be seen in the UCU is 14 minutes. Total time to be discharged was measured to be less than 30 minutes (an average of 28 minutes).During the second week of launching the UCU, the ED had a total of 2993 patients, 1012 patients were seen during the afternoon shift. 56% of the patients seen during the afternoon shift were in the UCU, making it a total of 569 patients. The UCU clinics were covered by specialists and GP’s from the ED, pulling them from their original post in the observation area / exam rooms. This lack of manpower was addressed by increasing the number of shifts for consultants in the morning, evening and night duties and during weekdays and weekends. We have observed that the implementation of the UCU clinics has given the opportunity to focus the care on more critical / serious injured patients this also decreased the waiting time for patients to be seen and had increased patients satisfaction. To ensure manpower coverpage in the UCU clinic, a recruitment of 10 GP physicians, which will cost 120,000 SR, (excluding housing allowance and issuing travel fares)is strongly recommended. The cost of the coverage of the UCU clinic during the month of April was 94,000 SR and it covers specialist and GP’S. For the manpower coverage of consultants the total cost would be 166,000 SR.
ICU & Endoscopy Building:
This is a six-story building; and specially designed to accommodate the increasing numbers of hospital patients. It consists of computer department, endoscopy unit and Medical, Surgical and Pediatric intensive care units. The project of the entire construction of this building was completed and it will be inaugurated for the patient service soon by the His Excellency, President of University of Dammam.
21
Introduction to KFHU
22
KFHU Annual Report 1435 - 2014
Introduction to KFHU
23
Clinical Departments
24
KFHU Annual Report 1435 - 2014
2. Clinical Departments
Internal Medicine Dental
General surgery Urology
Obstetrics & Gynaecology Pediatrics
Neurosurgery Orthopedics
Ophthalmology ENT
Neurology
Dermatology Psychiatry
Anesthesia
Family & Community Medicine
Clinical Departments
| INTERNAL MEDICINE ◢ INTRODUCTION
The Department of Internal Medicine is one of the leading departments of the College of Medicine, University of Dammam. It is staffed with 25 faculty members who are consultants internists in King Fahd Hospital of the University. Other staff includes eight consultants, one Senior Registrar, 18 n t at n fi n a t a n ng n ana a an n ta nt department’s subspecialty units include Cardiology, Gastroenterology, Pulmonary, Endocrinology, Hematology/Oncology, Nephrology, Infectious Diseases and Intensive Care Unit. All consultant nt n t a a nt fi f nt na n a ng t t a at n department conducts more than 48 OPD clinics weekly – 10 for general and remaining for various sub-specialties of Internal Medicine.
The Department of Internal Medicine is a major contributor to the continuing medical education ga gan t t at f a ffa an a n ng t g nn a S nt fi Meetings of the department. Topics that were covered were updates in different specialties each year as well other activities including awareness campaigns to the public offered by various subspecialty units time to time. The department is actively involved in various research projects not only intradepartmental but in association with other departments of College of Medicine. A large number of publications have appeared in local as well as international journals.
◢ Goals
1. Provide excellent academic services in accordance with international standard and higher 2.
educational quality. t
a a
ng a t
n
at
a
a a fi
t at f fi t
n
ng
3. To perform research health and medical studies.
at
a t
a
tan a tat
f
nt
t
n a an
an
t
4. Create the opportunities of training to attribute and prepare the excellence in human resources. 5. Establish strategical partnership with community and other services providers. 6. Cooperate with peer department locally, nationally and internationally 7.
ta
an a a
nt fi an
af
f
na
n
n
nt
8. Promote concept of academic medicine as principal health and medical care provider of human resource developer.
◢ Additional Services 1. A Fast Track Clinic was opened to minimize the overstaying of patients in the Emergency Room.
2. Insulin Pump Clinic was opened and we had around 90 patients in 2014. 3. Adult Vaccination Clinic was opened.
4. Periodical rounds by the Clinical Investigating Team to discharge overstaying patients in the
26
KFHU Annual Report 1435 - 2014
Clinical Departments
medical wards.
5. A hotline mobile number was created to relay critical lab values to the medical on-call team. 6. Routine monitoring of proper documentation in medical charts as per requirements of JCI. 7. Thyroid Awareness Campaign. 8. Liver Awareness Campaign
9. Internal Medicine page on Friday editions of Alyoum newspaper. 10. a n
t
ffi a
t
ft
at
nt
11. Objective Structured Clinical Examination (OSCE) was introduced in the 4th and 5th Year undergraduate courses.
12. Prof. Noel Gerard Mc Elvaney was invited as Visiting Professor from 25th to 29th May 2014 mainly to audit the research activities of the department.
13. Plan to open a Thrombosis Clinic next year.
â—˘ ATotal totalPatient. of 34,730 patients were seen by the physicians during the period of 12 months. seen 34,730
Figure 2: Internal medicine OPD Statistics
27
Clinical Departments
â—˘ Internal Medicine Units
A. Diabetic & Endocrine unit
It is an independent unit concerned with the treatment of diabetic persons and patients who suffer from hyper endocrine. Insulin pumps are used within the therapeutic program for patients with diabetics. A total of 250 patients were treated in this unit during the year 2014.
B. Adult Cardiac Lab This lab was established in 1981 to provide services to cardiac patients. It carries out several tests such as ECG, Echocardiography M-Mode, 2-dimensional and color Doppler, Treadmill Stress test and B-P monitoring and analyzing/programming of permanent pace-makers. Recently, the area of this lab has been expanded to accommodate more advanced equipment. â—˘
28
Total of 7,743 tests were done during this year.
KFHU Annual Report 1435 - 2014
Clinical Departments
Figure 3: Adult Cardiac Laboratory procedures
29
Clinical Departments
C. Respiratory Care Service Unit at a S n t at nt f at nt t fi n & abnormalities associated with cardiopulmonary system. Respiratory care practitioners (RCP) exercise a considerable degree of independence in clinical judgments in patient care under direct or indirect supervision of the physician. The scope of the services includes the application of technology and the use of protocols across all care sites including but not limited to the hospital. These responsibilities are supported by administration, Education & Research. ◢
Diagnostic activities include:
Obtaining analyzing and interpretation of physiological data, Arterial Blood Gases. Pulmonary function studies, Perform Sleep disorder studies. ◢
Respiratory Therapy activity includes but not limited to:
a at n an n t ng f a a n t n a f a t fi a a a n pulmonary hygiene, Hemodynamics cardiovascular support, Mechanical Ventilation support, Pulmonary Function studies, Sleep Apnea disorder. ◢
Beside the state of the art Pulmonary Function Testing machine the Respiratory Care Services
has other top quality instruments such as: •
Resmed BIPAP machine System
•
Dragger Evita XL ventilator
•
High Frequency Oxillation Ventilator
•
Servo I Ventilator
• • • • • • • • • •
Breas BIPAP machine V-60 BIPAP Machine
SLE Nitric Oxide Delivery System
Aeronox Nitri Oxide Delivery system G5 Vibramatic Machine
Jaeger Computerized PFT
Somnostar Z4 Sleep System Easy one pro Lab. Pediatric Cough Assist
Chest Physiotherapy
• • • • • • •
Dragger Evita 4 Ventilator
Dragger Baby log 8000 Infant Venti lator
Puritan Bennett 840 Ventilator
T 5100 Globe Trotter Incubator Vent ilator
Crossvent C4 Transport Ventilator Para Pac Plus 310 & Baby Pac 100 Transport Ventilator SIPAP Machine
The Respiratory Care Services in collaboration with College of Applied Medical Sciences play a vital role in Students & Interns education & Training program. ◢ A total of 233,497 procedures were done during the year 2014
30
KFHU Annual Report 1435 - 2014
Clinical Departments
Figure.4: Respiratory care procedures
31
Clinical Departments
D. Cardiac Catheterization Unit Cardiac catheterization laboratory is considered as one of the most important units of the hospital in general and for the cardiology department in particular. It is supervised by a professional medical team of doctors and consultants, technicians and nurses. The unit works seven days a week with a special working team for emergency situations outside the working hours and is supported by the senior management of the hospital. Cardiac cath unit also provides all the medical supplies required to perform the cardiac catheterization procedures including different types of balloons, barematel stents and drug eluting stents in order to deliver better care for patients with cardiovascular diseases. The total of what has been accomplished of cardiac catheterization procedures during the past year has reached the number of (707) cases, including the following procedure: Coronary angiogram percutaneous coronary intervention (pci) right heart catheterization f a t na nt a a a ta n nt a a t a n a Renal denervation temporary pacemaker. The department also has tremendous role in the educational process for doctors and students by giving the chance to attend cardiac catheterization cases, as well as the possibility of observing the ongoing procedure through an external, well developed display screens especially for this purpose. Recently a second
cath lab has been added to the unit in which electrophysiology studies (eps) and pediatric cardiac catheterization will be held and it is expected to function at beginning of next year 2015.
32
KFHU Annual Report 1435 - 2014
Clinical Departments
E. Endoscopy Unit This unit is under the supervision of Internal Medicine Department. It includes a number of consultants of different specialties. Different endoscopic procedures are done here for outpatients, inpatients and patients referred from other hospitals. The unit is equipped with advanced instruments for routine or special procedures and is ready to receive urgent cases throughout the 24 hours of the day. A total of 1,640 endoscopic tests were done this year.
33
Clinical Departments
Total seen 1640
34
KFHU Annual Report 1435 - 2014
Clinical Departments
Figure. : Endoscopy procedure
F. Hemodialysis Unit This unit is under the direct supervision of Internal Medicine Department. It provides services for patients with chronic and acute renal failure, including preparation for kidney transplant. The unit is equipped with advanced dialysis machines and it is ready to receive patients throughout the 24 hours of the day. Kidney biopsies are done in the ultrasound room. Acute dialysis for the critically ill-patients in ICU is also done. The unit is in constant contact and co-ordination with the Saudi Center for Organ Transplant (SCOT) regarding transplant evaluation and waiting list. The Hemodialysis Unit was recently shifted to a new building that allows the accommodation of a n f a t a t at nt t n fa fi n â—˘ ATotal totalseen of 10426 patients were treated during the year 2014. 10426
Figure. : Hemodialysis procedure
35
Clinical Departments
Nephrology (Dialysis) Center Building 00
36
KFHU Annual Report 1435 - 2014
Clinical Departments
G. Peritoneal Dialysis Unit n t a na g at n an affi at t t nt na n a t nt t by a nephrology consultants and supported with well-trained nurses. All necessary medicines are given to the patient free of charge. Some patients are trained on how to use curative devices that suit their case. A total of 1,010 procedures were done during the year 2014. Total seen 1,010
Figure : Peritoneal Dialysis
37
Clinical Departments
38
KFHU Annual Report 1435 - 2014
Clinical Departments
| Dental
◢ INTRODUCTION
The dental department is committed to provide a better treatment services to the patients, University of Dammam and King Fahd Hospital employees and their families in addition to the students and provides internship training program to interns all over the year. The dental department is composed of four dental clinics, dental radiography room and dental laboratory. All dental clinics are equipped to perform most specialized dental procedures including restorative dentistry, orthodontics, oral and maxillofacial surgeries and dental implants. The dental radiography room is equipped to perform all types of intra-oral radiographs, and extra-oral radiographs including panoramic, cephalometric and TMJ views. The dental laboratory is equipped with basic prosthetic and orthodontic appliances. The manpower of the dental department consists of 4 consultants, a senior registrar, a registrar, 7 dental residents, an oral Hygienist, 8 dental assistants and dental technician. Two residents are completing their postgraduate studies, in the USA and one resident is on Saudi Board program of restorative dentistry.
◢ Scope of services
The scope of services for dental department is to provide: • • • •
High standard comprehensive dental services including hospital dentistry, hygiene, orthodontic, and Oral/Maxillofacial surgery in order to satisfy the needs of our internal customers. Limited dental care mainly hospital dentistry and Oral/Maxillofacial Surgery [OMFS] to external customers with necessary follow-ups. n a a f an t a a at nt g a affi nt Surgical/dental procedures under general anesthesia as part of hospital plan and protocols.
◢ A total of 7,274 patients were seen by the dentists during the period of 12 months
39
Clinical Departments
Total Pt. seen 7,274
Figure 8: Dental OPD Statistics
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KFHU Annual Report 1435 - 2014
Clinical Departments
â—˘ Dental Department unit Ma illofacial Operations n t a na g at n 8 an affi at t t nt t a t nt by the College of Dentistry, University of Dammam. All maxillofacial operations are done by specialized consultants with the help of a team from the Dentistry Department. The unit receives patients referred by either the Emergency Department or other neighboring hospitals. â—˘ A total of 1243 surgical interventions were conducted this year covering various maxillofacial operations.
41
Clinical Departments
| General Surgery ◢ INTRODUCTION
The department of General Surgery at the KFHU was established in 1976, it includes several full time attending surgeons with training representing the entire spectrum of surgical experience. All members of the department were actively engage in the academic mission of the Department of Surgery - clinical excellence, teaching and research.
◢ Scope of services Our service is divided into 3 main domains: •
Research
• •
Clinical Service Teaching
These 3 domains interact and complement each other. They are accomplished through the following:
1. Scope of Clinical Service: We serve our patients in 5 main sectors namely OPD, ER, wards, OR and consultations. The department constitutes General surgery, Pediatric Surgery, Vascular Surgery, Cardio-Thoracic Surgery and Plastic Surgery Divisions. ◢
The department has 24 OPD sessions/week, (morning and afternoon sessions) supervised by a consultant.
•
Colorectal & Proctology Clinic – 2 per week
•
General Surgery & Laparoscopic Clinic – 4
•
Vascular Surgery Clinic – 2 per week
•
Breast disorder and Breast Oncology Clinic –
Plastic Surgery Clinic – 3 per week
•
•
Hepatobiliary Clinic – 1 per week
•
Pediatric Surgery Clinic – 3 per week
• •
Cardio-Thoracic Surgery Clinic – 2 per week
◢
per week
3 per week
Wound Care & Diabetic Foot Clinic – 4 per week
ER
Monthly on call Rota is covered daily by 1st on call (Junior Resident), 2nd on call (Specialist) and a 3rd on call (Consultant). ◢
Admissions
Patients are admitted according to the hospital regulations either from OPD or ER. Patients are admitted under supervision of the consultant in charge. Elective admissions are investigated before admission to reduce the hospital stay. ◢ •
OR.
a t nt a n n a an fi n f t cases which are under direct supervision of consultants. Emergency Operations are performed round the clock as and when required by all the units of the department.
•
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KFHU Annual Report 1435 - 2014
Clinical Departments
◢
Continuous assessment
Continuous assessment of medical services provided to our patient is done through monthly audit and case presentations.
2. Teaching Services
This is provided by the department all over the year, it is mainly done by the consultants but specialists and demonstrators also contribute to clinical teaching. Teaching is provided to the following: •
Undergraduate medical students
•
Undergraduate Nursing students
• • •
Undergraduate dental students
Post graduate residents in Saudi Board Program for General Surgery& Plastic Surgery
Post graduate residents in Saudi Board program or its equivalent for Family & Community medicine, Urology, ENT, Orthopedics Neurosurgery etc. having their general surgery rotations.
3. Research Service: • • •
Being a university hospital, research is one of the most important services conducted by our department in order to help prevention, control, diagnosis and management of diseases. Several clinical, experimental and epidemiological studies (Prospective, Randomized, retrospective, cohort, and case control) have been done by the department. More than 400 articles have been published in leading International and National journals. Several books pertaining to General Surgery have been published for undergraduates and postgraduates.
◢ A total of 18,371 patients were seen by the surgery during the period of 12 months 43
Clinical Departments
Total Pt. seen 18,371
Figure : General Surgery OPD Statistics
General Surgery Units A. Pediatric surgery
This unit was established in January 1989 to provide a high level of specialized care for newborn babies and below 12 years of old children’s. This unit also provides training on specialization in pediatric surgery for medical staffs
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KFHU Annual Report 1435 - 2014
Clinical Departments
B. Plastic surgery
nt a ta n 1 8 an n a t fi t n t f n an at g n Easter region. This unit accommodates all clinically complicated cases; it also provides treatment for cosmetic surgery and reconstructive surgery.
C. Heart & Chest
This unit provides heart surgery and chest expansion over the past years when the unit set up an open-heart surgery and laparoscopic surgery for the diseases of the chest. This unit collaborates with the unit of heart and respiratory diseases at the department of Alebatanh as an integrated team to provide the highest quality of medical care for patients.
D. Open Heart Surgery
n t a na g at n 8 an affi at t t n a S g a t nt operations are conducted under the supervision of consultants of heart and chest surgeries. The unit is constantly equipped with advanced medical instruments. A total of 23 open heart surgeries done this year together with several closed heart surgeries.
E. Breast surgery
This unit was established in 2014, and it is organized by senior consultants with extensive n n t fi f g a t at nt f a t an a g a a nta collaborates with the support unit such as the unit of cosmetic surgery, radiology, pathology, psychological and physical therapy to provide the best integrated medical care for patients. This unit treated more than 3000 patients successfully under the integrated medical care diseases. Aim of this clinic to make them centers of advanced breast clinic center in the world. 45
Clinical Departments
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KFHU Annual Report 1435 - 2014
Clinical Departments
F. Burn Unit
It is a 12-bed unit in which four beds are allocated for critical cases. It falls under the direct supervision of plastic surgery consultants. The Unit receives patients referred from various hospitals in the Eastern Region. A total of 97 patients were admitted to the Burn Care Unit the period under report. Bed occupancy rate was 43%.
