Directorate of Quality and Safety
Annual Report 2013 Messages Message from the President of UoD & Supervisor General of KFHU ........................................ 1 Message from the Director General of KFHU ........................................................................ 2 Message from the Supervisor General DQS.......................................................................... 3 Directorate of Quality & Safety Executive Summary .......................................................................................................................... 4 DQS Significant Achievements in 2013 Healthcare Quality Week .................................................................................................................. 4 HQW Activities.......................................................................................................................... 5 Lobby/Booth/Poster Presentation ............................................................................................. 6 Ambulatory Quiz ....................................................................................................................... 6 Open House ............................................................................................................................. 6 Performance Improvement Project ........................................................................................... 9 Other Activities ......................................................................................................................... 10 Joint Commission International (JCI) Mock Survey ......................................................................... 12 King Fahd Hospital of the University Annual Report 2013 ................................................................ 14 Strategic Plans .................................................................................................................................. 15 Performance Improvement & Accreditation Unit Executive Summary .......................................................................................................................... 18 Strength ........................................................................................................................................... 18 Recommendation .............................................................................................................................. 22 Clinical Performance Measure .......................................................................................................... 23 Managerial Performance Measure ................................................................................................... 27 Performance Improvement & Accreditation Unit Activities................................................................ 29 Utilization Care Review Report ......................................................................................................... 30 Documents Control Unit Policies and Procedures ................................................................................................................... 39 Job Descriptions ............................................................................................................................... 40 Hospital Forms .................................................................................................................................. 40 Scope of Service ............................................................................................................................... 41 Committees & JCI Chapters ............................................................................................................ 41 JCI Chapter Teams ........................................................................................................................... 42 JCI Joint Chapter Teams .................................................................................................................. 43 Teams ............................................................................................................................................... 44 Task Forces ..................................................................................................................................... 44 Environmental & Safety Unit Scope of Environmental & Safety Unit .............................................................................................. 46 Environmental Safety Monitoring Program ....................................................................................... 46 Environmental Safety Rounds Program............................................................................................ 46 Significant Achievements .................................................................................................................. 49
Risk Management Unit Overview ........................................................................................................................................... 52 Introduction ....................................................................................................................................... 53 Top Clinical OVRs............................................................................................................................. 54 Patient Overstaying in ER ........................................................................................................ 55 DAMA ...................................................................................................................................... 56 Break in Skin Integrity............................................................................................................... 57 OR Cancellation ....................................................................................................................... 58 Line, Tube, Drain or Catheter .................................................................................................. 58 Top Non Clinical OVRs ..................................................................................................................... 59 Missing Patient or Other Person............................................................................................... 60 Non-Clinical Equipment ........................................................................................................... 61 Building Structure or Infrastructure ........................................................................................... 62 Gas, Power, Water or Heating Failure...................................................................................... 63 Housekeeping Services ........................................................................................................... 63 Top Reporting Units and Departments ............................................................................................. 64 International Patient Safety Goals .................................................................................................... 65 IPSG 1: Identify Patient Correctly ............................................................................................. 66 IPSG 2: Improve Effective Communication .............................................................................. 67 IPSG 3: Improve the safety of high alert medication ................................................................ 67 IPSG 4: Ensure correct-site, correct procedure, correct patient surgery .................................. 67 IPSG 5: Reduce the risk of healthcare associated infection..................................................... 67 IPSG 6: Reduce the risk of falls................................................................................................ 68 2014 Goals........................................................................................................................................ 69 Education & Training Unit Introduction ....................................................................................................................................... 71 Activities of ETU................................................................................................................................ 71 Significant Accomplishment for 2013 ................................................................................................ 71 Interns Training ................................................................................................................................. 73 Performance Improvement Projects (PIPs) ...................................................................................... 74 Objectives of PIPs............................................................................................................................. 74 PIPs conducted from last quarter of 2012 to 2013............................................................................ 74 Decision Support Unit Introduction ....................................................................................................................................... 78 Directorate of Quality & Safety Goals for 2014 Major Goals....................................................................................................................................... 80 Glossary ............................................................................................................................................... 82
Directorate of Quality and Safety
Annual Report 2013 List of Tables Strategic Planning Table 1: Progress Report .................................................................................................................. 15 Performance Improvement & Accreditation Unit Table 1: Implementation of key performance measure & data collection ......................................... 21 Table 2: Opportunities for Improvement & Action Plan ..................................................................... 29 Table 3: Avoidable Days Report ....................................................................................................... 32 Table 4: Extra Pre-Operative Days ................................................................................................... 33 Documents Control Unit Table 1: Committees of KFHU .......................................................................................................... 41 Table 2: JCI Chapter Teams ............................................................................................................. 42 Table 3: Joint JCI Teams .................................................................................................................. 43 Table 4: KFHU Teams ...................................................................................................................... 44 Table 5: Task Forces ........................................................................................................................ 44 Environmental & Safety Unit Table 1: Responses Received versus Report Generated................................................................. 48 Risk Management Unit Table 1: Type of Break in Skin Integrity ............................................................................................ 57 Table 2: Causes of OR Cancellation................................................................................................. 58 Table 3: Type of Line, Tube, Drain or Catheter ................................................................................ 58 Table 4: Non-Clinical Equipment ...................................................................................................... 61 Table 5: Type of Building Structure or Infrastructure ........................................................................ 62 Table 6: Gas, Power, Water or Heating Failure ................................................................................ 63 Table 7: Top Reporting Departments................................................................................................ 64 Decision Support Unit Table 1: Decision Support Unit Activities & Tasks for 2013 .............................................................. 78
Directorate of Quality and Safety
Annual Report 2013 List of Figures Strategic Planning Figure 1: Progress Report................................................................................................................. 16 Performance Improvement & Accreditation Unit Figure 1: Clinical Performance Measure........................................................................................... 23 Figure 2: Managerial Performance Measure .................................................................................... 27 Figure 3: Avoidable Days Report ..................................................................................................... 32 Figure 4: Extra Pre-Operative Days .................................................................................................. 33 Figure 4a: Extra Pre-Operative Days ................................................................................................ 34 Figure 4b: Extra Pre-Operative Days ................................................................................................ 35 Figure 4c: Extra Pre-Operative Days ................................................................................................ 36 Figure 4d: Extra Pre-Operative Days ................................................................................................ 37 Documents Control Unit Figure 1: KFHU Departments Policy & Procedure ............................................................................ 39 Figure 2: Job Description Update ..................................................................................................... 40 Figure 3: Hospital Forms................................................................................................................... 40 Figure 4: Department Scope of Service ............................................................................................ 41 Figure 5: KFHU Committees ............................................................................................................. 42 Figure 6: JCI Chapter Teams............................................................................................................ 43 Figure 7: Joint JCI Teams ................................................................................................................. 43 Figure 8: KFHU Teams ..................................................................................................................... 44 Figure 9: Task Forces ....................................................................................................................... 44 Environmental & Safety Unit Figure 1: Process for Risk Reduction ............................................................................................... 46 Figure 2: Areas Surveyed ................................................................................................................. 47 Figure 3: Frequency of Surveys ........................................................................................................ 47 Figure 4: Department Compliance (January – November 2013) ...................................................... 48 Figure 5: Action Plan Reports Received ........................................................................................... 48 Figure 6: Staff Trainings Sessions .................................................................................................... 50 Risk Management Unit Figure 1: Total Number of OVRs for 2013 ........................................................................................ 53 Figure 2: Comparison between the 3rd & 4th Quarters ...................................................................... 53 Figure 3: OVRs Status ...................................................................................................................... 53 Figure 4: Top 5 Clinical OVRs for 2013 ............................................................................................ 54 Figure 5: Patient Overstaying in ER.................................................................................................. 55 Figure 6: Reasons for Overstaying of Patients in ER ....................................................................... 55 Figure 7: Non-eligible patients in ER ................................................................................................ 55 Figure 8: Location of Reported DAMA .............................................................................................. 56 Figure 9: Refusal of Admission / Treatment Form ............................................................................ 57 Figure 10: Reasons for DAMA .......................................................................................................... 57 Figure 11: Causes of Hematoma ...................................................................................................... 57 Figure 12: Pressure Ulcer ................................................................................................................. 57 Figure 13: Top 5 Non-Clinical OVRs for 2013 .................................................................................. 59
Directorate of Quality and Safety
Annual Report 2013 List of Figures
Figure 14: Location of Reported Missing Patient .............................................................................. 60 Figure 15: Electronic Exit Doors Malfunction in Psychiatry Unit ....................................................... 62 Figure 16: Reported OVRs related to Housekeeping ....................................................................... 63 Figure 17: Medical Reporting Departments ...................................................................................... 64 Figure 18: Reporting Departments.................................................................................................... 64 Figure 19: IPSG-Related Reported OVRs for 2013 .......................................................................... 65 Figure 20: Number of Reported IPSG-Related OVRs per month for 2013 ....................................... 65 Figure 21: Classification of OVRs related to IPSG 1 ........................................................................ 66 Figure 22: Classification of OVRs related to IPSG 5 ........................................................................ 67 Figure 23: Distribution of Age & Gender among Reported OVRs..................................................... 68 Figure 24: Falls in 2013 .................................................................................................................... 68 Education & Training Unit Figure 1: Lectures Conducted during Healthcare Quality Week ....................................................... 72 Figure 2: Lectures Conducted in 2013 & Attendees ......................................................................... 72 Figure 3: 2013 Calendar of Activities/Campaign/Lectures/Training .................................................. 73
KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
Message of His Excellency, the President, University of Dammam Supervisor General, King Fahd Hospital of the University
As the Directorate of Quality & Safety (DQS) enters its second year, the trail ahead has become clearer, and the determinations of this directorate have begun to transpire in its pursuit to promote the significance of quality and patient safety at King Fahd Hospital of the University (KFHU).
DQS have been able to overcome any challenges and they have exceeded all expectations, allowing them to consider 2013 a year of realized opportunities. One of last year’s major milestones was bringing the Joint Commission International (JCI) for the first mock survey and hosting the first Healthcare Quality Week at KFHU.
2013 has proven to be another year of significant achievements for DQS, and as they strive to achieve many more years of success to accomplish the high aspirations of KFHU. Overall quality, safety and patient care outcomes reflect an organizational culture dedicated to achieving and sustaining excellence for the patients we serve.
The quality improvement and patient safety effort started serves as a strong foundation for the strategic initiatives and health care reform challenges which lie ahead in 2014. This accomplishment is a representation of a comprehensive quality and safety program which incorporates through the combined efforts of physicians, staff and leaders of KFHU.
This report provides highlights of DQS’s activities over the past year, including their goals, accomplishments, challenges and opportunities for improvement and it is my pleasure to present the Directorate of Quality & Safety annual report for the year 2013.