Total seen 97
Figure 10: Total number of patients Burn unit 47
Clinical Departments
G. Surgical Endoscopy (SEU)
In this unit, various abdominal surgeries have been carried out using the endoscopy since 1994. The operations are conducted under the direct supervision of general surgery consultants specialized in this kind of surgeries.
â—˘ A total of 372 surgeries were carried out in the year under report. More details are found in the below tables. Table.4: Surgical Endoscopy procedure Particulars Hernia Endoscopic Procedure Peritoneal Dialysis Catheterization Appendectomy Cholecystectomy Gastric band removal Peritoneal Dialysis Catheter Front Amputation Surgery Splenectomy Gastrectomy Dental Endoscopic Surgery Semi-Colonoscopy Diagnostic Endoscopic Surgery
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KFHU Annual Report 1435 - 2014
No. of surgeries 3 36 41 143 3 6 27 3 71 10 5 24
Clinical Departments
|窶ザrology
笳｢ INTRODUCTION g a t nt gn fi ant ng t nt a t nt n n a n the number of medical staff serving in it. They currently include 5 Consultants, 4 Specialists and 5 Residents. The number of outpatient clinics increased to 5 clinics per week with an average of 30 patients seen in every clinic. In-spite of the very limited number of Urology beds in the hospital, the utilization time of operative procedures in the Operating Room is almost doubled as compared to 3 years ago. Further increase in utilization time is expected once more beds are provided for the Department. The concept of Urology Sub-Specialization Units is currently being initiated with the launching of Uro-Oncology, Functional and Pediatric Urology Units. This is a starting strategy with plans for
extension in the near future to involve other subspecialties. The strategy also includes the launching of outpatient urology subspecialty clinics instead of the current general urology clinics. New state-ofthe-art medical equipment and machines have been purchased by the department in the last year. They include Toshiba Ultrasound Machine, Laser Stone Fragmentation Machine, Laborﾃｩ Urodynamic Machine, 3 Storz Flexible Cystoscopes and 2 Flexible Ureteroscopes. Availability of this new equipment a t at nt anag nt an nt t a n ng gn fi ant S nt fi a t t nt n t t t n f t a t nt t at g n t intradepartmental activities by the residents and interns supervised by the consultants, as well as interdepartmental activities with the departments of Radiology, Pathology and Nephrology. Four Workshops in different areas were organized by the department in the last year for urologists in the Eastern Region and for general practitioners. The feedback from those various activities was positive with good incentive to continue and promote them. In addition ,the department has participated in t 1t a t nt a a an n t fi t ft t ntat n
49
Clinical Departments
◢ Scope of services •
The Urology Department offers thorough state-of-the-art evaluation and management of all
•
The Urology Department has at the present time 5 staff urologists and 5 urology surgical
urologic problems.
trainees under training. Being a tertiary referral center at a territory-wide base, the Department provides a comprehensive urology service to the public.
•
The scope of cases seen at King Fahd Hospital of the University covers the gamut of urologic diseases. The clinical faculty has particular expertise in the following urology subspecialties
1. Endourology
2. Pediatric urology
3. Urologic oncology
4. Minimally invasive surgery
5. Voiding dysfunction/incontinence 6. Erectile dysfunction
7. Reconstruction The department also caters for routine urological problems, such as inguino-scrotal disorders and prostatic diseases. ◢ A total of 5,128 patients were seen by the physicians during the period of 12 months Total Pt. seen 5,128
Figure 11: Urology OPD statistics 50
KFHU Annual Report 1435 - 2014
Clinical Departments
â—˘ Urology department unit Lithotripsy Unit
The unit is functioning as a Day Care Unit under the direct supervision of the Department of Urology and it is well-equipped with advanced machines. The total number of patients treated at this unit in the year under report reached at 1,227. Total seen 1,227
Figure 12: Lithotripsy procedures
51
Clinical Departments
Eurology Department Meeting
The First Eurology Endoscopy
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KFHU Annual Report 1435 - 2014
or shop
Clinical Departments
| Obstetrics & Gynaecology ◢ INTRODUCTION
The Department of Obstetrics and Gynecology at KFHU, and its many faculty members and researchers, are dedicated to provide every women and their families with the most advanced care available. Our commitment to patient- and family-focused care has shaped our Center for Women and Newborns. At KFHU – the quality of obstetrical and neonatal care are considered as world renoun and are equipped with the most comprehensive state-of-the-art obstetrical services. The Department supports women through all stages of life and works collaboratively with specialists in cardiovascular medicine, orthopedics, arthritis and neurology – to name a few – to provide comprehensive care.
◢ scope of services •
Antenatal care of normal & high-risk pregnancy
•
Infertility
•
Gynecologic/endocrinology conditions
◢ A total of 12,316 patients were seen during the year 2014. Total Patient. seen 12,316
Figure 13: Obstetrics and Gynecology OPD patients 53
Clinical Departments
â—˘ Delivery Room
This room is equipped with the latest equipment for obstetrics. The unit is consists of 4 labor rooms, 3 delivery rooms, 2 recovery rooms and 1 operating room for cesarean section. As per the regulations of the Ministry of Health all babies born in the hospital are being t ga f nt fi at n n a t nt t t t a t nt taff t midwives and specially trained nurses. â—˘ A total of 1,221 deliveries were attended during the year.
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KFHU Annual Report 1435 - 2014
Clinical Departments
Total Delliveries 1,221
Figure 14: Delivery Room OPD Statistics
55
Clinical Departments
|窶ケediatrics
笳｢ INTRODUCTION
Pediatric Department is one of the major clinical departments at King Fahd Hospital of the University. Since the department was established in 1981, it has been providing medical services and specialized and comprehensive medical care of high-quality for children from birth until the age of fourteen. Pediatric Department depends on elite of consultants, specialists and residents a ng an t an t a a fi n ng g an t n an Pediatric Department provides several services to the Saudi society which includes:
1. Medical care for patients through: Inpatient Wards, Pediatric Intensive Care Unit and Neonatal Intensive Care Unit, High Risk Pregnancy, Emergency Department, Outpatient Department and Pediatric Cardiology Unit. 2. Resident training program. 3. Teaching medical students at the University of Dammam.
笳｢ Scope of services Pediatrics department is committed to pediatric excellence beginning at birth and extending into areas of general and specialized care in both inpatient and outpatient settings.
笳｢ Inpatient settings: Pediatric
ards
This where children are fully investigated and received treatment for acute and chronic conditions in general pediatrics and subspecialties.
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Clinical Departments
PICU
The Unit meets the special medical, emotional and social needs of the sickest children and their families with great compassion and skills.
NICU
The Unit is similar to PICU but it is uniquely equipped to meet the needs of newborn born too early or too small, or who require special care or surgery.
â—˘ Outpatient settings: Pediatric Emergency
The Unit is consist of 2 separate rooms, day and night treating more than 50,000 children each year and have access to pediatric consultations 24-hours a day.
Outpatient Clinics
which has 4 clinics per day 9:00 AM to 4:00 PM, Sunday to Thursday which provides nearly 3,000 ambulatory visits per year in most of pediatric subspecialty (allergy/immunology, cardiology, endocrinology, gastro-enterology, hematology/oncology, infectious disease, nephrology, neurology and pulmonology). In addition to patient care are department is committed to high level of medical education and research for both under and postgraduates students as well as active participation â—˘ A total of 6,762 patients were seen by the physicians during the period of 12 months
57
Clinical Departments
Total Pt. seen 6,762
Figure 1 : Pediatrics OPD Statistics Total seen 134
Figure 1 : Total number of patients NICU 58
KFHU Annual Report 1435 - 2014
Clinical Departments
◢ Various patient care sections: 1. Inpatient
ards
Inpatient Ward contains 24 beds for the treatment of children from various diseases. Clinical care is supervised by residents, specialists and consultants in addition to the group of a fi n nt n a n a t a a
2. Neonatal Intensive Care Unit (NICU)
This unit started work in May 1981 and has been equipped with the latest devices such as nursery, mechanical ventilation and central screen to monitor patients, in addition to, the a fi f NICU is divided into three sections •
Intensive care unit and has 16 beds.
•
Isolation Room.
•
Neonatal unit.
◢ A total of 134 neonates were admitted to NICU during the year 2014, bed occupancy was 87%. Medical staff consists of a number of consultants who are available 24 hours a day. Doctors are supervising the clinical care in addition to the direct supervision of caesarean sections and cases of high-risk birth. Medical care in this unit includes care on surgical intervention which a t a a fi an a g a t a n at S g This unit has gained a good reputation and became a main referral center in the Eastern Region that offers such specialized medical care. Thus, the number of newborns with medical or surgical problems that was transferred to it from other hospitals across the Eastern Region has increased. There is close cooperation between this unit and Obstetrics and Gynecology Department t nt nt g a t ng t t nt nata These activities has resulted in continuous decline in mortality among newborns weighing less than 1000 grams and plans is moving in the future toward reducing the morbidity rate deaths among low birth weight newborns.
3. Pediatric Emergency Department
The provision of medical services for emergency cases is under the direct supervision of pediatric specialists. Emergency department has a room to measure vital signs by the nurse and two rooms for clinical evaluation by pediatricians and eight beds for the treatment of cases that require observation and further assessment. Emergency Department works harmoniously with the doctors working in inpatient unit and intensive care unit in order to provide complete care for patients as soon as possible.
59
Clinical Departments
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KFHU Annual Report 1435 - 2014
Clinical Departments
4. Outpatient Department (OPD)
OPD provides medical care services through clinics throughout the week from Sunday to Thursday under the supervision of pediatric consultants. Pediatric outpatient clinics includes fi g n a n n n a na t nt at n n ng cardiology clinics, two endocrinology clinics, one diabetic clinic, one gastroenterology clinic, one nephrology clinic, one pulmonary clinic, one allergy clinic and one infectious disease clinic, two hematology clinics, two neurology clinics, and one high-risk clinic for care of infants who required intensive care after their birth.
. Pediatric Cardiology Unit
This unit started work in 1982 under the supervision of a pediatric team consisting of a number of pediatric cardiology. This unit also includes a diagnostic laboratory for cardiac disease containing echocardiography. One of the objectives of this unit is to provide the clinical and laboratory services necessary to provide maximum diagnostic and therapeutic medical care for children who suffer from heart disease in addition to continuous medical care to all children admitted at the hospital or born in hospital suffering from congenital heart disease or transferred from other clinics and primary health care centers in eastern region.
â—˘ The total number of tests done the year under report was 2,737.
. Pediatric Cardiac Laboratory
This section provides a special care for newborns, infants and children who suffer from heart disease services, by ECG, waves rays ultrasound of the heart and ECG 24 hours .It is operated by consultants specialize in heart disease in children, and also it provides teaching and training for medical doctors & graduate students in the area of heart disease for children , it is also considered a center of reference and transformative for all children who have heart problems in the Eastern Province and other areas as needed.
â—˘ A total of 882 pediatric cardiac examinations were done during the year 2014.
61
Clinical Departments
â—˘ Resident Training Program Perhaps one of the most important objectives of the pediatric department is to train doctors in the specialty of pediatrics, in accordance with the Saudi Council of Medical Specialties requirements. t a n ng a ng t t an a t at n a fi Recently, the training program gained a good reputation and now includes Scholarship doctors from neighboring Gulf countries.
â—˘ Teaching medical students at the University of Dammam Pediatric Medicine is a basic axis in the Curriculum of medicine. Teaching of 6th year students has been provided by pediatric faculties. Educational process includes lectures and intensive clinical education for two months ending by practical and written assessment.
â—˘ Future of the Pediatric Department at a t nt ng f t nt n nt t nt nt n ng efforts through fellowships in all the pediatric specialty and subspecialties internally and externally n t g tt a t a t an f nt a fi ft at a t nt such as metabolic diseases, infectious diseases, kidney disease, and endocrinology. One of the aims which we hope in the present time is to create a special unit for dialysis for children in order to be a main center for referral cases that require dialysis in the eastern region.
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Clinical Departments
| Neurosurgery
◢ INTRODUCTION t n nt
a ffi a n n 1 81 Staff g a a n a t taff an a ng t fi f at n an a a a t t t t n ft at n g n n g a t nt t fi t a a a t nt gn n t ng f Saudi Arabia. The Department participated in the teaching and training of medical students, and also trains Saudi doctor trainees enrolled in graduate programs. The program has attracted some n ta nt fi an a n tt t n n t ng f Sa a a t a at n Department performs hundreds of surgeries per year and include treatment of brain tumors and cerebral bleeding under the arachnoid membrane and the outer nerve injuries, as well as the treatment of birth defects in the nervous system of children. a t nt a a n f nt fi a n nt nat na na a a research in the areas of birth defects, wounded head, Tumors of central nervous system, slipped disc spine and brain abscess. The department has several unique features & characteristics: •
t at
nt
nt f
ft
an
ant t
af
a n t
t
ng
nt
ng a
t
•
Treatment of head injuries moderate to severe.
•
Follow-up the Cases of neurological by a team (ICU nerve).
• •
• • •
ag
na
f
t
The treatment of spinal injuries.
A brain and nerve surgery by ultra-precision equipment such as binoculars and modernity
cerebrospinal surgical microscope and surgical navigation device inside the brain and device control physiology.
Unit Vascular Surgery brain through a catheter interventional. Brain tumors surgery without anesthesia.
Establishing a specialized clinic for children birth defects such as hydrocephalus and hematomas meningitides and maximize visibility early.
◢ scope of services
The Department of Neurosurgery provides neurosurgical care and procedures like microscopic brain and spine, neuroendoscope, stereotaxy, navigation, pediatric and endovascular neurosurgery. We supervise and train postgraduate residents aiming for neurosurgery as their specialty. We teach 5th year medical students and interns as part of their curriculum in medicine. The department conduct nt fi a n a at n t t a t nt n an t t ta an t Kingdom. We provide annual continuing medical education activities like conferences to provide channel of updates in neuroscience and most importantly neurosurgical care and management.
63
Clinical Departments
Total Pt. seen 5,323
Figure 1 : Neurosurgery OPD Statistics â—˘ A total of 5,323 patients were seen by the physicians during the period of 12 months
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KFHU Annual Report 1435 - 2014
Clinical Departments
| Orthopedics ◢ INTRODUCTION Orthopedic Surgery Department began to work independently in Muharram 1403H. It was in the Department of General Surgery since the opening of the hospital; there are a number suites and units of Interior to this section 31 beds, 20 beds for men and 5 beds for women and 6 beds for children. t n t a a t nt n t fi f t g an t a n ng f nt doctors Departments of Orthopedic Surgery, General Surgery, family and community medicine and emergency medicine. The orthopedic department is one of the most important sections clinical nt ta n t a at n f nt fi a a an g a t at at a t nt a t t f a a a tant a n t fi ang t joints industrial, osteoporosis, sports medicine, shoulder surgery and endoscopy, orthopedics and distortions children. In addition to research and studies, such as complications of bone surgery for patients with sickle cell, hip fractures, paralysis of the spine and spine fractures. Has been published several case reports and presented in conferences and seminars both internal and external.
◢ Scope of services •
Outpatient clinics: There is subspecialty clinics including • • • • •
Spine Arthroplasty Sport Pediatric
Shoulder & upper limb
•
All clinics introduce high standard specialized orthopedic surgical care.
•
There are 4 fractures clinic which follow and treat patients with general musculoskeletal
•
• • • • •
The clinics were distributed between morning and afternoon time according to the schedule. trauma and fractures.
Inpatient services can be done under direct orthopedic supervision for patient admitted to the male, female or pediatric orthopedic ward.
Patient admitted under other services can be evaluated and treated through formal consultation.
All patients underwent full medical evaluation and investigation before intention surgical or non-surgical treatment.
Surgical procedure done at the OR for inpatient.
Some surgical procedure can be done as outpatients’ services at the day surgery.
65
Clinical Departments
Total Pt. seen 14,030
Figure 18: Orthopedics OPD Statistics â—˘ A total of 14,030 patients were seen by the physicians during the period of 12 months
â—˘ Orthopedics department units
1. oints industrial change unit n t n ff n tant t at a an ffi nt t a n ng f t t n t in the world. This section is associated in weekly specialized clinics. An average number of patients seen was 100 patients per week. A total of 135 surgeries were conducted by this unit during the year 2014.
2. Sports Trauma & Arthroscopy Clinic S t n tant t n f t fi t a nt nt at n g n Also associated with this unit is a specialized clinic weekly and patients with a rate of 30 patients per week. The total repair anterior cruciate ligament operations from the beginning of this clinic in 2009 amounted to about 700 cases.
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Clinical Departments
3. Shoulder Surgery and Upper Limb Clinic n t n ff n tant t at a an ffi nt t a n ng f t t n t in the world. This section is associated in weekly specialized clinics. An average number of patients seen 25 per week. A total of 90 surgical operations were conducted by this unit during this year.