H.E. Dr. Abdullah Al Rubaish President, University of Dammam Supervisor General, King Fahd Hospital of the University
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
Message of the Vice Dean, Hospital Affairs and Director General, King Fahd Hospital of the University
I am pleased to present the Annual Report of the Directorate of Quality and Safety (DQS). The report highlights the 2013 accomplishments and activities of DQS.
This is the second year of reporting progress and represents the efforts of the DQS staff, the many hours of work in all aspects of performance improvement, risk management and patient safety as we strive to deliver the highest quality of care at King Fahd Hospital of the University (KFHU).
Along with our physician, nursing staff, allied healthcare professionals and all KFHU employees, we continue to develop and implement best practices, altogether with the goal of creating a safer environment and the highest quality experience for our patients.
We understand that quality and patient safety extend beyond our clinical teams to encompass everyone at KFHU, and, in fact, some of the most effective ideas come out of process improvement exercises that consist of multidisciplinary teams.
I would also like to take this opportunity to thank all employees of the Directorate of Quality & Safety, as well as the dedicated professionals who deliver first-rate health care to all patients of King Fahd Hospital of the University.
Dr. Khalid Al Otaibi Vice Dean, Hospital Affairs Director General, King Fahd Hospital of the University
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
Message of the Supervisor General, Deanship of Quality & Academic Accreditation University of Dammam Supervisor General, Directorate of Quality & Safety King Fahd Hospital of the University
At King Fahd Hospital of the University (KFHU), we strive to be leaders in healthcare services, which means keeping our patients and employees safe and delivering only the highest quality services. I am honored to present this second annual report. It has been an extraordinary and busy year for the Directorate of Quality & Safety, filled with challenges and accomplishments that make us proud of our staff and their service to KFHU. 2013 has been a very busy year for DQS staff who has been working so hard to be able to meet the JCI’s stringent clinical, management and academic standards. As KFHU prepares for the JCI accreditation, DQS facilitated various training opportunities, on-site consultations by external quality professionals.
In collaboration with the KFHU staff, we continue to develop and implement best practices, all with the goal of creating a safer environment and the highest quality experience for our patients. We have so much to be proud of for the year 2013. DQS hosted two major events at KFHU: JCI (Joint Commission International) first Mock Survey and 1st Healthcare Quality Week. These two major events were our remarkable achievements demonstrating our enormous efforts made in improving quality and safety through the joint work of all employees of KFHU.
As 2013 ends, DQS will continue to develop a culture of continuous quality improvement through effective governance structures, clinical effectiveness, outcome measurements and evaluation will remain at the center of our approach to improving services at KFHU. DQS will continue every year to review, evaluate and improve our processes and efforts throughout the hospital from the previous year.
Our successes are the result of our team hard work, their talent and dedication. I am honored to represent them as we serve KFHU and its patients. I hope you will enjoy reading our 2013 Annual Report.
Dr. Ahmed Al Kuwaiti Supervisor General, Directorate of Quality & Safety King Fahd Hospital of the University Page 3 of 82
KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
Executive Summary The core elements in the provision of health services are safety and quality of care. The Directorate of Quality and Safety (DQS) takes a lead role in planning, managing and evaluating patient safety and quality for King Fahd Hospital of the University (KFHU). DQS focuses on quality improvement, evaluation and review, clinical management systems and measurement, clinical performance related to patient safety and quality, and risk management. DQS also coordinates the accreditation process for KFHU. The whole team of DQS is currently working based on the JCI 5th edition standards to ensure that King Fahd Hospital of the University is ready for its Joint Commission International accreditation assessment in 2014. It is our pleasure to present to you our 2013 annual report. Our commitment to quality starts at the very top. Quality improvement in health care is not just a project; it is the primary function of King Fahd Hospital of the University to continuously assess and improve effectiveness and efficiency. Our second annual report showcases our continued work in identifying opportunities for improvement in KFHU through quality monitoring activities. The year 2013 was a very busy and hectic year for the Directorate of Quality & Safety (DQS). We are proud of the work we have done, the goals we have accomplished and the improvements we have introduced, we realize that quality is a journey not a destination. We continually strive to introduce tools and techniques, principles and practices to help us better monitor, manage and improve our services and programs. We also focused on strengthening a culture that values, supports and promotes continuous improvement to quality and patient safety. DQS has achieved great success over the past year with the implementation of many Quality initiatives and will continue to drive the quality agenda all over King Fahd Hospital of the University (KFHU). DQS Significant Achievements in 2013 In 2013, DQS has hosted two big events, namely the Healthcare Quality Week and JCI Mock Survey in addition to its current activities. Healthcare Quality Week The Directorate of Quality & Safety (DQS) hosted and organized the first “Healthcare Quality Week” at King Fahd Hospital of the University. The five-day event highlights the importance of quality and patient safety in healthcare. This year’s theme is “KFHU Soaring High for Excellence.” DQS rallied to create an atmosphere of celebration, education, and sharing of performance improvement initiatives and services that promote improved healthcare outcomes, internal support systems, patient satisfaction, and efficiencies in care and resources.
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DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KING FAHD HOSPITAL OF THE UNIVERSITY
The Healthcare Quality Week that ran from September 8-12, 2013 drew the enthusiastic participation of all hospital staff from across King Fahd Hospital of the University (KFHU). Articulating KFHU' commitment to providing quality and safe healthcare practices for the Eastern Province community, the aim of the event is to promote coordination and collaboration within KFHU, while laying the ground for future quality and safety initiatives as well as accreditation process. KFHU seek to promote a culture of safe medical practices among our patients, visitors and staff.
The Healthcare Quality Week celebration encouraged creativity, teamwork, responsibility, and collaboration among the KFHU staff - influences that we believe are integral to organizational success and staff empowerment. This celebration also came as an endorsement of the administration's support to maintaining world-class quality and safety standards throughout KFHU. The Healthcare Quality Week event included a variety of activities built around the initiative's theme of “KFHU Soaring High for Excellence� and hosted competitions to evaluate performance improvement projects, quality booths, posters, open house presentation and sports competitions. The activities that were conducted through the week fostered a healthy competitive environment and presented an opportunity to discover staff creativity, ingenuity and critical thinking skills. HQW Activities The week long activity, which took place from September 8 - 12 recognizes and demonstrates KFHU's continuous commitment to quality improvement and safety. The event this year witnessed enthusiastic engagement from staff across KFHU. The event aimed to increase awareness about quality, foster coordination and collaboration, and strengthen KFHU's foundation for future quality and safety initiatives as well as accreditation projects. "The Healthcare Quality Week Celebration fosters creativity, teamwork, responsibility, and collaboration among KFHU staff; these are important aspect of organizational success and staff empowerment. The event demonstrates management support for quality and safety all throughout KFHU. This is also a manifestation of our effort to create a safety culture for our patients, customers, visitors and staff.
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
Lobby / Booth / Poster Presentation: The five-day event provided an opportunity for the different departments within KFHU to showcase, through booth exhibition and poster presentation their performance improvement projects focusing on enhancing quality and patient safety. His Excellency, the President of the University of Dammam and Supervisor General of King Fahd Hospital of the University, Dr. Abdullah AlRubaish, was the guest of honor of the week-long event. Dr. Abdullah Al-Rubaish and Dr. Khalid Al-Otaibi, Vice Dean for Hospital Affairs and Hospital Director opened the week-long event.
The hospital lobby was decorated with balloons, posters and promotional items from all participating departments of KFHU. Each department had assigned staff to develop colorful, eye-catching exhibits about their respective departments.
Ambulatory Quiz
As part of HQW activities, DQS staffs did rounds in every unit wherein questions (medical and administrative views) were asked to the staff as part of involvement and continuous education. DQS staff initiated this quiz for those KFHU staff who does not have the opportunity to participate and provided them with instant prizes. Open House To provide an opportunity for the community and other KFHU staff to obtain more information about the services provided by other departments throughtout the hospital, some of the units of the hospital has participated in the open house activity.
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
Units participated for this year’s open house were:
The objective of the open house activity is to provide each participating unit an opportunity to present each unit in it’s entirety.
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
The Cardiac Care Unit (CCU) won this year’s best Open House. CCU has demonstrated teamwork to deliver the highest quality healthcare in the safest possible way to every patient admitted to CCU. Performance Improvement Project:
The involvement of PI Projects gives them an opportunity to show what they accomplished and what they can do more to continually improve services. Progress will not be made unless we are enthused about quality and can convince others to share in our enthusiasm. This is also to encourage KFHU staff to focus on the importance of quality, enhancing patient safety, improving patient care and strengthening knowledge, performance and attitudes among staff members.
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
Other Activities
Other healthcare quality activities included: a) Essay Writing Competition: An essay writing contest was held as part of the HQW activities. This was well participated by different staff of units at KFHU. First prize winner came from the Department of Nursing Services, Ms. Mary Ann Dasalla; second prize winner was from the Department of Physiotherapy, Mr. P. Shahul Hameed. b) Search for Quality: aims to promote team spirit and to assess staff awareness of the Infection Control Program. This year Search for Quality focuswa on Infection Control and its impact on patient care. The unit that excel in this year’s Search for Quality is the Nursery Unit. c) Sports activities: The aim of the sports activities is to promote teamwork, staff morale and the basis of successful implementation of quality management principles such as QI team. Sport activities were female volleyball and men’s basketball.
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
The Healthcare Quality Week event included a variety of activities and competitions. The competitions aimed to foster a friendly competition environment and presented an opportunity to discover staff creativity, ingenuity and critical thinking skills. The week-long event culminated in the closing and awarding ceremony which took place on Thursday, September 12, 2013 and witnessed the participation of KFHU staff and was attended by the top hospital administrators. Joint Commission International (JCI) Mock Survey King Fahd Hospital of the University (KFHU) was the first university hospital in the Kingdom of Saudi Arabia to be surveyed based on the 4th edition (expanded). This edition includes two additional chapters: MPE (Medical Professional Education) and HRP (Human Subject Research Program). The expanded edition is used to survey hospitals that are affiliated with a university or medical school. The aim of having an accreditation by the Joint Commission is an important element of the original vision and ensures that continuous improvement is integral to the operation of KFHU. The JCI Mock Survey process gives KFHU an opportunity to determine our readiness as the JCI actual survey draws near. The JCI consultants identify opportunities within KFHU to ensure coordination of all activities with the aide of standard practices, latest health care innovations and strong foundation of guidelines, and policies and procedures. Further, they will identify the weaknesses that may hinder the success and will provide KFHU with the best solutions. In November 3-11, 2013, three JCI consultants, an experienced professional nurse, physician and hospital administrator spent 7 days surveying all elements of the hospital’s services. The survey was hospital-wide with a multi-disciplinary approach. The purpose were to evaluate KFHU compliance to JCI Patient Centered and Organization Management Standards using 4th Edition Hospital Standards Manual, provide training and education on JCI Standards and selected topics identified during tracer activities and provide support through action planning process for selected areas of compliance. The JCI team conducts site visits to facilities to evaluate the implementation of the JCI standards. The team assessed the compliance with the JCI standards and KFHU readiness for the actual survey which was planned in mid-2014. The JCI standards were demanding and wide-ranging, covering staff competency, good governance, evidence-based clinical practice, patients, facility safety, medical professional education and human research. At the completion of the site visit the JCI team assisted in developing an improvement plan to achieve compliance with standards within achievable time frames. The JCI team conducted a workshop to assist all JCI chapter leaders in the action planning. All leaders reviewed their chapters for compliance with all the elements of performance. The JCI mock survey cultivates a partnership with all KFHU staff to develop improvement efforts, assess the current state of actual survey readiness and identify gaps in our systems or processes. The DQS team will help all departments of KFHU to develop and execute a plan to implement practical solutions aimed at improving the quality and safety of care delivery at KFHU.