4. Orthopedics unit for ids n t n ft n tant t at a an ffi nt t a n ng f t t n t in the world. This unit is associated with weekly specialized two clinics. Medical care is provided to patients 50 per week.
. Spine surgery unit It is under the supervision of two consultants. This unit is associated with weekly specialized two clinics. An average number of patients seen per week is 50.
.
ee ly clinic specialized in surgery foot bone surgery
It is under the supervision of an orthopedic consultant, this unit was established in 2014
. Fractures and injuries unit It organizes four clinics a week at a rate of 30 patients, each clinic follow-up cases of fractures and injuries.
67
Clinical Departments
| Ophthalmology ◢ INTRODUCTION
The department was established in October 1980; the main activity was undergraduate teaching. It started admitting patients in 1982. Postgraduate teaching activity began in 1983. Since then the department has gradually expanded. The department deals with clinical, didactic and researches activity. •
At present the department consists of 11 consultants, 6 demonstrator and 35 trainee
•
Five residents are completing their postgraduate studies
residents, 4 optometrists and 10 technicians.
•
The department consists of eight clinics (six clinics for consultants and two clinics for refraction to help the consultants).
•
The department is well equipped to perform all types of requirements like Laser, FFA, Minor OR, Visual Field / Ultra Sound and IOL Master / Topography.
•
The Minor OR is equipped for the minor surgeries in the OPD.
•
The all clinics are equipped to perform the care of patients Total Pt. seen 22,363
Figure 1 : Ophthalmology OPD Statistics ◢ A total of 22,363 patients were seen by the physicians during the period of 12 months
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KFHU Annual Report 1435 - 2014
Clinical Departments
69
Clinical Departments
| ENT
◢ INTRODUCTION Department of ENT began in 1981 and was composed of one consultant physician. Faculty member of the section now includes six consultants and 10 specialists in addition to a group of Doctors of audiologist have a doctoral and master’s degree and specialists in the unit of treatment of diseases of speech and pronunciation of the master’s holders. Section operates in outpatient clinics daily in the morning and afternoon period. There are special rooms for Audios and communication in outpatient clinics, the department work 5 full days in surgery rooms’ major operations. nt a a a ant a n t fi t n t g n n a t n t t a ng fift a t nt t a t f n an nt t t S t n t a n Sa
doctors enrolled in a graduate program in the specialty of the nose and ear. The department is actively involved in continuing medical education programs of the university establishment Conferences, seminars and workshops frequently work over the year In addition to participating in the deployment and provide research in local and international forums.
◢ Scope of services Our service is divided into 3 main domains: •
Medical Service
•
Research
•
Teaching
These 3 domains interact and complement each other. They are accomplished through the following:
Scope of Medical Service:
◢
We serve our patients in 5 main sectors, OPD, ER, wards, OR and consultations.
1. OPD
The department has 2 OPD sessions/day, morning and afternoon session. 24- clinics are running/ session supervised by a consultant. Which mean 20 clinics/week.
•
Audiology Unit consists of 4 rooms; 2 rooms for basic audiological assessment, one room
for preoperative evaluation of cochlear implant patents, postoperative programing and follow up, 4th room for BERA, ENG and VNG. The unit serves our patients suffering
fromhearing loss or disequilibrium, patients referred from other departments and those •
referred from other hospitals.
Speech clinics, 4 rooms working morning and afternoon sessions each session 2 working clinics, they also serves outpatients, referrals from ENT clinics and referrals from other departments or other hospitals.
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KFHU Annual Report 1435 - 2014
Clinical Departments
71
Clinical Departments
2. ER. Monthly on call Rota is available that covers daily by 1st on call (Junior Resident), 2nd on call (Specialist) and a 3rd on call (Consultant) according to the availability of the staff.
3. Admissions. Patients are admitted according to the hospital regulations either from OPD or ER. Patients admitted through OPD are admitted through an additional admission clinic under the supervision of the consultant in charge. Most of our elective admissions are investigated before admission to reduce the hospital stay.
4. OR The department has 4 OR days for elective cases which are under direct supervision of consultants. Continuous assessment of medical services provided to our patient is done through monthly audit and case presentations for cases that need brain storming. ◢
Teaching Services
This is provided by the department all over the year, it is mainly done by the consultants but specialists do contribute mainly in clinical teaching. Teaching is provided to the following: •
Undergraduate medical students
•
Post graduate residents in Saudi Board Program for ENT
•
Undergraduate dental students
•
Post graduate residents in Saudi Board Program for family & community medicine
•
Post graduate residents in Master Program for family & community medicine
•
These services are conducted through the following activities and procedures:
•
n ng
nt fi a t
t
•
Clinical teaching for the residents in the OPD
•
Problem based lectures for the undergraduates (Medical & Dental)
•
OR supervision for the residents
•
Clinical rotations for the undergraduates
•
Preparation of the OSCI and MCQ exams for the undergraduates
•
Daily inpatient rounds
•
Weekly Grand Round
◢
Research Service
Being a university hospital, research is one of the most important services conducted by our department in order to prevent, control, diagnose and management of diseases.
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Clinical Departments
Total Pt. seen 15,328
Figure 20: ENT OPD Statistics 笳｢ A total of 15,328 patients were seen by the physicians during the period of 12 months
|窶クeurology 73
Clinical Departments
| Neurology ◢ INTRODUCTION The Department of Neurology provides clinical outpatient services in general neurology and multiple neurological subspecialties. In summary, both the outpatient and inpatient programs continue to increase in patient volume, and we are pleased with the high quality specialty care that is provided to our patients. The department is also involved in outreach educational activities within the region, providing lectures in many neurological subject areas including movement disorders, stroke, cognitive disorders, multiple sclerosis, and others.
◢ Scope of services •
n
n
tant
t
an
n
tat n
f
n
nt an t
n
ang
by another Consultant. The other consultants remain busy during this time to conduct
the OPD’s morning meeting, teaching, research activities and their respective duties, like Neurophysiology.
•
at
nt f
g
a an n a
ta f
nt a fi t n a
a
S
a t
as 2nd on call (most of the days of the month) and a Consultant as 3rd on call (whole month). On-calls among consultants are divided according to the number of available consultants.
•
Floor physician has to cover the service during working hours after which on call team is n
•
t ta
a
fa
n
tat n an
n at nt
The Department of Neurology provides regular service to all the internal and external customers by
offering standard clinical neurophysiological services including EEG, NCS/EMG and evoked potentials.
•
The Department of Neurology also provides Botox injection therapy to relevant patients.
◢ A total of 5,998 patients were seen by the physicians during the period of 12 months
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KFHU Annual Report 1435 - 2014
Clinical Departments
Total Pt. seen 5998
Figure 21: Total number of OPD patients
Neurology
Total Pt. seen 1,452
Figure 22: Neuro diagnostic procedures â—˘ A total of 1,452 procedures were done by the physicians during the period of 12 months 75
Clinical Departments
| Dermatology
â—˘ INTRODUCTION
The Department of Dermatology has eight outpatient clinics in a week in the hospital in addition to one outpatient clinic in primary health care center. Section includes doctors and consultants and Demonstrators and resident doctors and participates in Academic activities where they are teaching medical students Rapporteur academy of the Special skin disease for three weeks for graduate students has begun implementation of Dammam university fellowship program in the specialty of dermatology formally in January 1990. The department offers a training program for medicine dermatology and genital for Saudi commission for health specialties and the Arab Council for Health Specialties. Among other activities undertaken by the department provided In particular for doctors that trainees Al seminars and nt fi na ntat n n a t ng an a f t and month Where the resident doctors to prepare cases and coordinate the activities Discussion cases histopathology sessions and participate in research activities section they include research projects Psoriasis Disease altitude and Leishmania and baldness and chemotherapy photosynthesis and fungi skin In addition to clinical readiness studies and cases reports, And employees of the departments actively participated in all the seminars dermatologist in the Kingdom of Saudi Arabia and in global conferences. Total Pt. seen 10,993
Figure 23: Dermatology OPD Statistics â—˘ A total of 10,993 patients were seen by the physicians during the period of 12 month
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Clinical Departments
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Clinical Departments
| PSYCHIATRY
◢ INTRODUCTION
The start of the founding of the Department of Psychiatry with the establishment of clinical departments of the Faculty of Medicine in Dammam in 1975. Two faculty members were appointed in the Department of Internal Medicine in 1980; they are working on teaching students and provide service to outpatients. The students of psychiatry were used to be taught in Bahrain, Al-Ahsa and Aramco Hospital in Dhahran. Outsource professors and doctors of external examiners from Bahrain, Riyadh and neighboring hospitals were asked to arrange student exams. In 1982, it became an independent department with a representative in the College Board on an equal footing with the major clinical departments. The department settled in a rented building till 1988. Then the current building of at a na g at t n t fag n f t at nt n ng at an at n f nt g t t n a g n fi t an n are allocated for in- patients (men and women), 18 beds each. Training and clinical activities are n t nt n n t a a fi t a t nt t a f a a g an n psychiatry for students of the Faculty of Medicine. It also teaches courses that respond to needs of other colleges such as the College of Dentistry, Nursing and Applied Medical Sciences. As for Graduate Studies, the department trains male and female doctors in psychiatry fellowship g a f Sa S at t fi at f at an f n ng a a n t an also providing the training for the master program in clinical psychology in Arab Psychiatry in the academic year 14351433-h. The department is considering training programs in Psychological n ng ga a nt fi fa t n
◢ Scope of services •
Proper psychiatric history and mental state examination
•
Collaboration with other psychiatric centers in the Eastern province (eg. Al-Amal Hospital,
•
Proper investigation.
National Guard, Armed Forces Hospital and Child abuse centers) and in other areas of the country.
•
Provide different therapeutic options starting from drug oriented to highly specialized therapy like ECT (Electric compulsive therapy).
•
Referral for further management with more sophisticated treatment modalities.
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Clinical Departments
79
Clinical Departments
Total Pt. seen 11,471
Figure :24 Psychiatry OPD Statistics â—˘ A total of 11,471 patients were seen by the physicians during the period of 12 months
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Clinical Departments
| ANASTHESIA
◢ INTRODUCTION The anesthesia department at King Fahd University Hospital offers a variety of services to patients 24 hours a day. These services represent in the major operations, which consists of (10 operating rooms) Equipped with the latest equipment and anesthetics to perform all the various surgeries also service surgeries emergency and accidents. The department also contributes to the provision of medical care for all patients before, during and aft g a at n n a t n t fi t t a t an Supervision the surgical for intensive care unit. And treatment of acute and chronic pain, as well as contribute to the cases treatment of Critical birth as part of the work of the medical team as part of the work of the Integrated medical team. The department also provides a variety of services to sections at CT scan and MRI, Binoculars digestive, psychiatric department and emergency department. a t nt a tn t a t t fi n gan ng a n f na an workshops of local and global action with a select group of doctors and professors distinguished in t anf a an nt nat na n t an ta gn fi ant nt t n a a t a t nt n t fi f nt fi a a t nt a an nt fi a n a an nt nat na na an a a t tt t a a a t t t a t nt g t a t a an a fi at n a t an t aS a t f t fift a t nt f a a t t a ant t tg a at t nt an Sa t f n t a fi at n a t nt f n t a considered most important training centers in the Eastern region and the Kingdom.
◢ Scope of Medical Service: The Department of anesthesia provides complete anesthesia services, including consultation for patients and other physicians, General anesthesia, regional anesthesia, Obstetric anesthesia, sedation and management of surgical intensive care patients, and acute and chronic pain management. Service is available 24 hours a day, seven days a week. Anesthesia department provides complete anesthesia services in: •
Ten Operating Rooms
•
One Operating Room in Delivery Room
• • • • • • •
Anesthesia Preoperative Evaluation Clinic (APEC) Endoscopy Unit
Interventional Radiology Suite
Supervision of Post anesthesia care unit patients Seven surgical ICU bed
Pain medicine and acute Pre-Operative pain management Emergency Airway Management.
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Clinical Departments
◢ Teaching Services •
This is provided by the department all over the year, it is mainly done by the consultants but
•
Undergraduate 5th year medical students
specialists do contribute mainly in clinical teaching. Teaching is provided to the following:
•
Post graduate residents in Saudi Board program for Anesthesia & SICU
•
Post graduate residents in Saudi Board program for Emergency Medicine, Pediatrics and Ob-Gyne.
◢ Research Service Being a university hospital, research is one of the most important services conducted by our department in order to improve patient management. Many articles have been published in leading International and National journals. ◢ A total of 4,666 patients were seen by the physicians during the period of 12 months Total Pt. seen 4,666
Figure 2 : Anesthesia OPD Statistics
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Clinical Departments
| Family and Community Medicine ◢ INTRODUCTION
This department provides continuous education and professional development for staff and physicians, and most recently, patient and family education. Our vision goes beyond creating excellence in student education to include creating excellent patient outcomes through leadership in all aspects of education. ◢
Internal Customers
•
Out-Patients: Our services are available to all outpatients on an urgent and elective basis,
•
Health Care Worker (HCW): Clinical and other staff workers who have regular, clinical contact
from Sunday through Thursday.
with patients this includes staff such as physicians and nurses.
◢
E ternal Customers
•
All clinical & diagnostic departments in KFHU whose patients are referred to us for further consultations or investigations.
•
t ng an n t fia
a
n t n a
a
◢ Scope of services Supporting the delivery of primary care that encourages a healthy start to life, and a long and healthy life, through: •
Improved early detection and effective management of chronic diseases.
•
Expanded program for immunization.
•
Locally endemic disease control.
•
Maternal and Child Health including responsible parenthood.
•
Treatment of communicable and non-communicable diseases.
•
Mental health, child development and social and emotional wellbeing Education for Health
•
More effective primary health care management and information systems.
•
Presenting high quality level of health care services which are: •
Effective
•
Continuous
• • • •
Productive Accessible Equitable
Responsive
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Clinical Departments
◢ Goals •
Provide comprehensive patient-centered.
•
Provide high quality up-to-date family and community medicine learning and teaching.
•
Optimize the quantity and quality of human resources.
•
Conduct ethical researches that follow Islamic value and international standards.
◢ A total of 1,763 patients were seen during the year 2014. Total Pt. seen 1,763
Figure 2 : Total number of patients Patient Education
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KFHU Annual Report 1435 - 2014
3. Special Services
Intensive Care Units Coronary Care Unit Operating Room Day Care Unit
Physiotherapy Unit Radiology
Interventional Radiology & Vascular Catheter Unit Outpatient Department Emergency Room
Special Service
|窶オntensive Care Unit (ICU) 笳｢ Medical Intensive Care Unit (MICU) This unit accommodates (5) beds furnished with one Isolation Bed with all required equipment. It provides intensive health care service round the clock for critical cases and cases referred by departments of KFHU or other hospitals. It avails good training opportunities for physicians and nurses from inside and outside the hospital. The MICU is usually equipped with the latest advanced equipment to ensure the provision of better healthcare. The number of patients admitted to this unit during the year 2014 reached 99. The bed occupancy rate was 100%.
Total seen 99
Figure 2 : Total Patients MICU
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KFHU Annual Report 1435 - 2014
Special Service
â—˘ Surgical Intensive Care Unit (SICU) This unit, which accommodates 6 beds with one Isolation Bed, provides intensive medical care service round the clock for patients with critical surgical condition admitted by KFHU or referred by other hospitals. The unit avails good training opportunities for junior surgeons and nurses working in the hospital. It is usually equipped with advanced devices and equipment to ensure better medical care service for the needy in-patients. The number of patients admitted to this unit during 2014 reached 126 with an occupancy rate of 100%.
Total seen 126
Figure 2 : Total Patients SICU
89
Special Service
â—˘ Pediatric Intensive Care Units (PICU) This is a new unit, which started with two beds only, then expanded to become an independent unit with four beds with an extra separate bed for isolation. The unit provides intensive care for all critical cases of children, including post-operative cases (such as Ear, Nose and Throat operations, Neurosurgery, Ophthalmology, etc.). PICU is supervised by a specialized medical staff including subspecialized consultants and pediatric specialists. The number of patients admitted to this unit during the year 2014 reached 102.
Figure 28: Total Patients PICU
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KFHU Annual Report 1435 - 2014
Special Service
|窶イoronary Care Unit (CCU)
CCU is a 10-bed level-1 facility where continuous ECG monitoring, intensive medical and nursing care is provided for all cardiovascular patients. This Unit is well-equipped to handle all cardiac emergencies and can handle invasive procedures including the insertion of temporary pacemakers and Swan Ganz thermo dilution catheters. Four (4) telemetry units are used for monitoring the patients. A total of 403 patients were admitted to CCU during the period under report. The bed occupancy rate is 91%. Total seen 403
Figure 2 : Total Patients CCU
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Special Service
|窶グperating Room
It is a ten-room complex with a ten-bed recovery unit. It provides service to patients 24 hours a day. A total of 6,111 operations were performed in this complex the year under report.
Table: Surgical Operations during the year 2014 Types of Surgery
No.of patients
Pediatric Surgery
199
Thoracic Surgery
213
General Surgery
Orthopedics Surgery Gynecology Surgery Plastic Surgery
Ophthalmology Surgery Neurosurgery ENT Surgery
726 401 390 947 290 651
Vascular Surgery
180
Urology Surgery
477
Dental Operations
98
Pain Management
79
L.S.C.S
324
Others
145
Total
92
991
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KFHU Annual Report 1435 - 2014
Special Service
Total Pt. seen ,111
Figure 30: Total Patients Operating Room
93
Special Service
| Day Care Unit
It consists of two rooms, one for Day-Surgery and second for endoscopy. It is supervised by both the General Surgery Department and Internal Medicine Department. Chemotherapy, blood transfusions, endoscopies, minor surgeries and diagnostic / therapeutic procedures are carried out in this unit. This unit is equipped with the latest instruments of endoscopy and monitoring. A total of 947 patients were treated during the year 2014.
Total seen: 4
Figure 31: Total patients
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KFHU Annual Report 1435 - 2014
Day Care Unit
Special Service
| Physiotherapy Unit
The Department of Physiotherapy provides care to out-patients as well as in-patients from various specialties. It also receives referrals from other hospitals. A separated physiotherapy services are given to the male and female patients on a daily basis. Senior staffs were assigned to these areas for close supervision. Pediatrics physiotherapy program was continued during the year. The department participated in a number of educational and research activities, lectures to nursing and physiotherapy student’s activities. A total of 69,641 patients were treated during the year 2014
Total seen
, 41
Figure 32: Total patients Physiotherapy services
95
Special Service
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KFHU Annual Report 1435 - 2014
Special Service
| Radiology
The Radiology, which was established in 1981 provides diagnostic services for inpatients, outpatients, ER & hospital related center patients. It also provides services for patients referred from other hospitals and health centers in the Eastern Region. The department carries out academic and educational activities to students of college of themedicine and interns. The department also participates in education and teaching of the a g t f fift a a g t nt f t n t f a a t departments provides training for interns of King Saud University, the students of Health College in Dammam and the residents. Moreover, the department participates in public lectures and conferences. Also the department involve the hospital activities associated with the another departments, and produce different kinds of x-ray (normal x-ray, CT scan – ultrasound – MRI and all kinds of diagnostic x-rays) following the Quality Management and secure safety in all department tests. A total of 85,914 procedures were performed during the year 2014. Total procedures 8 , 14
Figure 33: Total procedures Radiology
97
Special Service
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KFHU Annual Report 1435 - 2014
Special Service
| Interventional Radiology & Vascular Catheter Unit The unit was established in 2010. It conducts various diagnostic and treatment processes using the latest techniques of therapy and diagnosis. The unit carried out the following: • • • • •
Vascular dilution at nt f n fi Treatment of some cases of hepatic tumor Treatment of maternal bleeding using catheter Some cases of varicose catheterization
The unit is linked to a clinic served by a consultant specialized in these kinds of treatment. The number of patients treated at the unit this year reached at 678.
99
Special Service
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KFHU Annual Report 1435 - 2014
Special Service
|窶グPD
The Out-patient Department conducts referred clinics 5 days a week. All clinics are supervised by consultants and specialists. There are 287 specialty / subspecialty / referral clinic sessions conducted per week. A total of 186,714 patients were seen during the reporting year. Appointment scheduling and registration for various clinics were computerized. SMS messages were used to notify patients of their medical appointments. OPD witnessed big expansion this year, especially ophthalmology, ENT, speech, Dermatology, Urology and some of the Internal Medicine Departments.
Total OPD seen 1,8 , 14
Figure 34: Total number of OPD patients
101
Special Service
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KFHU Annual Report 1435 - 2014
Special Service
|窶ウmergency Room (ER)
This department provides services 24 hours basis / 7 days a weekfor the management of urgent and emergency cases. It also provides educational and training opportunities for the students of medicine, nursing, and emergency medicine technicians. a tn a a nt n t f a t an ant t g a fi medical care is employed and advanced equipment is used in the department which is built with tan a fi at n
笳｢ Manpower
taff t g a fi an t an a t a t a f 5 consultants holding fellowships in subspecialties of ER from US and Canada. ER specialists ng a t fi at at f a nt a t nt Sa physicians graduated from the Saudi Board of ER have been employed in the department this a Sa an f a n a t a fi nt t f n n US and Canada.
笳｢ Units of ER
Er consists of the following sections:
1.
Reception
2.
Triage Area
3.
Initial e amination
4.
Critical Care Unit
5.
Observation Unit
It receives and electronically registers patients in critical conditions. All registration procedures are completed in the presence of the patient family at nt a nta n nt a a t a a an a fi a ng t t seriousness of their cases using the internationally recognized Canadian standard. Patients who are mildly sick are received in this area for initial checking. The area is divided into two sub-sections: one for males and the other for females. Each of these sub-sections consists of a room for checking vital signs of the patient before being seen by the ER physician. It consists of medical instruments and machines necessary for crash care and treatment of patients and injured who are in critical or very serious conditions. This unit covers two separate areas : one for males and the other for females. The area allocated for males consists of 13 beds, while the area allocated for females consists of 8 beds. Patients with medium medical or surgical conditions are treated in these two areas.
103
Special Service
6.
Pediatric Care Unit
7.
Minor operations room
8.
Gypsum room
9.
Psychiatric cases room
10.
Isolation room
11.
Ophthalmology & ENT emergency cases clinic
12.
It is an eight-bed unit in which care is provided for pediatrics with medium to critical conditions. Simple surgical procedures are conducted in this room. Visitors with bone-fracture received bone-bondage or gypsum in this unit This room is used for receiving emergency or unstable psychiatric cases. Patients with infectious diseases are referred to this room to ensure the safety of the patients
ound dressing room
In this room, wounds are dressed and wound bondage are changed
Total Pt. Seen 1,8 ,
0
Figure 3 : Total Emergency Patients A total of 186,690 received medical care in the Emergency Room during the year 2014
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Special Service
105
Special Service
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KFHU Annual Report 1435 - 2014
Special Service
107
4. Specialized Clinics
Employees Health Service Primary Healthcare Clinic Royal Clinic UOD Clinic
Specialized Clinics
|窶ウmployees Health Service
EHS
This clinic provides comprehensive healthcare to employees of the hospital and undertakes medical examination procedures for students of UD. It also carries out medical examination for new employees and students. Hepatitis and meningitis vaccinations were given. A total of 10,164 EHS patients were seen during this year.
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Specialized Clinics
Total Pt. seen 10,1 4
Figure 3 : Total patients EHS
111
Specialized Clinics
|窶ケrimary Healthcare Clinic
The Primary Care Clinic is developed by the department of FAMCO in collaboration with KFHU and MOH for providing training to Saudi medical graduates and undergraduates in Primary Health Care and Community Health Nursing. The clinic has three major units, MCH, Adult Family Medicine and Health Promotion Unit providing curative, preventive and promote services. A total of 17,161 patients were seen this year. Average was 48 patients a day. Administration of a a n a a n at t an n n a t n nt n t year.
Total Pt. seen 1 ,1 1
Figure 3 : Total Patients Primary Healthcare Clinic
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KFHU Annual Report 1435 - 2014
Specialized Clinics
|窶コoyal Clinic
This clinic treats employees working in the palace of Royal Prince of the Eastern Region. It is staffed by one doctor and one nurse. Patients who need more medical investigations are referred to the OPD of the hospital. A total of 2,076 patients were seen at Royal clinic in 2014, an average was 6 patients daily.
Total Pt. seen 2,0
Figure 38: Total patients
Royal Clinic
113
Specialized Clinics
|The UOD Health Clinic in Dammam
The clinic provides basic health emergency medical care to students and staff of UD-Main Campus and their families. Some cases are referred by the clinic to KFHU for further medical investigations. A total of 3,994 patients were treated during the year 2014.
Total Pt. seen 3,
Figure 3 : Total patients
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UOD Health Clinic
4
5. Auxiliary Departments
Nursing
Laboratory Medicine & Blood Bank Pharmacy
Electronic Health service and information systems • Health information department • Information technology
Patient Rights & Relations
Central sterilization and supply Social medical service section Dietary
Infection control
Section.5 | Auxiliary Departments
| Nursing The Department of Nursing Services is the largest department of KFHU boasting nearly seven hundred (700) nurses in various capacities. Nursing Services are available round the clock, 24 hours a day, 7 days per week. The Department of Nursing Services strives to provide its utmost n n a at nt a fin t at ng S n t at n ft hospital, as Nursing is a vital, integral and equal member of the healthcare team. The nursing community is a multi-national work force who comes to KFHU for the mutual purpose of delivering optimum nursing services to our patients.
◢ Director of Nursing Services The department of nursing services is under leadership of the Director of Nursing Services, who plans, oversees, supervises, evaluates and personally approves all departmental activities which are patient-focused to the core. This encompasses the following steps to the ultimate goal of providing high-quality holistic patient care services and achieving patient satisfaction: •
Early ‘drawing board’ stages of planning and designing innovative tools for the improvement of patient care and hospital-related services
•
Establishment of solid, evidence-based, policies and standards of nursing practice
•
Assurance of strong leadership and management of nursing personnel
•
Selection, recruitment and evaluation of high-quality, choice nursing personnel
•
Intensive training and education of nursing personnel on updated skills and techniques in holistic patient care
•
Supporting continuous education and research at all levels in the interest of producing outstanding healthcare professionals dedicated to patient care services, who will uphold the KFHU commitment to excellence
•
Ensuring provision of high quality clinical nursing services and patient care services on patient care areas
•
Continuous assessment, evaluation and re-evaluation of all plans, innovative designs, patient and personnel management, delivery of patient care services and patient care outcomes.
All matters and executive decisions pertaining to any and all aspects of the Department of Nursing Services, which includes Patient Care Services and Nursing Personnel, are ultimately the responsibility of the Director of Nursing Services. By default, the Director of Nursing Services is the supreme representative of the Department of Nursing Services on any committee or in any activity or function.
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Section.5 | Auxiliary Departments
â—˘ CENTRAL NURSING OFFICE nt a ng ffi t t t at f ng S divisions and sub-divisions:
ft
nt a
at
nt f ng ffi
ng S
an nt t
anat f f ng
1. The Division of (Clinical) Patient Care Services, which is comprised of: a. In-Patient Care Services (Sub-Division) b. Ambulatory Care and Psychiatric Services (Sub-Division) Each sub-division operates under the direct supervision of a respective Assistant Director of Nursing Services who functions under the direction and direct supervision of the Director of Nursing Services. 2.
The Division of Planning and Development, which is comprised of: a ng a t anag nt ffi S n ng at n a n ng an Staff nt ffi S
n
Purpose of the Central Nursing Office Provides the utmost quality of safe and effective patient-care services through the following: 1. Shortening the current chain of command in order to facilitate more direct supervision by the director of all operations of the department, and to eliminate room for possible error and misinformation 2. Provision of divisions which encompass a systematic approach to all aspects of patientcare which lead to the ultimate goal of holistic safe and effective patient-care services in the areas of continuous assessment, planning and innovation, establishment, education, implementation and evaluation of outcomes. 3.
ff t an t (nurse to patient ratios)
anag
nt f
an
t
n
af
taffing att n
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Section.5 | Auxiliary Departments
DIVISION OF (CLINICAL) PATIENT CARE SERVICES The Director of Nursing Services is directly responsible for the activities of the two Assistant Directors of Nursing Services who represent the Division of Patient Care Services, which is subdivided as follows: 1. In-Patient Care Services 2. Ambulatory Care and Psychiatric Services The Assistant Directors of Nursing Services perform the following functions to ensure the overall safe and effective delivery of patient-care services on clinical nursing units: 1. Direct supervision of the Unit Clinical Nursing Supervisor and Team in all matters concerning the clinical patient-care nursing unit – predominantly, in the areas of patient-care, nursing nn an taffing 2. 3. 4.
n
a
taffing
nt
f
n a n
ng n t
nt taffing an a at n an approval of the Associate Director of Nursing Services. an n t a na tt n to the Directorate of Nursing Services.
t
fn
t
ng
n t an fina nn
t fina
n
5. Conduct daily clinical rounds on respective patient-care areas to ensure and enforce compliance to established policies and procedures in all activities.
6. Provide an intermediary link between the Unit Nursing Team and the Directorate of Nursing Services. The Clinical Nursing Coordinator is accountable to and works under the direction and direct supervision of the respective Assistant Director of Nursing Services, and provides support and guidance to the Unit Clinical Nursing Supervisors, upon the orders of the respective Assistant Director of Nursing Services or the Directorate of Nursing Services.
The Clinical Nursing Coordinator shall accomplish tasks and provide guidance to nursing personnel as ordered by the Directorate of Nursing Services, or the instructions of the respective Assistant Director of Nursing Services. Off Shift House Supervision t f ffi a n ff S ft t nt a ng ffi nt Off Shift House Nursing Supervisors who report directly and continuously to the Directorate of Nursing Services and perform the following functions: 1. Immediate trouble-shooting of current problems which arise during assigned shift hours 2. Sat fa t n f
120
at
taffing
KFHU Annual Report 1435 - 2014
nt
ng a
gn
ft
Section.5 | Auxiliary Departments
3. Reporting of sick leaves and absences to the Nursing Administrator on-call
4. Conduct clinical patient rounds of the ‘house’ during assigned shift hours to facilitate coordination of patient care and enforce and ensure safe and effective delivery of patient care services as per established nursing policies and procedures in keeping with the philosophy, goals and objectives of the Department of Nursing Services during off-shift hour.
CLINICAL PATIENT CARE NURSING UNITS Each Assistant Director of Nursing Services is responsible for the following respective patient-care areas: IN PATIENT CARE SERVICES
AMBULATORY CARE AND PSYCHIATRY SERVICES
Cardiac Catheterisation Laboratory
Out-Patient Department
Coronary Care Unit
Medical / Surgical Intensive Care Unit Paediatric Intensive Care Unit Burns Unit
Emergency Department Haemodialysis Unit
Peritoneal Dialysis Unit
Operating Room and Recovery Room
Labour and Delivery Room
Day Surgery and Endoscopy
Well-Born Nursery
Short Stay Unit
Neonatal Intensive Care Unit
Obstetrics and Gynaecology (2C, 2D)
Surgical Units – Adults (1C, 1D, 3C, 3D, 3E, 4D, 4E) Medical Units – Adults (3A, 3B, 4C) Paediatric Surgical Unit (4A)
Lithotripsy
Satellite Clinics (FAMCO, KFU, Royal)
Central Supplies and Sterilisation Department (CSSD) Psychiatric Units (5A, 5B)
Paediatric Medical Unit (4B)
◢ UNIT NURSING TEAM Each clinical patient-care nursing unit shall be run by a Unit Nursing Team, which is comprised of the following team members: 1. Unit Clinical Nursing Supervisor – Team Leader
2. Senior Charge Nurse (formerly known as ‘Head Nurse’) – Desk and Clinical Leadership support ng ffi a n 3. Charge Nurse – Desk and Clinical Leadership support during off-shift hours 4. Staff Nurses (Levels I, II and III) 5. 6.
n
an
tant S
S
fi
fi
nt
nt
7. Paramedics (Emergency Department and Division of Ambulance Services) 121
Section.5 | Auxiliary Departments
â—˘ DIVISION OF PLANNING AND DEVELOPMENT The Division of Planning and Development is the backbone of the operations and functions of the Department of Nursing Services. Under the expert and supreme leadership, guidance, direction and direct supervision of the Directorate of Nursing Services the Division of Planning and Development facilitates the ultimate goal of providing high-quality holistic patient care services through its two complementary subdivisions, which are: 1. 2.
ng
a t
ng
anag
at n
nt
ffi
a n ng an Staff
S
n
nt
ffi
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n
Nursing Quality Management Office ffi
n
f
t
f
ng f n t n
1. Continuous assessment and analysis of current KFHU practices, policies and procedures 2.
nt fi at n f t at a t including the analysis of incident reports
f
a t
at nt a
an
taff
f
an
3. Innovation, recommendation, planning, developing, designing, coordinating , directing, modifying, establishing implementing and evaluating programmes of quality improvement/ assessment/management applicable to and unique to KFHU 4. Continuous research, analysis and update of policies, procedures and job descriptions 5. Composition, preparation, review and revision of all written directives in the form of policies, procedures and job descriptions, as well as, all written material pertaining to quality initiatives and programmes, in accordance with Islamic Code of Conduct and approved customs of the Kingdom of Saudi Arabia 6.
anag
nt f
t
n
nf
at n
t
t nt
nt a
ng
ffi
Nursing Education, Training and Staff Development Office ng t a n ng an
taff
nt
ffi
n
f
t
f
ng f n t n
1. Coordination of all educational activities directed towards nursing personnel and based on
t an t ffi 2. Planning and coordination of continuous educational programmes for the theoretical and practical training and development of nursing personnel. 3. Orientation of newly employed nursing personnel on the expectations of KFHU and the Department of Nursing Services. 4. Collaboration with the College of Nursing on the orientation of nursing students and interns to nursing and hospital policies and procedures. 122
KFHU Annual Report 1435 - 2014
Section.5 | Auxiliary Departments
| Diagnostic Laboratories & Blood Ban This department is composed of eleven different sections. It provides diagnostic services 24 hours a day. The department also participates in the training of both under-graduate and postgraduate students with relevant medical specializations. It also supports the relevant approved research projects. n a a at a a t a n ng t nt f a nt n n t fi f histopathology and pathology. In addition to that, the department takes part in testing water samples for KFHU, evaluating the effectiveness of antibiotics, and boosting infection control endeavors. The total number of investigations done the year under report was 2,521,320. Average was 6,908 per day. Total diagnostics : 2, 21,320
Figure 40: Total number of Laboratory Diagnostics
123
Section.5 | Auxiliary Departments
◢ Blood Ban The Blood Bank Department, located at the Administration Building, was established in 2006; an t a ffi a na g at n t a f n nt an t Dean of College of Medicine on The World Blood Donor on 2007, with the highest international standards. The Administration of both the hospital and the Blood Bank are fully aware of this department requirement. So they have established the Blood Bank on the right place, created the conducive atmosphere of work. All needs are provided to facilitate the donation process, and to attract many voluntary blood donors. The Blood Bank building has an independent external entrance located on the street in the southwest point of the main building of the hospital making it easier for donors and patients to get in and out without having to mingle with other entrances of the hospital departments. The interior design of this building allows easy and smooth movements of donors and employees. Taking into account the peculiarity of the Saudi society, the Blood Bank has allocated special t nf a n an an t f f a a t f t fi t priority for the Blood Bank. So, this department is equipped with the latest devices and equipment to guarantee safe blood donation. Before the blood transfusion process, a donor blood specimen is tested through the technique of DNA testing to make sure it is free of viruses that cause infectious diseases such as hepatitis and AIDS. Needless to say that blood cannot be made. Thus the best ways to be obtained are: 1.
nta
n
2. The patient’s relatives, 3. Applicants for a job or a driver’s license 4. Blood donation campaigns organized throughout the year
Steps of the blood donation process The Blood Bank conducts clinical examination and some other preliminary tests such as blood screening for blood group and the hemoglobin percentage at the beginning of any blood donation process. Then possible donor will be given a form to answer some question relevant to
a a t t a fit t a n at t t n a in the extraction of approximately 500mls of blood from the door. The extracted blood is pumped nt a t ag nt ta t n fin t an taff t n a a f t n t a t ng t nat n Blood banks of the eastern Region collaborate with each other to cover any a shortage of blood groups, specially the rare ones.