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KFHU Performance Improvement process continues to drive improvement efforts hospital-wide. The sixteen JCI chapter teams continue to meet regularly to identify further opportunities for improving processes and to co-ordinate and drive these initiatives.
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
King Fahd Hospital of the University Annual Report 2013 Another milestone that the Directorate of Quality & Safety had for the year 2013 was the completion of the King Fahd Hospital of the University (KFHU) Annual Report. The KFHU Annual Report 2013 was one of the major projects that were achieved by DQS. The 2013 KFHU annual report was submitted to His Royal Highness Prince Saud Bin Naif, governor of the Eastern Province of the Kingdom of Saudi Arabia.
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
STRATEGIC PLANNING The following are the updates on the departmental strategic plans:
# 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Table 1: PROGRESS REPORT KFHU – Departmental Strategic Plans – Year End 31 December 2013 Department Status Academic Affairs, Training, Patient Ed & Med Lib, Directorate Complete! Allied Medical Services (AMS) Complete! Anesthesiology (ANES) Complete! Dentistry Complete! Dermatology (DERM) Complete! Nutrition In process Emergency Room (ER) Complete! Family & Community Medicine Center (DFCM) In process Health Information & Medical Records Complete! Housekeeping Complete! Human Resources (HR) In process Infection Control Complete! Information Technology (IT) & Data Processing Complete! Internal Medicine (IM) In process Laboratory In process Medical Supply & Stores Complete! Neurology Complete! Neurosurgery In process Nursing, includes Day Surgery In process Obstetrics & Gynecology (OBGYN) Complete! Ophthalmology In process Orthopedics In process Otorhinolaryngology (ENT) Complete! Outpatient Department (OPD) In process Patient Relations & Rights Administration In process Pediatrics (PED) Complete! Pharmacy Complete! Physical Therapy (Physiotherapy) & Rehabilitation Medicine Complete! Psychiatry (PSY) Complete! Quality, Academic Accreditation & Safety, Directorate Complete! Radiology (RAD) In process Respiratory Therapy Not available Security Services Not available Socio-Medical Services Complete! Surgery Complete!
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DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KING FAHD HOSPITAL OF THE UNIVERSITY
# 36 37
38
PROGRESS REPORT KFHU – Departmental Strategic Plans – Year End 31 December 2013 Department Status Urology (URO) Complete! Support Services A. Operations & Maintenance Not available B. Biomedical Engineering Not available C. Laundry Services Not available D. Telecommunications Not available Administration A. Purchasing Not available B. Housing Not available C. General Store Not available D. Administrative Communication Not available E. Finance Not available
* CSSD Department, Not applicable; ** List of departments = To the best of our knowledge
Figure 1: Progress Report: Summary from 38 departments, Year End 31 December 2013: 4 12
22
Complete 22/38 or 58% In process 12/38 or 32% Not available 04/38 or 10%
22 20 18 16 14
12
12
Complete 22/38 or 58%
10
In process 12/38 or 32%
8 6
4
Not available 04/38 or 10%
4 2 0
Complete In process Not available 22/38 or 58% 12/38 or 32% 04/38 or 10%
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
PERFORMANCE IMPROVEMENT & ACCREDITATION UNIT Executive Summary 2013 was a year of great strides at Directorate of Quality and Patient Safety. Overall quality, patient safety, patient experience and performance improvement outcomes demonstrated a culture dedicated to achieving and sustaining excellence. DQS is committed to transparency and to meeting the needs and expectations of our customer. Sharing performance results empowers patients, staff, leaders and stakeholders to make informed health care choices. To improve, we have to measure. This report reflects the enormous effort that goes into measurement and serves as a means of conveying the department accomplishments. In addition to the information provided in this annual report, the organization realized the following strength and opportunities for improvement in 2013: STRENGTH •
Patient Safety Culture Survey - the result of patient safety culture survey shows the organizational learning – continuous improvement increased from 81.0% to 83.2% followed by management support for patient safety from 66.2% to 70.8%. The increased indicates the adherence and support of administration to KFHU staff regarding quality improvement and patient safety program. Non-punitive response to error 18.9 % is the lowest average percent positive response compare to last year 24.9%
•
IPSG # 4 Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery – Implementation of IPSG # 4 started in November but no data to prove the percentage of compliance. Data will be gathered during closed record review as well as observational starting January 2014
•
IPSG # 5 Reduce the Risk of Health Care–Associated Infections – Hand hygiene campaign done in July as the implementation of the PI project in and September this year
•
IPSG # 6 Goal 6: Reduce the Risk of Patient Harm Resulting from Falls – Implementation of IPSG # 6 started in December data collection will start in January to be included in the Key performance Indicator report in quarterly.