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KFHU Annual Report 1435 - 2014
Section.5 | Auxiliary Departments
The Blood Bank of King Fahd Hospital of the University plays role during Hajj season. It is well known that the kingdom of Saudi Arabia receives millions of pilgrims every year during the pilgrimage season; so it is the duty of the Blood Bank to supply hospitals of the Western Region with blood to cover the seasonal, urgent and growing need for blood transfusion. The Blood Bank participates in local and international conferences, to cope with developments in services of blood transfusion medicine. This department provides best pharmaceutical care services for inpatients Outpatient ambulatory, Works in Section pharmacists and technicians have the expertise and distinctive skills in the preparation and disbursement of pharmaceutical compounds with using the exchange pharmacological unit which provides treatment to the patient within 24 hours, The department encourages education and training activities in the fi f a a t a a t a f at a n a t n n t fi f n a an at nt a n at nt an t at nt an t required information on medicines.
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Section.5 | Auxiliary Departments
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KFHU Annual Report 1435 - 2014
Section.5 | Auxiliary Departments
| Pharmacy
Services Pharmacy Care consists of two parts: 1. Assessment, selection and purchase, storage and control the dispensing of medicines, Chemical substances, Pharmaceuticals, Prepare recipes, processing the quantities required for the patients. 2. Submission of Clinical Pharmacy Services, This section was founded in 2009 clinical pharmacist an n an n n t f fi n a a a t at an n n a pharmacy from outside the UK and inside, Care providers pharmaceutical clinical for Sections intensive care, Hearty, Internal Medicine,Children and General Surgery. Clinical pharmacist working in the wards where patients involved in too much of crowd on patients such as a member of the medical team and following functions: • • • • • •
Access to the patient’s history therapeutic and pharmacological. Selection and recommendation means therapeutic appropriate. Answer to inquiries doctors and other from health workers. Teach patients and respond to consulting.
Provide guidance and recommendations pharmaceutical relating to drug.
Assess patients in need Parenteral Nutrition, according to Consulting Medical.
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Section.5 | Auxiliary Departments
In this year achievement for pharmaceutical care services were as follows: • • • • •
128
Activating the Drug Information Program and toxins electronically recorded and regulations medicine
Special equipment for the application of the electronic exchange Pharmaceuticals Program ( Omni- Cell for Pharmacy Automation)
In the wings of the hospital to facilitate the exchange and storage of medicines in accordance with the process of global safety regulations for the hospital. a n t fi t ann a a before medication safety.
a gn f
t
Opening of Operations Pharmacy
KFHU Annual Report 1435 - 2014
af t
ft
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t
gan f
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Section.5 | Auxiliary Departments
Total diagnostics : 2, 21,320
Figure 41: Total number of Pharmacy wal ins.
| Electronic Health Services and Information System This Directorate works as a link between patients and service providers to achieve the highest f n fi a at fa t n a t at n f a t an a t n t at n a nt at n an gg t n f t at nt an t fa t fin and implement the appropriate solutions.
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Mission S at nt t g n f a t a t at at fi t n a a an ta an touch to the medical services provided, create an appropriate university education environment t n t t a ng ta t a n t at a an t nt fi a
Goal Provide high quality service within the framework of Health Services Public Commission’s policy and procedures.
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Section.5 | Auxiliary Departments
| Electronic Health Services and Information System The Department work as a link between patients and service providers to achieve the highest f n fi a at fa t n a t at n f a t an a t n a t nt n a nt at n an gg t n f t at nt an t fa t fin the appropriate solutions.
Mission S at nt t g n f a t a t at at fi t n a a an ta an touch to the medical services provided, create an appropriate university education environment t n t t a ng ta t a n a t a ann t nt fi a
Goal g a t and procedures.
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The functions of theDepartment are as follows
• • • • • • • • • •
Fix and maintain computers Align the new medical equipment with the medical electronic system Receive treatment applications from outside KFHU Know and implement KFHU’s policy and procedure relevant to inpatients and outpatients. Co-ordinate patients obtaining of rights entitled to them. Co-ordinate referral of patients to health establishments out of KFHU. Co-ordinate patients’ referral to the top administration or other medical authorities within KFHU. Co-ordinate patients’ medical or administrative investigations. Refer patients to either internal or external services. Register patients of the Emergency Room
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KFHU Annual Report 1435 - 2014
• • • • • • •
•
Co-ordinate patients’ arrival to the medical examination clinics, inpatient wards or any other internal facility. Register appointments of inpatient and outpatient clinics. Request and follow up issuance of patients’ medical reports and reports of their co-patients as well. Co-ordinate and follow up patients’ complaints. Train the health care on the electronic system of KFHU. Maintain server rooms and make sure that all servers are functioning well 24-hours a day. Initiate new ideas and consultancy regarding health computerization prior to be discussed with the relevant departments. Develop screens that match the requirements of each department.
t
Section.5 | Auxiliary Departments
This department is composed of two sections: Health Information Department and Computer Department. Health Information Department consists of two sub-departments: •
Medical Records and
•
Patient Affairs
As for the medical records, it consists of three main sections: 1. Management and Arrangement Unit 2. Analysis and Abstracts Unit 3. Disease & Treatment Procedure Coding Unit 4. Filing Section: It consists of three units: •
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Record Preservation Unit.
Table: Medical Records Dept. Activities & Tas s during the year 2014 Particular Medical records withdrawn from various a t nt fi ng Medical records analyzed, abstracted, and coded Medical reports typed Discharge summaries typed Operative reports typed
No. of Records 111,848 23,967 1,200 1,600 700
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Section.5 | Auxiliary Departments
|窶ケatient Affairs Department Information Section It consists of several sections: It receives the patients, responds to the public questions and shows the visitors the various wards and departments of KFHU.
Birth Section t
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Death Section t at n t fi at n ta f n n an t n hand over such bodies to their families after making sure that all required regular actions were done.
Medical Report Section This section issues medical reports with both Arabic and English languages after the completion of the regular procedures of KFHU. It also issues sick leaves according to the system of the hospital.
Admission Office ffi a t t f at nt t t of admission are computerized.
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Eligibility Office ffi a at nt f f t t ta an a nt t n whether they are eligible to be treated in KFHU. The patient documents are sent to the clinical departments of the hospital so as to be considered prior being referred to the relevant outpatient clinic.
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KFHU Annual Report 1435 - 2014
Section.5 | Auxiliary Departments
Table ( ) Patient Affairs Dept. Activities & Tas s Table During the Year 2014 Activties & Tasks
No.
Medical Reports.
7182
Police Reports.
1711
Death Reports.
462
Delivery Reports.
1257
Admission cases
10560
Treatment Eligibility
7350
Total
28522
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Section.5 | Auxiliary Departments
|窶イomputer Department The Computer Department exerted utmost efforts in 2014 to speed up and guarantee the provision of high quality healthcare to the patients in a very short time. It uses advanced computer system that technically support all medical, research and administrative procedures. A number of software has been developed to push forward all endeavors aimed at realizing the vision of KFHU. An integrated system has been used for following up the patient care since1997. The department provides training opportunities on computer for the hospital employees as well as UOD students and others. The most important projects and achievements were as follows: 1. Construct a new server room within KFHU. 2. Use mobile SMS to remind patients with their appointments. 3. Supply and install a number of advanced servers to match the version developed from the medical program. 4. Obtain the new version of medical program. 5. Supply and install a number of new computer programs. 6. Supply and install a number of printers. 7.
A new server room will be constructed in the new endoscopy building.
8. Implement the medical dictation program and provide the necessary training for its system users. 9. Technical support solution program. 10. Add space for data storage. 11. Wireless network installation program.
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KFHU Annual Report 1435 - 2014
Section.5 | Auxiliary Departments
| Patient Rights and Relations Department It was established in 2012 and it is considered the link between the patient and the various departments of KFHU. The department, which falls under the direct supervision of the Medical Services Director, removes almost all obstacles that encounter patients in the hospital. Patient Rights Department consists of three sections: A. Patient Complaint Section: Receiving daily more than 70 complaints / suggestions the year under the report. These complaints and suggestions were forwarded to the KFHU administration to be solved. B. Medical Co ordination Section: The activities of this section are as follows: •
To refer certain cases to the appropriate specialized hospital in Saudi Arabia
•
To coordinate the waiting list with other hospitals in Riyadh or any other city
•
To receive and send medical reports of inpatients
C. The Administrator on Call Section: The main tas s of this section are: •
To solve problems that might occur between the patient and the medical cadre.
•
To encourage the patient to accept and use the prescribed medicine or treatment as per the rules and regulations of KFHU.
•
To document the criminal medical cases and to co-ordinate with the pertinent government bodies concerning the appropriate actions.
•
To facilitate the procedures of the inpatients interested to leave the hospital as per the acceptance or advice of the concerned physician.
•
To report the problems unsolved to the higher administration of KFHU.
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Section.5 | Auxiliary Departments
Table: Demonstrating activities carried out by Patient Relations& Rights Department. Statement
Fre uency
Patients referred to King Fahd Specialist Hospital, Dammam.
152
Patients referred to hospitals of health affairs in the Eastern Region Patients referred to Saud Albabteen Hospital,Dammam.
Patients referred to King Fahd Medical Complex, Dhahran.
Patients referred to King Faisal Specialist Hospital, Riyadh( Evacuation)
Patients referred to King Faisal Specialist Hospital, Riyadh (Ambulance) Patients referred to hospitals outside of the Eastern Region. Patients referred to King Faisal Specialist Hospital, Riyadh.
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KFHU Annual Report 1435 - 2014
307 212 157 73 81 45
1 0
Section.5 | Auxiliary Departments
| Central Sterilization & Supply Department Central Sterile Supply Department (CSSD) centralizes the sterile processing activities, in which reusable medical devices, surgical instruments, and equipment are processed. The Department’s goal is to decontaminate all instruments and equipment received in CSSD and to re-process, cleaned, prepared processed, sterilized, stored, and distribution of sterile supplies for use in clinical areas within the hospital.e.g. O.R, O.P.D, E.R., D.R, Burn Unit, Day Surgery wards etc. A total of 1,199,148 received items were sterilized this year. Total diagnostics : 1,1 ,148
Figure 42: CSSD cases
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Section.5 | Auxiliary Departments
Socio medical Services Department This department is one of the ancillary departments of KFHU. It plays a vital role in responding to the psycho-social needs of some patients. The main function of the social worker is to remove the psychological and social hurdles that hamper the patient’ treatment. This is to be done through several channels such as the social center and the charity and voluntary societies. The department dealt with 21,371 cases in this year. Here under are the details of actions taken concerning such cases. The Socio-medical Department is mainly concerned with the following functions: •
Entertainment programs: The department prepares and organizes entertainment programs f n at nt ng t ffi a f t a
•
Awareness campaigns: It prepares awareness and educational campaigns during the time of organizing medical exhibitions at KFHU. The department is introduced to the public in one of the exhibition centers.
•
UOD student training: The Social Service section of this department supervises a one semester training program for the University students. The students are provided with all necessary information about medical sociology.
•
Workshops: The department organizes workshops in which a number of social workers take part (Profession stakeholders). The workshops are organized within the continuous education program.
•
Impatient visits: It organizes visits conducted by school students and voluntary organizations to inpatients.
•
Children Library: The department supervises the Kid Library that provides the appropriate information and entertainment for the inpatient pediatrics of KFHU.
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KFHU Annual Report 1435 - 2014
Section.5 | Auxiliary Departments
Sl.NO
The social sevice provides
Frequency
1
Follow up of inpatients
802
2
Follow up of patients with long period of stay
123
3
Follow up of cases of violence and injury
13
4
Coordination with patients referred to other specialized hospitals
504
6
Follow up ER Patients
194
7
Referring certain cases to the social centers and charity organization
83
8
Follow up of completion of data relevant of some patients
75
9
Meeting inpatients during the daily round
5571
10
Completion of procedures of some cases referred to the General Medical Corporation in Dammam
33
11
Referring blood donors to the regional blood bank in Dammam
10
12
f a health affairs, the court)
161
13
Coordination with the medical evacuation team in case the patient is admitted
2
14
Follow up of cases of illegitimate babies
12
15
Talking with the families on how to respond to the needs of their patients
5325
16
Issuance of co-patient license
2023
17
f ffi a tt nt f departments or other institutions
18
Administrative works and typewriting
5
19
Follow up outpatients
n fi a Total
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nt
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at
at
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174
279 4224
a
1763 21371
139
Section.5 | Auxiliary Departments
The department activities: The Social Medical Department has many activities, the most important of which: •
(Eids).
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•
To arrange visits by school students, social clubs and voluntary organizations to the inpatients with the aim of boosting their morals.
•
To co-organize medical exhibitions and academic symposia with the medical departments of KFHU.
•
To supervise the training of student social workers on how to deal with the patients professionally.( they were120 students this year)
•
To supervise the training of student social workers of Distance Education and provide them with the information relevant to social work.(They were 120 students this year).
•
To supervise and secure the needs of Children Library Section in cooperation with the voluntary societies.
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KFHU Annual Report 1435 - 2014
Section.5 | Auxiliary Departments
| Dietary This department consists of two sections: Clinical Dietary and Normal Dietary. The Clinical Dietary gives medical advices to the patients on how to feed themselves and the appropriate foods for them. The Normal Dietary Section deals with the food supplied to KFHU’s restaurant and cafeteria. In general the department carries the following activities: •
Provision of dietary services to the nurses and administrators on call.
•
Provision of dietary services to the inpatients.
•
Giving dietary advices
•
Development of food contracts and compiling statistical reports concerning the patient’s dietary services
•
Training of students of College of Applied Medical Sciences (King Saud University)
•
Training of students of College of Agriculture and Food (King Faisal University)
•
Training of students of College of Health Science
•
Taking part in the health educational activities of KFHU departments.
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Section.5 | Auxiliary Departments
Particular
Num
Patients of dietary clinics
88
Dietary Theraeutic Advice
Obesity patients
62
Carbohydrates Clinic
55
Patients Meals
3 3
Nurses Meals
20 241
Symposia, wor shops and health e hibitions
3
Students trained in the department Academic lectures delivered Table ( ) Dietary Dept. Activities & Tas s During the Year 2014
142
4
KFHU Annual Report 1435 - 2014
2 12
Section.5 | Auxiliary Departments
| Infection Control Department This department provides quality patient care through surveillance, control and prevention of infectious diseases and nosocomial infections. Communicable and epidemic diseases discovered in KFHU are reported to the Ministry of Health (M.O.H). S gn fi ant att nt n
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Regular lectures, workshops and awareness campaigns on infection control are given to the hospital staff. The department closely follows up the services provided by the various departments with the aim of taking joint efforts to prevent the spread of any epidemic disease in KFHU
The main functions of Infection Control Team are as follows: • • • • • •
• •
•
Devise an annual plan for implementation of infection control program within the health establishment. Provide the necessary consultancy for the team in whatever relevant to infection control works, and create safe environment for both patients and the work team. Develop policies, procedures and bylaws of the Health establishment.