•
Performance Improvement Project – Nursing department have 18 on going performance improvement project and it’s in the implementation phase Increase of Infection Rate Non-compliance of Dress Code Patient No show on the day of procedure Hematoma Overstaying in ER Malfunction of Equipment during procedure in OR Patient Identification Informed Consent for emergency CS
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KING FAHD HOSPITAL OF THE UNIVERSITY
•
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
Non Compliance in using PPE for bedside procedures Ecchymosis post procedure (CAG) Poor Compliance of Aseptic Technique on dressing IPSG 6 Fall IPSG 5 Poor hand hygiene compliance IPSG 4 Preparation of Surgical Site Marking Intravenous infiltration Impaired skin integrity Surgical procedure at bedside Unavailability of some psycho tropic and Controlled drugs in Psyche pharmacy
Accreditation - Joint Commission International Mock Survey held November 3 – 11, 2013 Organizational Strengths Enthusiasm of Leadership in consultation and accreditation process Commitment to culture of quality and patient safety Enthusiasm and involvement of staff in the process Participation and interest of medical staff in process
Priority Issues Some Policies and Procedures are unsigned and most have not yet implemented Clinical staff in patient care areas were not trained Staff Qualification and Education Primary source verification – Lack of specifics regarding the process used by Data Flow. It is questionable if 100% of licenses and education are verified with the originating agency. This deficiency could result in an unsuccessful survey. Privileging of Medical Staff- All medical staff practicing at hospital must have evidence of privileges granted for the services provided. During the survey one physician performing surgery or working in the hospital without license or privileges is a significant risk for unsuccessful survey. Evidence of Licensure – During personnel file review, it was noted that one physician, one nurse, and an MRI technician are practicing without evidence of a current license. This is a significant risk for unsuccessful survey. International Patient Safety Goals The surveyor identified the gaps in practice and policy in most IPSGs that need focus and immediate resolution to comply with the four month track record Policies should be revised and streamlined for clarity and conciseness to be useful policies to guide staff Access to care and continuity of care The consultant suggest that hospital could identify exceptions where the outpatient summary list is not required as these type of patients are under the care of a physician in the clinic, such as outpatient physical therapy treatment, dialysis and wound care clinic. Patient Care Processes: Assessment / Reassessment and care of Patient Significant improvement opportunities include consistent assessment of minimum content by the various disciplines for inpatients and outpatients;
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
completion of informed consents where required: plan of care that is measurable and individualized to the patient’s needs and reviewed by medical staff; pain screening, assessment and reassessment; and patient education that is collaborative according to the patient needs. Quality and Patient Safety The consultant suggests that the hospital streamline the number of indicators and ensure that all required topics in QPS and GLD are included in the program with evidence. The organization should immediately begin the validation process for all clinical measures identified. Governance, Leadership and Direction The organization should clearly define in written documents the governance structure and responsibilities held by governance structure and responsibilities held by governance and those governance responsibilities delegated to hospital leaders. Governance should define criteria for annual performance evaluation and this should be conducted prior to the JCIA survey. The organization should focus on effective oversight of contracted services using key performance indicators. The data generated can be used to monitor contract performance and management, and can be used by leadership in evaluation of renewing contract. Facility Management and Safety Leadership should take an active role to ensure that the fire and safety and general overall safety and security risks throughout the hospital are investigated and resolved. Medical equipment management plan should be established with active ongoing preventive maintenance initiated and documented. Key performance indicators should be established for each of the six management plans with the data used in the ongoing evaluation. There are no annual evaluations of six management plans.
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DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KING FAHD HOSPITAL OF THE UNIVERSITY Opportunities for Improvement:
Table 1: Implementation of the following key performance measure and data collection. JCI Standards
#
Indicators
2
Surgical cases with prophylactic antibiotic administration 5 – 50 minutes before surgery Surgical cases with appropriate selection of prophylaxis antibiotic
3
Medication Error per 10,000 items dispense
4
Aspirin within 24 hours of patients arrival
5
Use of relievers of children inpatient asthma
6 7
% of life saving medication Staff satisfaction
8
Staff turnover rate
IPSG 1
9
% compliance to Patient Identification
IPSG 2
10
% Critical Value reporting within 30 mins.
IPSG 3 IPSG 4
11 12
% compliance storage of high alert medication % compliance surgical site marking
IPSG 5
13
% compliance hand hygiene
IPSG 6
14
Incidence of Falls
15 16
Preoperative diagnosis and post-operative diagnosis Blood Transfusion reaction Hospital Acquired Associated Infection - UTI incidence per 1000 device days - BSI incidence per 1000 device days
1
QPS 2
QPS 8 17
QPS 8
GLD 6
18
% Near Misses
19
Unplanned Recovery Room Stay longer than 1 hour for medical reasons
20 21 22 23
Surgical procedure Cancellation Rate Housekeeping response time to call Food Service - Customer / patient satisfaction Laundry – # of soiled linen post wash
24
Patient complaints
Department Pharmacy Pharmacy Risk Management CCU & ER Pharmacy, Pediatric Unit PI Human Resource Nursing QI Laboratory and Radiology Pharmacy Nursing QI Infection Control Nursing QI Risk Management Laboratory Laboratory Infection Control Risk Management Closed Record Review QI Nursing PI Laundry Patient Relation
Page 21 of 82
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KING FAHD HOSPITAL OF THE UNIVERSITY
JCI Standards
#
QPS 2
22
ALOS
23
Bed Occupancy rate
24
Admission
25
OPD visit
Managerial
Indicators
Department Statistics Unit Statistics Unit Statistics Unit Statistics Unit
Recommendation Key Performance Indicator is vital information for Hospital Leadership and decision maker. It is very necessary to provide accurate and reliable data to the Leadership for them to decide and improve the outcome of care. •
Review the Utilization Care Review process
•
Review the data definition of each key performance indicator / measures with the concerned department
• • •
Identify the data source and data abstractor Each department /unit should review the staffing plan to identify the data abstractor. Submit the data on time
Page 22 of 82
Clinical Performance Measure
January - December 2013
Numerator: Number of AMI patients in a month who received aspirin within 24 hours before or after hospital arrival Denominator: Number of AMI patients in a month
JCI ILM Aspirin within 24 hours of arrival in the Hospital 100% 80%
Data Owner: Dr. Al Mansori
60% 40% 20% 0%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Target
2012
2013
Blood Culture Contamination Rate
Analysis: The graph indicates KFHU compliance to the JCI library of measures. Patients received aspirin within 24 hours before or after hospital arrival. Recommendation: • To monitor compliance in AMI clinical pathways • To include Emergency Department in data collection
▼ Good
Numerator: Number of cultures contaminated (i.e., with species listed under the graph) in a month Denominator: Number of blood cultures in a month
5.0 4.0
Data Owner: Ms. Sausan, Clinical Laboratory
3.0 2.0
Analysis: The data for the last quarter of 2013 is not included due to the staff are busy for CAP accreditation
1.0 0.0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Target
2012
2013
▼ Good
Blood Product Wastage Rate
Denominator: Number of units of blood or blood products that were transfused and discarded within their expiry date in a month
20% 15% 10%
Data Owner: Ms. Sausan, Clinical Laboratory
5% 0%
Numerator: Number of units of blood or blood products that were discarded within their expiry date in a month
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Target
2012
Analysis: The data for the last quarter of 2013 is not included due to the staff are busy for CAP accreditation
2013
Page 23 of 82
Clinical Performance Measure
January - December 2013
▼ Good
BSI Incidence per 1000 device days 25.0 20.0
Denominator: patient days
15.0
Data Owner: Ms. Samia, Infection Prevention and Control
10.0 5.0 0.0
Numerator: Number of blood stream infections (i.e., clinical signs and symptoms, positive culture of CVP tip, and the same microorganism isolated in blood culture > 15 cfu) in a month
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Mean
2012
Analysis:
2013
Note: the statistics include all critical areas Hospital Acquired Healthcare Associated Infection
▼ Good
Denominator: number of inpatient days
6.0 5.0
Data Owner: Infection Prevention and Control
4.0 3.0 2.0 1.0 0.0
Numerator: Number of healthcare-associated infections.
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Mean
2012
Analysis: The graph indicates the infection rates increased in October due to MRSA outbreak in Orthopedic department. 3 staff nurses are colonizing with MRSA and they were treated sand out of the Unit.
2013
Hospital Acquired MRSA
▼ Good
Numerator: Number of healthcare-associated MRSA infections in a month Denominator:
10.0 8.0
Data Owner: Samia, Infection Prevention and Control
6.0 4.0 2.0 0.0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2012
2013
Analysis: An increase in healthcare acquired MRSA in the month of October due the 3 staff nurses are colonizing with MRSA. The 3 staff nurses were treated and transferred.
Page 24 of 82
Clinical Performance Measure
January - December 2013
JCI ILM Cesarean Deliveries
▼ Good
50%
Denominator: Number of nulliparous patients delivered of a live term singleton newborn in vertex presentation
40% 30% 20% 10% 0%
Data Owner: Labor and Delivery Unit Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec WHO Target
2012
2013
Surgical Procedure Cancelation Rate
▼ Good
15% 10%
Numerator: Number of surgery cases cancelled on the same day of surgery in a month.
Data Owner: Daliah, Operating Room
5% Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Target
2012
2013
▼ Good
UTI Incidence per 1000 device days 15.0
Analysis: Data collection for the last quarter of 2013 is not included, OR staff cant’ can’t provide the number of scheduled cases due to lack of secretary as verbalize by the Assistant Director of Nursing Numerator: Number of urinary tract infection in a month Denominator: device days
12.0 9.0
Data Owner: Ms. Samia, Infection Prevention and Control
6.0 3.0 0.0
Analysis: The graph indicates significant decreased of nulliparous patient delivered of a live a singleton newborn in vertex presentation by cesarean section in 2013 it is below the benchmark WHO due to proper data collection and more clarification on data exclusion
Denominator: Number of surgery cases scheduled in a month.
20%
0%
Numerator: Number of nulliparous patients delivered of a live term singleton newborn in vertex presentation by Cesarean section
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec NHSN
2012
2013
Analysis: The data for the last quarter of 2013 is not included due to the Infection Control staff are busy data not yet analyze
Page 25 of 82
Clinical Performance Measure
January - December 2013
Numerator: Patients who received VTE prophylaxis or have documentation of why no VTE prophylaxis was given: ♦ The day of or day after ICU admission or transfer. ♦ The day of or day after surgery end date for surgeries that start the day of or day after ICU admission or transfer.