Follow up and improve the daily activities relevant to infection prevention (especially infection that might occur while providing healthcare).
Establish a monitoring system for infection acquired within the health establishment. nt f an fin t n f n nt ng nf t n nt when no solution is found, the problem will be submitted to the Infection Control Committee of KFHU.
Develop an annual training and educational plan for the staff. The plan covers all aspects of infection control. Ensure availability of the requirements and equipment of infection control. In case of any shortage in such requirements and equipment, the Infection Control Committee of KFHU is to be informed. Co-investigate with the appointed medical team the spread of epidemic diseases in the health establishment. Then inform the Infection Control Committee about the outcome of such investigation.
Table ( ) Infection Control Section Activities & Tas s During the Year 2014 Activities & Tasks n t fi at n
f
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a
t
Participations in Educational Activities inside the hospital
.Participations in Educational Activities outside the hospital
.No
771 6 1
143
Section.5 | Auxiliary Departments
144
KFHU Annual Report 1435 - 2014
Section.5 | Auxiliary Departments
145
Section.5 | Auxiliary Departments
146
KFHU Annual Report 1435 - 2014
6. Supportive Services Department
Maintenance and Operating Section
Cleaning, Laundry and Medical Waste Security
Biomedical Engineering Central Section
Landscaping Section
Safety facilities and Occupational
Supportive Services Department
| Maintenance and Operating Section
This department provides operational, maintenance, preventive maintenance and repair services to all hospital building and housing compounds. This includes mechanical and electrical works of engineering,ß air-conditioning and phone communications done in the hospital. a t nt taff t ffi nt ng n t t n an implementation of KFHU projects so as to make sure that they are done according to the required standards and as per the terms and conditions of the signed contracts. na t n t t at t a t nt new construction projects from A to Z.
nat
| Cleaning, Laundry and Medical
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◢ House eeping Section: It supervises the conclusion of contracts relevant to the cleaning ◢
◢
150
of KFHU and the housing compounds. Laundry Section: This department provides laundry, tailoring and repair services to the hospital uniforms of medical, nursing and technical staff. It also cleans and irons uniforms of the operation room as well as the special hospital linens and blankets provided to the inpatients. Medical Disposals Section: t g tt ng f a a an t materials in KFHU through conclusion of contracts with specialized and liscenced companies. The contracting process is co-ordinated with other relevant government ministries.
KFHU Annual Report 1435 - 2014
Supportive Services Department
151
Supportive Services Department
| Security Department
It supervises the security services provided by a national security company to KFHU and the affi at ng t t an n t ta a gn t t a t nt a
◢ To issue identity cards to the employees of KFHU and the contracting companies. ◢ To issue entry permits for vehicles of the hospital staff. ◢ To issue permits for vehicles entering the Housing Compound. ◢ To Supervise and follow up works of the company providing security service for KFHU. ◢ To solve the security problems that might encounter the patients or the hospital staff. ◢ To compile a monthly report (abstract) on the performance of Al Yousuf Security Service Corporation.
◢
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◢ To make the necessary security arrangements when meetings were held. ◢ To issue co-patient cards. ◢ To conduct surveillance through security cameras. ◢ To make visitors leave the premises of KFHU after the end of the visiting hours. ◢
a ang t t affi
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| Bio Medical Engineering Department
t affi
at n t t
at
f
f ng ta a a gn t t a t nt ◢ To maintain all medical instruments of KFHU (3000 medical instruments) or do the same through the instrument importing company. ◢ a tan a an fi at n f t n nt nt an a n ◢ t n nt nt an a t at t f fi t fi at n ◢ To purchase spare parts continuously needed by the medical instruments. ◢ To train staff of the concerned departments on the right way of using medical instruments. ◢ To monitor the technical service provided by agents or distributors of medical instruments. ◢ To do technical evaluation for new appliances included in the purchase orders of KFHU›s departments. ◢ To provide technical support for other hospitals after obtaining approval of KFHU. t an ng ng t 1. Completion of the construction works of Endoscope building. 2. Sta t ng t f nt f n ng a f
◢
152
Equip and furniture the Endoscope Department.
KFHU Annual Report 1435 - 2014
Supportive Services Department
153
Supportive Services Department
◢
Equip and furniture the Intensive Care Unit.
◢
Project of Pediatrics and Adults Intensive Care.
3. Project of supplying and installing MRI equipment for Radiology Department. 4. Project of supplying and installing equipment of Heart Cather Unit. 5. Project of establishing rooms for wastes, sentinel, and the backup generator of the Endoscope building. 6. Project of constructing three buildings at the Housing Compound No (1). 7. Development of sidewalks of Housing Compound No (1). 8. Substitution of desalination station and water tanks of Housing Compound No (1). 9. Enhance the electricity grid of Housing Compound No (1). 10. Preparation of Standards for development of cooling towers and networks, a project to be 11. 12. 13. 14.
tt f ng n t a Development of public facilities for housing compounds 1 &2. Submit the Central Sterilization Department›s project for bidding. Substitute one central cooler with a power of 400 tons. Development of the central cafeteria’s withdrawing system.
15. Sta t an n ta at n f a t at t ng ft nt a af t a 16. Follow up the operation works, the routine and corrective maintenance, and provide technical support for the various departments of KFHU.
| Landscaping Section
It implements, maintains and supervises the irrigation networks. It also carries the ornamentation trimming of trees and grass in the hospital’s premises. t nf t ant a na t at ant a an an a g a of KFHU.
| Telephone E change Department
a a
1. nt na an t na t n nta t t n t f t t t n fi a 2. To make calls through microphones. 3. To receive the calls of the Ministry of Health and other relevant medical centers then refer them to the Administrator on Call. 4. To contact the concerned physician or employee through the payer system to respond to the urgent cases. 5.
154
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KFHU Annual Report 1435 - 2014
Supportive Services Department
155
Supportive Services Department
156
KFHU Annual Report 1435 - 2014
Supportive Services Department
157
Supportive Services Department
158
KFHU Annual Report 1435 - 2014
Supportive Services Department
159
7. Administrative Departments
Transportation
Administrative Communication Arabic transcription
Monitoring & Follow-up Human Resource Finance
Purchasing
Warehouse
Medical Supplies and Medical Equipment Housing
Administrative Departments
|窶サransportation Dept.
It carries out all transportation activities including the transportation of KFHU employees. The a t nt a t f f a t n ng 8 a an a gn f the ER department. It is responsible for the transportation of female hospital staff on duty from the Housing n t t ta an t affi at n ta t an tat n f the single female staff to and from the airport during vacation / leave as well as transportation services for the new staff from the airport to the hospital. It further provides transportation services for female residents of Site 2 for shopping. Other transportation services are given on demand of the KFHU administration.
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KFHU Annual Report 1435 - 2014
Administrative Departments
|窶アdministrative Communication Department
This department is responsible for all incoming and outgoing mail services whether within the hospital or to and from the hospital. It is also responsible for the sorting and distribution of personal mail of KFHU staff. Table ( ) Communication Dept. Activities & Tas s During the Yea Particular
Frequency
Incoming external mail
3727
Outgoing mail to UOD
767
Ordinary outgoing mail
8
2014
|窶アrabic Transcription
t n affi at t t ffi ft t n a f t n f a typewriting services especially the typewriting of letters prepared by the various sections and departments of the hospitals. Table (12) Arabic Transcription Section. Activities & Tas s During the Year 2014 Particular ffi a
Frequency tt
t
Internal Referrals
2115 11
163
Administrative Departments
| Monitoring and Follow Up Department t
◢ ◢ ◢ ◢
affi at t t t n a f an t a gn t t f ng ta a n t t fing nt t f n t ng t t fa a an at of the hospitals staff. To inquire the various sections and departments of KFHU concerning the absence and unpunctuality of the employees. To practice monitoring procedures and to carry out any necessary investigations with regards to the performance of the various sections and departments of KFHU. n t n t na t t t a a t nt f t ta t fin tt a a of short coming and to discover the cases of procrastination and breach of the functional t a t a t t n n at n an nat n t t
◢
◢
◢
◢
relevant authorities of UD. nt t g f at t t a f a ng t n a t dominant rules and regulations; besides reporting complaints to the Monitoring Department f a t fi f ta ng t a at a an a t n To conduct investigations, in co-ordination with the Monitoring Department of UD, with the employees in all breaches and contraventions prior suggesting the appropriate punishment to the administration. To prepare monthly report on the extent of the staff punctuality showing details of those a at t a nt an t ft t ffi ng t ng without permission or acceptable excuse. To co-ordinate with the representatives of the Monitoring and Investigation Board as regards conducting monitoring rounds in the departments of KFHU.
| Human Resource Department
This department is responsible for all personnel affairs. It provides services for all hospital employees of various categories and nationalities. It includes a number of sections such as a a t a at n fi ng nt a t ng ta at an fa t affa ffi t an a t n f a n t t g a n fi t n t t an a t t a t t a t nt t a
1
KFHU Annual Report 1435 - 2014
Administrative Departments
|窶ェinancial Affairs Department
nan a ffa a t nt n ta a finan a f an t This includes accounting and auditing procedures in addition to the staff salaries and the finan a f n a an an at n t t t n t finan a t an a t n KFHU.
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Table ( ) Finance Department Activities & Tas s during the Year 2014 Particular
Frequency
Contracts completed
1
Authorized letters
8
Individual transactions received Air vouchers completed
1
165
Administrative Departments
| Purchasing Department at
nt
a
gn
t t
f
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◢ Implement the governmental bidding and purchasing law and its executive regulation. And follow up the secure of KFHU needs through direct purchasing.
◢ Develop annual bids for medical, laboratory, pharmaceutical and medical solutions› requirements, and conclude contracts relevant to them.
◢ Follow up implementation of ongoing projects› contracts. ◢ Secure the needed medical instruments. ◢ nf
t n n relevant committees.
ffi a
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a t nt
t ng
◢ Audit the approved letters and contracts of direct purchasing as well as bids and budget reports.
◢
166
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ta
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f
KFHU Annual Report 1435 - 2014
f
Administrative Departments
| Medical Supplies and Medical E uipment
It is one of the supportive departments and lies under the allied medical services. It consists fg f t an a t n a n n nt nt a nt t a at f t t ag f a t a t n ng n t nat ft t a f 1.
a an a nt stored. 2. n nt n t n 3. a t an nt g nt a at nt n t 5. at nt n t a nt ng a at Medical Supply Department.
an
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Main services provided by the Department: ◢ maintain the availability of all medical equipment and machineries, disposables and
biological items either medicines or laboratory reagents that required to -provide the optimal service of the hospital and patient care, store medical supplies under the required conditions, disribute medical supplies to the hospital department through the proper channels, n a t nat t n f a n ta a a nt a a t Follow up implementation of medical supplies› contracts. a at n t ng f tt ant t t a a t nt Provide KFHU with the annual consumption and the statistics necessary for budget estimations.
◢ ◢ ◢ ◢ ◢ ◢
Other Services and Acheivements a
ntat n f t
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◢ a nt 1 t ◢ n an a t n 8 t ◢ Reagents and laboratory requirements at
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tat n tat n
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f
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167
Administrative Departments
Table demonstrating the activities and acheivements of Medical Supply Department during the year 2014. Particular
Frequency
Received supplies
t
Medical requirements & Respiratory items
1
t
Reagents and laboratory items Medicines and medical solutions Number of supply orders received from KFHU›s departments
t 8
t t
Medical requirements and & respiratory items
2126 items
Reagents and laboratory items
1
t
Medicines and medical solutions
t
Dispensed items
8
Medical requirements and respiratory items
t t
Dispensed items
8
Medical requirements and respiratory items
t t
Reagents and laboratory items
1
t
Medicines and medical solutions
1
t
Total
1 8
8
KFHU Annual Report 1435 - 2014
Administrative Departments
| Housing Department
Housing Department This department supervises all utilities of KFHU with special focus on the housing of staff affi at ng t t ta an t g f n n ◢ ng n S t 1 t a gn f fa a at n an ng f a taff t n t f a an a a t nt ◢ ng n St t n t f a a t nt an t a at f f a ng staff. ◢ nt a ng n t f a a t nt a gn f t n taff f ◢ a t nt a t t a at t ng n t 1 a a the Sports Center. ◢ The swimming pool and play grounds. ta
n
ta
t
f
ng ta
◢ To receive and distribute electricity bills to the residents of Housing Compound Site 1. ◢ To issue statements to the Personnel Department regarding the accommodation allowance of ◢ ◢ ◢ ◢ ◢ ◢
employees resident outside Housing Compound Site 1. To issue statements concerning residents of the Housing Compound. To secure accommodation for new employees arriving from other countries. To issue exit permits for employees and their families. nat t t a nt nan an ng a t nt ga ng t be done at the Housing Compounds. To renovate and expand the sports center. nat t t ng a t nt ga ng t n f to remove scrap electrical appliances from the housing compounds.
t
169
8. Academic Affairs and Training & Medical Library
Academic Affairs and Training
Continuous Professional Development Unit External Training Unit Internal Training Unit Audio-visual Unit
Medical Photography Unit Design Unit
Translation Unit
Health Education unit
Life Support Programs
Evidence Based Medicine Program
Medical Library
Academic Affairs and Training & Medical Library
| Directorate of Academic Affairs and Training & Research
It plays a vital role in the development of skills and performance of the medical staff. It effectively contributes in the tertiary process of students of medicine and applied medical science studying at UD or other Saudi academic institutions. The department consists of the following units and sections:
◢ ◢ ◢ ◢ ◢ ◢ ◢ ◢ ◢ ◢ ◢
172
Continuous Professional Development Unit External Training Unit Internal Training Unit Audio-visual Unit Medical Photography Unit Design Unit Translation Unit Health Education unit Design Unit Life Support Programs Evidence Based Medicine Program
KFHU Annual Report 1435 - 2014
Academic Affairs and Training & Medical Library
1.Continuous Professional Development Unit This unit is concerned with the constant professional development activities such as training sessions, symposia, conferences, workshops, lectures and other professional activities. These activities are usually carried out in coordination with the concerned departments inside and outside KFHU. The total number of activities done by the department this year reached 60 and the number participants stood at 7,509.
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Academic Affairs and Training & Medical Library
Table No: (1) .NO
ACTIVITY TITLE
(DATE(S
1
Bronchoscopy Symposium & Hands-on
January 1 - 2, 2014
2
Workshop : The Art, Science and Technique
NO. OF ATTENDEES
VENUE
ORGANI ER
81
Med. Educ.
Surgery
Ctr. Site 1
Radiology Conference
January 6 – 9, 2014
1,250
Med. Educ.
Radiology
3
1st Symposium and Workshop on
January 12, 2014
132
Med. Educ.
Urology
4
Lecture: Fall prevention in pediatrics
January 13, 2014
86
Aud. Bldg.
Nursing
Horizons of Neurosurgery VI:
January 13 – 15,
80
Coral Hotel,
Neurosurgery
5
Urodynamic
The First Walter E. Dandy Meeting in the Middle East
2014
Ctr. Site 1 Ctr. Site 1 500
Al-Khobar
6
Emergency and Critical Care Ultrasound
January 16 – 17,
27
Med. Educ.
Emergency
7
Basic Course in Microsurgery
January 29 – 30,
10
Temporal
Surgery
February 2 – 6,
25
8
Course
Evidence Based Practice Specialized Workshop
2014 2014 2014
Ctr. Site 1
Bone Lab.
Cl. Skills Lab. Bldg. 500
Medicine
Family &
Community Medicine
9
Lecture: End of Life care
February 3, 2014
140
Aud. Bldg.
10
Genetics in Medicine
February 3, 2014
132
Bldg. 11,
February 5 – 6,
41
Med. Educ.
February 12, 2014
551
Med. Educ.
Dermatology
Med. Educ.
Surgery
Aud. Bldg.
Nursing
Med. Educ.
Dermatology
11
n
a
fi at n
2014
12
2nd Dermatology Update Symposium
13
Basic Surgical Skills Course
February 19, 2014
26
14
Lecture Care of post-partum depression
February 24, 2014
92
15
Laser Basics and Phototherapy
February 28, 2014
61
174
(risk for infanticide)
KFHU Annual Report 1435 - 2014
500
UoD
Ctr. Site 1 Ctr. Site 1 Ctr. Site 1 500
Ctr. Site 1
Nursing
Pr. Mohammed Center for
Research, UOD
Ophthalmology
Academic Affairs and Training & Medical Library
.NO
ACTIVITY TITLE
(DATE(S
16
8th Functional Endoscopic Sinus Surgery
March 1 – 3, 2014
Symposium & Specialized Workshop
NO. OF ATTENDEES 22
VENUE
ORGANI ER
Med. Educ.
ENT
Ctr. Site 1 & UoD
Anatomy Lab.
17
Sickle Cell Disease
March 12, 2014
44
18
Lecture: Awareness of the process and
March 17, 2014
93
19
Research Methodology Course
March 16 – 20,
21
20
Wound Care Course
March 19, 2014
34
Cl. Skills Lab.
21
5 Alumni Day
April 3, 2014
130
Med. Educ.
College of
22
Lecture: Pain assessment and
April 7, 2014
146
Aud. Bldg.
Nursing
23
5th Annual Medical Resident Research
April 12, 2014
78
Basic Surgical Skills Course
April 17, 2014
27
Advanced Hematology & Transfusion
April 27 – 30, 2014
335
24 25
barriers to informed consent
th
management Day
Science Symposium & Workshops
2014
Aud. Bldg.
Research Centre
Aud. Bldg.
Nursing
Cl. Skills Lab.
Family &
500 500
Bldg. 500
Bldg. 500
Ctr. Site 1 500
Community Medicine Nursing
Medicine
Med. Educ.
-
Med. Educ.
Surgery
Med. Educ.
Clinical
Ctr. Site 1 Ctr. Site 1 Ctr. Site 1
Laboratory
Science, College of Applied
Medical Sciences
26
Lecture: Organ donation and SCOT
April 28, 2014
82
Aud. Bldg.
27
First Medical Students Research Day
May 10, 2014
156
Med. Educ.
-
28
Lecture: Holistic approach in the care of
May 19, 2014
79
Aud. Bldg.
Nursing
29
Research & Publication Ethics
May 24, 2014
150
Med. Educ.
Directorate of
guidelines
mentally challenge children
500
Ctr. Site 1 500
Ctr. Site 1
Nursing
Academic Affairs & Training
175
Academic Affairs and Training & Medical Library
.NO
ACTIVITY TITLE
(DATE(S
30
1st Saudi International Symposium
May 31 – June 1,
31
on the Art and Science of One Lung ventilation
2014
NO. OF ATTENDEES
VENUE
ORGANI ER
318
Med. Educ.
Anesthesia
Ctr. Site 1
Lecture: Hospital Codes
June 9, 2014
145
Aud. Bldg.
Nursing
32
Evidence Based Practice Specialized
June 15 – 19, 2014
40
Cl. Skills Lab.
Family &
33
Research Methodology Course
June 22 – 26, 2014
27
Workshop
500
Bldg. 500
Cl. Skills Lab. Bldg. 500
Community Medicine Family &
Community Medicine
34
Lecture: Nursing Documentation and
June 30, 2014
91
Aud. Bldg.
35
Lecture: provision of privacy During
August 4, 2014
147
Aud. Bldg.
Nursing
Oxygen Therapy Modalities Symposium
September 4, 2014
170
Med. Educ.
Respiratory
37
Basic Surgical Skills Course
September 18,
25
Med. Educ.
Surgery
38
Advanced Surgical Skills Course
October 15 – 16,
16
39
Clinic and Lab: Bridging the Gap
October 22 – 23,
309
40
Hot Topics in Molecular Research
October 26, 2014
160
36
care Plan
Care and Protecting Patient Belongings
2014 2014 2014
500 500
Ctr. Site 1 Ctr. Site 1
Nursing
Therapy
Med. Educ.
Surgery
Med. Educ.
Laboratory
Bdlg. 11,
Clinical
Ctr. Site 1 Ctr. Site 1 UOD
Medicine
Laboratory
Science (College of Applied
41
12 Temporal Bone Dissection Course &
10
Temporal
Basic Surgical Skills Course
November 15, 2015
24
Med. Educ.
Surgery
13th Saudi Gastroenterology Meeting
November 24, 2014
175
Medical
Internal
5 Cochlear Implant and bone Bridge th
42 43
Workshop
& 2nd SASLT Meeting (Pre Conference
2014
Workshop) 44
13 Saudi Gastroenterology Association th
Meeting & 2 SASLT Meeting nd
45
176
Medical Science)
November 3 – 6,
th
10th Symposium and Workshop on Vascular Access
Bone lab.
Ctr. Site 1
Education
Centre, Site November 25 – 27,
900
December 15 – 16,
47
2014 2014
KFHU Annual Report 1435 - 2014
& KFHU
ENT
Medicine
Le Meridien
Internal
Med. Educ.
Surgery
Hotel
Ctr. Site 1
Medicine
Academic Affairs and Training & Medical Library
.E ternal Training Unit The unit serves as a coordinating point for the training opportunities offer by KFHU to the medical and assisting medical cadres as well as the students of medicine and the assisting medical sciences. The training opportunities cover radiology, pharmacy service, medical supply, health nf at n a ta at ta a n t at n t finan t a respiratory therapy, nursing, dietary, diagnostic laboratories, intensive care, emergency cases and other opportunities availed by the various departments of the hospital. The External Training Unit closely supervises the training process. This is usually done in coordination with the relevant departments of KFHU so as to guarantee a conducive environment of training. No doubt this conducive environment would enable trainees to pick up knowledge and up-grade their skills and abilities.
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Academic Affairs and Training & Medical Library
EXTERNAL TRAINING PROGRAMS Institution /Speciality
No. of Trainees
College of Applied Medical Science ◢ Radiology ◢ Pharmacy (Intern) ◢ Pharmacy ◢ Respiratory ◢ Physiotherapy ◢ Laboratory (Master Program) ◢ Laboratory Pathology ENT Dermatology (FAMCO) Pediatrics Physician (FAMCO) Medical Physician (FAMCO) Laboratory Female Students Laboratory Medical Students Laboratory Respiratory Nursing Internship Respiratory Therapy (3rd Year) Medical Secretary Program Physiotherapy Information Technology (Interns) Physiotherapy (3rd Year) CAMS-UOD Medical Secretary Program Dental Interns Medical Students (Summer) Male Students Laboratory Health College – Nutrition
18 14 6 43 20 2 5 4 6 6 6 25 24 2 40 155 17 19 8 45 30 8 6 23 25 4
1.University of Dammam
Institution /Speciality
2.King Saud University Pharmacy Physiotherapy Clinical Nutrition Laboratory Speech Audiology Ophthalmology Health Education
3.King Khalid University Laboratory 178
Riyadh
Riyadh
KFHU Annual Report 1435 - 2014
No. of Trainees 6 3 2 3 4 4 3 3 2
Academic Affairs and Training & Medical Library
4.Um Al Qura University
2
Laboratory
.Saudi Council for Health Specialties
Pharmacy Technician Nursing Laboratory Clinical Psychology ER Physicians (FAMCO) Physiotherapy Nutrition Social Worker Internal Medicine (Physicians)
2 7 10 3 2 2 3 2 2
Laboratory Nursing Medical Secretary E.M.T Technician
2 10 2 4
Laboratory
4
.Prince Sultan College of Science and Health Military
. Al ouf University
Institution /Speciality
8. Dammam Technical College
No. of Trainees
Biomedical Engineering Medical Supply Purchasing Finance/Accounting
1 2 1 2
Psychology (Physicians)
2
Hospital administration Executive Secretary
1 2
Computer Maintenance
6 2
. Ministry of Health
10. Institute of Public Administration 11. Dammam Technical College 12 King Faisal University Architecture
College of
13. Al Khaleej University
Bahrain
Nutrition
ER Medicine
22 2
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3.Internal Training This division is concerned with the development of skills of employees of KFHU as well as the orientation of new staff. Some 700 trainees took part in the training session organized by this division the year under report (for more details see the following table) SNo.
Parti cular
Trainees/ Interns
Staff members
Total Number
1
Health diloploma
30
-
30
Medical Laboratories
8
15
23
Medical Research
-
2
2
4
Medical Secretary
-
5
5
5
Nursing
180
82
262
6
Dietary
15
-
15
7
Pharmacy
12
13
25
8
Physiotherapy
17
-
17
9
Quality
-
2
2
10
Radiology
8
-
8
11
Repiratory Therapy
10
-
10
12
Speech and
2
-
2
13
Emergency (Emergency Medicine Technicians)
4
6
10
308
30
338
2 3
14
180
Hearing Therapy
Physicians
KFHU Annual Report 1435 - 2014
Academic Affairs and Training & Medical Library
4.Audio visual Unit
The unit provides the following services: A. Audio-visual service B. Classroom service C. T.V. service The above mentioned services are provided to the student of medicine, nursing, applied medical sciences and the graduates. The unit coordinates the use of classrooms according to the daily schedules. As for the T.V.Service, there are three TV channels. One is for Islamic culture. The other two channels are assigned for child programs and the health culture. Besides that there are
181
Academic Affairs and Training & Medical Library
182
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Academic Affairs and Training & Medical Library
.Medical Photography Unit
It carries out all photographing activities at KFHU including taking photos for some medical a fi a an t t t t a a a t nt f a academic purposes. The unit also covers the conference and symposia held at the hospital. There are advanced digital cameras that give picture with high quality. Details
No. of Participants
Pictures of CME Activities, Conference, Symposium, Workshop etc.
46
Pictures of Hospital Departments events
69
Pictures of the Hospital Annual Report
345
184
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.Designing Unit
It designs all poster, booklet, brochure and pamphlets relevant to the activities of the Continuous Medical Education and Health Education. Details
No. of Participants
Design of Roll up
30
Design of Posters
174
Design of Cards
96
Design of Logos
8
Design of Brochures
43
.Translation Unit This unit started from the start of the hospital. It provides translation services to the Hospital administration and all departments of KFHU. This includes the translation of medical reports, t an at t fi at a tt t a ag nt a t an n t t fi at n t fi at an nt f na t nt t other translation services provided on demand of KFHU administration.
8.Health Education Unit
It upgrades the level of health culture of all segments of the community. Educational health programs are used to make the community members pursue the right health behavior and prevent themselves from diseases. The health education is given to in-patients and out-patients. It aims to help the patient understand his disease and the ways of cure and co-existence with chronic diseases such as diabetes. The unit provides health education on World Health days through exhibitions and health campaigns. Several health, educational, and social sectors in the Eastern Region take part in such health educational programs. The department is also involved in the training of female students interns specialized in Health Education besides the training of new staff. If further takes part in the organization of health symposia and the research done by UD.
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Academic Affairs and Training & Medical Library
Item
Number
Diabetic Patients Consultations
350
OPD Diabetic Patients Diabetic In-Patients
Pediatric Diabetic Patients
Antenatal Diabetic Patients Blood Sugar Test Machine Insulin Pumps
Plaster Patients
Community Health Education
Health Education Orientation Interns
Distribution Health Education Hand Books Health Education Brochures Printing
186
KFHU Annual Report 1435 - 2014
2338 626 36 40
400 300 211
5000 933 5
17540 83
Academic Affairs and Training & Medical Library
.Life Support Center
This center includes BLS, ACLS, NARP, PALS programs in addition to ATLS & DMEP programs. See tables below: Advanced Cardiac Life Support (ACLS) course anuary 2014 to December 31, 2014 Date
No. of Participants
January 26-27, 2014
10
February 16-17, 2014
11
April 14-15, 2014
8
May 12-13, 2014
9
August 30-31, 2014
12
September 20-21, 2014
13
October 25-26, 2014
9
November 15-16, 2014
11
December 13-14, 2014
11
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Academic Affairs and Training & Medical Library
Basic Life Support (BLS) course anuary 2014 to December 31, 2014 Date
No. of Participants
January 11, 2014
18
January 16, 2014
16
February 3-4, 2014
32
February 15, 2014
31
February 22, 2014
36
March 1, 2014
18
March 8, 2014
28
April 17, 2014
17
May 4,5,6, 2014
49
June 2-3, 2014
36
June 22-23, 2014
30
August 9,10,17,23,24, 2014
87
September 6,7,27, 2014
52
October 14, 2014
15
November 1,8,13,20,27,29,30, 2014
134
December 6-7, 2014
34
188
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Pediatric Advanced Cardiac Life Support (PACLS) course anuary 1014 to December 31, 2014 Date
No. of Participants
February 11-10, 2014
7
March 16-17, 2014
5
April 8-9, 2014
6
September 13-14, 2014
4
December 20-21, 2014
11
Cardiac Pulmonary Resuscitation (CPR) course anuary 1014 to December 31, 2014 Date
No. of Participants
March 18,19,20,31, 2014
45
April 1,2,3,5, 2014
49
November 22, 2014
6
ADVANCED TRAUMA LIF SUPPORT anuary 1014 to December 31, 2014 Date
No. of Courses
No. of Physician
No. of Participants non-physician
Total No. of Participants
March 18,19,20,31, 2014
1
16
8
24
March 25-27, 2014
2
16
7
23
May 20-22, 2014
3
13
8
21
November 18-20, 2014
4
16
8
21
Disaster & Emergency Preparedness Courses anuary 1014 to December 31, 2014 Date
No. of Courses
No. of Physician
No. of Participants non-physician
Total No. of Participants
February 12, 2014
1
11
2
13
May 7, 2014
2
6
4
10
December 17, 2014
3
6
7
13
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10.Evidence Based Medicine Program The Evidence based Medicine Program was established to meet the needs for researches and practitioners of the King Fahd Hospital of the University (KFHU). The program was accredited by the Gulf and National Center for Evidence Based Health Care (GNCEBHC) and recognized as an approved center in the eastern province of Saudi Arabia. During the last year the evidence based unit provided three (5-day) research methodology courses and one (one-day research and publication ethics course. In addition, the program has accommodated four interns from the department of Health Information Technology and Management at College of Applied Medical Sciences for one month period training for each. The future plan includes, recruiting a full-time systematic review specialist and introducing new courses such as systematic review course, mateanalysis courses, and online searching courses.
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| Medical Library
It was established in 1983 to provide services to the hospital employees as well as the faculty and students of UOD. There is special section for Islamic books in the library. The computer system is used in search for the required books, references or other publications. The library is linked to the automated University System. It operates under the direct supervision of the Deanship of Library Affairs.
191
Academic Affairs and Training & Medical Library
192
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193
Academic Affairs and Training & Medical Library
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195
9. Directorate of Quality & Safety
Accreditation Unit
Credentialing & Privileging Unit Decision Support Unit
Documents Control Unit
Environmental & Safety Unit Risk Management Unit
Performance Measurement Unit
Directorate of Quality & Safety
| KFHU consultation journey Baseline Assessment Phase
This was aim to provide KFHU an in-depth analysis of our current ability to meet the JCI standards at the early stages of our preparation process. The assessment phase cover the entire KFHU and include all the chapters related to patient-focus, organizational management and academic medical center standards. The assessment also covers t nt nat na at nt Saf t a an nt fi ga nt gan at n f an an expectations of the goals. The consultants’ baseline assessment looked at the quality data currently available in KFHU and compared that data to the JCI requirements of the quality monitoring standards. The results of the baseline assessment were used as a guide in the development of a detailed action plan. The Baseline Assessment was arranged according to the JCI standards and demonstrates KFHU tat a ng t t tan a n ng fin ng an n at n t a an The consultants also collect and analyze baseline quality data as required by the quality monitoring standards (e.g., medication errors, hospital-associated infection rates, antibiotic usage, surgical complications, etc.). Part of the assessment, they establish an ongoing monitoring system for data collection (e.g., monthly, with quarterly data analysis) to identify problem areas and track progress in improvement. At the end of the assessment phase, the consultants provided KFHU a report indicating and prioritizing the standards that needed improvement. When there was an area for improvement, a nt a t n an f a tan a fin ng a n t at t n ann ng ng t fin ng f t a n a nt St a a ta t an ta t ng fi t t t a a ft tan a n t a and time frames were assigned (e.g., revise informed consent policy, develop a new informed consent statement, educate staff in the next two-month time period.) 1. KFHU hospital wide JCI accreditation preparation activities: at na a t t f S t at an t at t taff t a t awareness to some policies, procedures, forms, JCI chapters and FMEA project. The Accreditation nt f S n t an t ng aft a n tant t fina t an t ng a fin ng t at t a t n
Awareness Campaign
Improvement
or shop
Project Failure 198
Performance Indicators
New Systems for Documents and
KFHU Annual Report 1435 - 2014
Approval
Clinical Guidelines Trac s Systems
Regulationes
or ers Cliniclans
and Non Cliniclans
Directorate of Quality & Safety
2. At King Fahd Hospital of the University (KFHU), Hospital-wide KPI was launched as per the
approval of H.E. the President of University of Dammam & Supervisor General of KFHU, Dr.
3.
Abdullah Al Rubaish last 23rd of April 2014. tat n
nt ft
t
at
f
a t
Saf t
a
a
1
a t
binders on Patient Centered Standards, Organization Management Standards and Academic Hospital Standards.
4. A total of 440 forms were done and out of this number 298 were approved, printed and 5.
uploaded to the hospital portal. t ta
f1
to the hospital portal.
an
n an
gn
t
a
An approximate number of 21 Scope of Services was done and is continuously being updated on a regular basis.
7. There are 28 departments that had submitted a signed strategic plan and 10 departments were still pending for the department’ chairpersons’ signature. Compared with the 2013 strategic
plan an increase of 27% was obtained in collaboration with the departments’ chairpersons.
Strategic plans completed and signed
8. Improvements relevant to OVR system were introduced. All policies and procedures related to the Risk Management Unit such as the sentinel event were also reviewed and revised. 9. t a a f an at t at at f 1 t t a a 1 fi f a a tt at nt n a nt n fi f t at nt n a ta a tt f an f S ng t a 1 n a for the achievements of all units of Directorate.
The finding and recommendations of e ternal consultants (wor shops meetings)
Dental
E.N.T.
Internal
Diseases
Neurosurgery Physiotheraapy Psychiatric
Respiratory
Urology
199
Directorate of Quality & Safety
| Accreditation Unit
The efforts of this unit focused on following up the accreditation process of KFHU by JCI. The t ngt an a n a a nt fi tt a t a f t completing the accreditation journey.
Strength
KFHU JCI Accreditation percentage of achievements Standard
Score
International Patient Safety Goals
Access to Care and Continuity of Care Patient Family Rights
Assessment of Patient
82.4%
Medication Management and Use
80.7%
a t an
84.8% 81%
at nt Saf t
79.1%
Governance Leadership and Direction
75%
Prevention and Control of Infection Facility Management Safety Staff
a fi at n an
at n
70%
Medical Professional Education
75%
Human Research Program
70%
Table 1: KFHU CI Accreditation percentage of achievements •
Forms, Policies and Procedures done and implemented.
•
Hospital and departmental Scopes of service done.
t n
gn
an
a
n
2 Clinical Pathways implemented.
KFHU Annual Report 1435 - 2014
87.9%
80%
Management Of Information
200
75%
Care Of Patient
Patient and Family Education
•
75% 81%
Anesthesia and Surgical Care
•
81.7%
fi
Directorate of Quality & Safety
| Opportunities for Improvement 1. International Patient Safety Goals • •
Some physicians are not aware of IPSG.
IPSG 3 High Alert Medication Policy and Procedures is not available.
2. Access to Care and Continuity of Care • • •
ag ng a a
a t
at nt
nfi
nt a t
Overstaying Performance Improvement Projects is to be completed; target date is end of February 2015. t a
t
an t
t t
t ag ng
t
a
an
•
Delay appointments in Radiology, Cathlab surgery but no documentation.
•
Clinical Dietician, Clinical Pharmacist, Physical Therapist, need to provide education.
• • • •
a
t t
Death. t
n ta a
fa
nf
t
nf
t t
nf
n an
t
t t
3. Patient and Family Rights • •
fi
t
natt n
at t
taff
ag
an t n
t
nt
t
t n ag
at t t
a taff fi
nt n a
nt ng n t
at nt fi
t
t
Initial assessment is incomplete physician and nursing
•
Reassessment should be done even weekends
• •
a
f
n
gn fi ant ata
• •
a
a
tt
t
an
a tan
n f
ng
End of Life Care Patient needs not assessed.
4. Assessment of Patients •
an t
ag
nt
gnat
Physician discharge planning was not initiated
KPI for radiology should include result discrepancy Infection Control is not observed in blood bank
5. Care of Patient • •
Integrated care plan was not done properly
AMI Clinical Pathways not fully implemented
201
Directorate of Quality & Safety
• • • •
Key Performance Indicator for Code blue not available
There is weakness in nutritional assessment in particular those patient at nutritional risk More training in the end-of-life care Pain assessment no reassessment after intervention
6. Anesthesia and Surgical Care • •
Anesthesia form need to revised Implant device need to monitor
7. Medication Management and Use •
Policies and procedures are not available.
•
Pharmacy Medication Management Plan not Available.
•
Drug Usage Evaluation program not available.
• • •
f
an
n
at
ata n t
a
t
t
at
f
a t an Saf t
Pharmacy Scope of Service not Available. Adverse Drug Event data.
8. Patient and Family Education •
Physician, nursing, and other healthcare provider need to document to the Multidisciplinary Patient and Family Education form the education given to the patient, family or care giver.
9. Quality and Patient Safety • • • •
S
at n
an a a a
tn t
nt
Safety Risk Assessment for the contractors not done
Patient Safety Culture Survey (employee survey) done but not yet analyzed at nt a
t
a t
a t ft
waiting for the list of allocated budget for each patient:
nt
n
t an
ffi
n
• Ordinary Case. • Surgical Case. •
• Obstetrics Case. t f S nt n
an
nt n t
10. Prevention and Control of Infection
t fina
•
Safety Risk Assessment for Contractors not done by the Infection Control.
•
Some areas which are critical areas from infection control point of view such as laundry,
•
Immunization coverage of the staff should be monitored in each department by Infection
202
CSSD, mortuary, kitchen need to be strictly monitored by Infection control practitioner. control department.
KFHU Annual Report 1435 - 2014
Directorate of Quality & Safety
• • •
tan f
nt n an
nt
f nf
t n
at n
n ta a a
Educational program for Laundry staff not available. n ng f
a n
an
t
nt
taff
11. Governance Leadership and Direction
nt
•
Dr. Khalid Al-Otaibi Job description should be signed by President Dr. Abdullah Al-Rubaish.
•
Clinical Pathway not fully implemented. The physician just started the emergency case and
•
Leadership rounds not yet implemented. Checklist available.
•
Please see the attached comments from the Consultant Surveyor.
ignore the other days.
12. Facility Management and Safety
13. Staff Qualification and Education • •
f
fi at n
fi
ata
f
n n Sa
t fi at an t
a
a
Departmental orientation not available.
14. Management of Information •
Printer for printed stickers (addressograph) is underway.
•
Closed and Open chart review started – poor compliance.
•
Poor compliance to the documentation policy.
•
Scope of Service by the Clinical Affairs.
•
Job Description of Resident and Intern Coordinator.
•
Staff promotion policy not available.
•
Forms, Policies and Procedures, Organizational Chart not available.
15. Medical Professional Education
16. Human Subjects Research Program
203
Directorate of Quality & Safety
|窶イredentialing & Privileging Unit
t a ta n 1 t fin t at n n frequency of ongoing evaluation for all KFHU staff to meet patients need.
g an
n t ta an f gat ng fi at n an a at ng t nt a f those clinical hospital staff to provide patient care and build a quality professional staff. Also, it made soft copy and hard copy of clinical privileges for clinicians (specialists and consultants) available to those locations in KFHU hospital in which the medical staff member will provide services.
204
KFHU Annual Report 1435 - 2014
Directorate of Quality & Safety
| Decision Support Unit
The collection of meaningful statistics is an important function of a hospital or clinic. Decision support unit is the primary source of data used in compiling health care statistics. Health service statistics are used for: •
Comparison of present and past performance of the hospital or clinic.
•
Guide for planning future development of the hospital or clinic.
•
Preparation of statistics for Ministry of Health.
•
Research.
Primary objective of this unit is to collect various data relevant to the service provided by KFHU to the patients. The key initiatives in 2014 were: •
Data validation for Bed Occupancy.
•
Data validation for Average Length of stay.
•
t f
g
an
a
a
•
Developed a standard template for Hospital statistics.
•
Developed a standard template for KPI analysis.
205
Directorate of Quality & Safety
Hospital Statistics at a glance
|窶オn Patients
Total Pts.11,240
of Patients
In Patient
A total of 11,240 patients were admitted at Inpatient clinics by various departments in 2014. The number of patients seen at Inpatient service during 2014 was an increase of 11, 240 (10.8%) on the number seen during the previous year (10140).
KFHU Annual Report 1435 - 2014
Directorate of Quality & Safety
|窶グut Patients
Total OPD seen 1,8 , 14
of Patients
Out Patients
Months t ta n a
1
f 1 8 1 at nt 1 n at nt an 11 ng 1 a an n a
at f1 8
t at nt t n n 1 nt
n n
n 1 f at nt n
n t f n at t at nt ng t
207
Directorate of Quality & Safety
|窶ウmergency Patients
Total Pt.Seen 1,8 ,
0
of Patients
Emergency Patients
Months t ta f 1 8 at nt n at ng 1 the previous year (1, 57,590).
208
n at a an n a
KFHU Annual Report 1435 - 2014
g n f1 8
n 18
1
n nt n
f at nt n ng
Directorate of Quality & Safety
|窶サop 10 Surgical Procedures
n
fi
na
at
ga
Low cervical cesarean section Episiotomy Repair of other current obstetric laceration Insertion of drug-eluting coronary artery stent Dilation and curettage following delivery or abortion Laparoscopic cholecystectomy Repair of current obstetric laceration of bladder and urethra Other cystoscopy Other appendectomy Ureterotomy Laparoscopy Tonsillectomy with adenoidectomy Arthroscopy of knee
Procedures
A total of 1154 top 10 surgical procedures were performed in 2014. The number of Top 10 g a ng 1 a an n a f 11 1 nt n n ng t previous year (1043).
209
Directorate of Quality & Safety
|窶サop10 Diagnosis
Mother with single liveborn n
fi
nt a
t n
n
Single liveborn, born in hospital, delivered without mention of cesarean delivery Diabetes mellitus t
an
n
fi
a
Other postsurgical status Single liveborn, delivered by cesarean delivery Other sickle cell disease Previous cesarean delivery, with or without mention of antepartum condition Surgical or other procedure not carried out because of patients decision
A total of 3197 patients were listed in the top 10 diagnosis
210
KFHU Annual Report 1435 - 2014
Directorate of Quality & Safety
Average Length of Stay
|窶アverage Length of Stay
An average length of stay (ALOS) for the entire service was 9 days, The ALOS decreased from a rate of 10.5 days in 2013 to a rate of 9.0 days in 2014.
211
Directorate of Quality & Safety
|窶ィed Occupancy rate
An average percentage of Bed occupancy during the year 2014 was 84.4%
212
KFHU Annual Report 1435 - 2014
Directorate of Quality & Safety
|窶ィirth Statistics
A total of 1248 new births were registered at Delivery room in 2014.
213
Directorate of Quality & Safety
| Document Control Unit ntf t t n gn ng an a a f1 an f thirty eight departments at the Hospital. They are to ensure quality of service and to promote patient safety in its full standard. And for ease of accessibility, these policies are now uploaded nt nt an t f t ta nt a t nt 8 tt t t n f their employees. Forms from all units of the Hospital were. Revisions and reprinting were made a t n fina f f t nt fi a t nt a n a a a nt fina n n n a a t nt f ta a n a at a a n ng nt a t nt f a tt t f departments (74%) have submitted their strategic plans.
214
KFHU Annual Report 1435 - 2014
Directorate of Quality & Safety
| Environmental Safety Unit In 2014, Environmental Safety Unit completed the second audit cycle carrying out 90 initial visits and numerous follow up visits.
Some of the significant achievements: 1. Revised the checklist for environmental rounds making it comprehensive and easy to use. 2. Facilitated to initiate renovation at laundry department through recommendations laid down in environmental rounds report.
3. Established guidelines for storage space. 4.
an fina
ta
at
an a
Saf t
n
5. Completed approximately 90% of FMS documentation.
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
81%
80%
73%
85%
75%
80%
58%
78%
81%
69%
70%
54%
81%
82%
81%
79%
70%
65%
60%
54%
89%
87%
89% 76%
74%
69%
57% 44%
2013
ا ة قني ت
ال
ال نك ب
امل
جرا ال
ف
األ
ملعل
وما
IT
ت
ية يدل ص
دم
كت
بة
س
ية
هار
الن
لط
حة
ا م
ش
ئ
وار
عة
عيو
ن
ية س
E.N.T. Ophtha Radiology ER Day Library Blood Pharmacy lmology Surgery Ban
رة نج
2 ثفة
ملك
ا ة ناي ع
ال
عن
اية
امل
كث
ال
عي
ادا
ال ت
1 ِ فة
ال
ية جلد لح ال وا ف ألن وا ذن األ
PT
لنف ا
دة حح و
دة وح
ال
2014
OPD ICU 1 ICU 2 Psycho PT Derma tology
ية رج خا
88%
79%
215
Directorate of Quality & Safety
| Ris Management Unit
A total number of nine thousand one hundred fourteen (9114) Occurrence Variance Reports (OVRs) were received by the Risk Management Unit (RMU) for the year 2014. Increased awareness of OVR reporting and giving importance to the “culture of safety” approach, nt t gn fi ant n t n a n f tt t t t at f a t and Safety.
ta t t f a t a t nt f ng S t a f t Medical Services and the Allied Medical Services in which the Department of Laboratory Medicine and Physical Therapy were included. Seventeen percent (17%) of the OVRs received for the year 2014 were about Overstaying of at nt n n t g n f t an t f t t ta
n
2014, 1277 (14%) were about Left Against Medical Advice (LAMA). Three years consecutively, a nt n t t t t ta f 8 ft at to procedure cancellation. The top most contributing factor for Procedure Cancellation is “patient didn’t come “ to the theatre. 483 surgeries done in the Operating Room (OR) were cancelled. The top reasons for OR cancellation were patient didn’t come, and patient’s condition needs further evaluation. For the year 2014, Gas, power, water or HVAC occurrence was included in the ten (10) most reported occurrences in KFHU. A total of 159 submitted OVRs fell in this at g t fa t 1 a ta n at 8 received OVRs were related to International Patient Safety Goals (IPSG): identify patient correctly, improve effective communication, improve the safety of high alert medication, ensure correctsite, correct-procedure, correct-patient surgery, reduce the risk of healthcare associated infection, and reduce the risk of patient harm resulting from falls.
1
KFHU Annual Report 1435 - 2014
Directorate of Quality & Safety
Number of Various Events Reported Annually
Various Events Reported Per Month in 2014
an
Feb
Mar
Apr
May
un
ul
Aug
Sep
Oct
Nov
Dec
217
Directorate of Quality & Safety
| Conclusions and recommendations Findings
Recommendations •
• • The total number of OVRs increased by
Continue conducting and strengthen
educational presentation about reporting of Occurrence Variance.
Provide continuous feedback to the OVR reporter.
Encourage the other departments nt fi
a n ta t
t
out and stress out the importance of
14% this 2014 as compared to 2013. It was due to the continuous education of the OVR reporting system and reaching out to a t nt a n nt fi a n t active reporters for the previous year.
a
reporting OVRs as a means in identifying risks.
• Respiratory Therapy • Dietary
• Social Service
• Patient Relations and Rights
• Operations and Maintenance • CSSD
• Dental •
• Biomedical Engineering
Promote and implement “Culture of Safety” to encourage staff to report t
n Misses
t ng f S nt n
nt an
a
•
Miss.
S nt n
nt an
a
Exemplify a blame-free or non-punitive
environment to encourage staff to report errors or near misses without fear of
An increase of 202% in reporting of Procedure • Cancellation. “Patient didn’t come” is the highest contributing factor accounting to 75%.
218
KFHU Annual Report 1435 - 2014
reprimand or punishment.
The result will be shared with the
Performance Improvement Unit (PIU) and a Performance Improvement (PI) project will be proposed.
Directorate of Quality & Safety
Although there was a decrease in reported “Overstaying of patient in ER” by 2%, it has been the third year of being the top most reported variance in the hospital. 220 (2%) of reported OVRs were about false fi a a n
•
Although there was a decrease in reported “Overstaying of patient in ER” by 2%, it
has been the third year of being the top • • •
most reported variance in the hospital.
Identify the causes and prevent recurrence f fa
fi
t
aa
nt
t
fi
aa
Encourage all healthcare staff to report all medication related OVRs (i.e. Dispensing, Prescribing, Storage, Administration,
Under reporting of Medication-Related OVRs
a tag
•
ntat n n
Miss.
ng
a
Work closely and hand-in-hand with
the Department of Pharmacy to identify incidents and near misses related to
•
• Feedback not submitted within allocated time
medication.
Assignment of OVR liaisons by each
department who will work closely with the Risk Management Unit (RMU).
The RMU will conduct educational sessions to all OVR liaisons about the OVR system
and process, including how to respond to •
letters or request for feedback.
Chairmen and department heads needs
to reinforce compliance to the policy and
provide feedback and action plans within • 280 (3%) of the total OVRs received were related to IPSG.
•
t
fi
t
Strengthen the awareness of staff about International Patient Safety Goals.
Facilitate continuous education thru
campaign, tracer activity, and workshop.
219
Directorate of Quality & Safety
| Performance Improvement Unit f an following topics:
nt
nt f
t
at
f
a t an Saf t
nt
1. KPI Dashboard (2014).
2. JCI library of measures analysis and interpretations. 3. KFHU KPIs, analysis and interpretation.
4. Performance improvement projects conducted in 2014 and there outcomes. 5. Other PI unit activities:
• Committees and JCI Chapters facilitated by PI Unit. • Record Review Activities (Open and close). • Hospital Orientation Program. • Tracer for hospital departments.
The Unit measured satisfaction of patients. The inpatients’ satisfaction in the second quarter of the year under report reached more than 80% while the satisfaction of outpatients in the second quarter of the same year stood at77.3%.
Inpatient Hospital Satisfaction Rate
80
Percentage
Target
t
220
at
S
n
KFHU Annual Report 1435 - 2014
at
at
t
at
Directorate of Quality & Safety
Reza Outpatient Rate
Percentage
Target
t
at
S
n
at
at
80
t
at
| Performance improvement projects PI Project conducted in 2014: •
ng at nt
a
t
ng
n
n a a
nat n
Ongoing Quality Improvement Project: •
an
t
at t
nt S
at
nt
•
Overstaying of patients in Emergency Department (with Emergency Department).
•
Reducing OR Cancellation Rate (with Anesthesia Department).
•
Reducing Radiology Report Turnaround Time outlier rate (with Radiology Department).
Upcoming Quality Improvement Projects •
ng
at
t
ng
at
nt
221