% of Venous Thromboembolism Prophylaxis 100% 95% 90% 85% 80%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Target
2012
Denominator: Patients directly admitted or transferred to ICU who is at least 18 years of age. Data Owner: Adult Critical Care
2013
Analysis: After clarification of data definition and abstraction the graph indicates 100% compliance. ▼ Good
Specimen rejection Rate 6.0 5.0 4.0 3.0 2.0 1.0 0.0
Numerator: Number of specimens rejected (in accordance with criteria above) in a month Denominator: Number of specimens received in a month Data Owner: Ms. Sausan, Clinical Laboratory
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Target
2012
Medication Error per 10,000 Items Dispense
2013
▼ Good
5
Analysis: The data for the last quarter of 2013 is not included due to the staff are busy for CAP accreditation
Numerator: Number of medication errors in a month Denominator: 10,000 medication items dispensed in a month
4
Data Owner: Elizabeth Zipagan, Risk Management Unit
3 2 1 0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2012
2013
Analysis: An increased in the medication error noted in the last quarter of 2013. Data abstractor can’t explain what is the reason of the increased of medication error Recommendation: • Identify the type of medication error such as administration, dispensing, labeling, omitted dose etc. • Clarify the areas included in data abstraction where the medication error occur
Page 26 of 82
Managerial Performance Measure
LAMA per 100 Admission 7 6 5 4 3 2 1 0
January - December 2013
â–ź Good
Number of LAMA submissions
Denominator: Number of admission X 100 Analysis: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2012
2013
Numerator:
OVR admission per 100 Admission
Number of inpatient OVR
submissions
60.0
Denominator: 100 patient days
50.0
Data Owner: Elizabeth Zipagan, Risk Management Unit
40.0 30.0 20.0 10.0
Numerator:
Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2012
2013
Analysis: Although there is an increased of OVR submission but there are departments and staff does not submit OVR due to the feeling of punitive response to error. It shows in 2013 result of Patient Safety Culture report which is 18.9% Note that a higher result reflects the success of the implementation of the "no blame" reporting culture and is not necessarily a reflection of a higher number of reportable events.
Sharps Injury
â–ź Good
15
Number of reported sharps injuries in a month Denominator:
12
Data Owner: Elizabeth Zipagan, Risk Management Unit
9 6 3 0
Numerator:
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2012
2013
Analysis: The graph shows an increased in number of sharps injury due to the education and encouragement of Infection Control Officer to all staff to report the sharps related injury incident.
Page 27 of 82
Managerial Performance Measure
Average Length of Stay
January - December 2013
▼ Good
15.0
Numerator: Total number of inpatient services for a given period of time Denominator: Total number of days in the same period
10.0
5.0
Analysis: The graph indicates the average length of stay is above the AHRQ length of stay Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Benchmark
2012
2013
Numerator: Inpatient days of care
Occupancy Rate
Denominator: Bed days available X 100 100% 80% 60% 40% 20% 0%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
CDC
2012
2013
Inpatient Admission
Analysis: Although the occupancy rate meets the benchmark in first and last quarter of 2013 but the average length of stay is high and no changes in the inpatient admissions. It only indicates the ineffective utilization care review and patient care management Recommendation: •
Review the Utilization Care Review process
•
Review the data definition of Occupancy rate and ALOS
•
Identify the data source
Numerator: Number of Inpatient Admission
1,200.0 1,000.0 800.0 600.0 400.0 200.0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2012
2013
Page 28 of 82
PI & Accreditation Unit Activities
January - December 2013
Table 2: Opportunities for Improvement & Action Plan Opportunities for Improvement Closed Record Review
Action Plan • •
Key Performance Indicator
Patient Satisfaction Survey (Inpatient and Out Patient Satisfaction survey) Employees Satisfaction Survey
• •
• • •
Utilization Care Review
•
Quality Improvement Projects
•
Healthcare Quality Week 2014 JCI Accreditation
Theme: COMMUNICATING QUALITY: THE
Outcome
PIA staff
Analyn Khadija
Analyn Khadija
Yolanda
Analyn Analyn Khadija All Staff
VOICE FOR HEALTHCARE IMPROVEMENT • • • • • •
Committees
Start in January 2014. Monthly report to the Medical Director and Hospital Executive Committee New KPI to be discuss in the next QMC Meeting. Explain to the department the data definition and data collection Monthly report to be sent to Quality Management Committee and Hospital Executive Committee Coordinate with Statistician about the monthly result. Coordinate with Social service and patient relation for data collection Formulate a team. Request letter from Dr. Kuwaiti to Ms Nada, Dr. Mohye and Dr. Jumaan to nominate staff to be member of the team To obtain the accurate result monitor the bed utilization in percentage Follow-up the PI projects from different units
Responsible
•
On-going review of the 5th edition Review and revise with the chapter teams the policies and procedures and Forms if necessary Educate all employee to the new policies and procedures and forms Implement the policies and procedures Monitor for compliance and identify for the opportunities for improvement To obtain the Gold Seal of approval of the Joint Commission International Accreditation on September 2014 Attend the committee meeting in which the PIA staff are secretary and members to identify opportunities for improvement
All Staff
All PIA staff
Page 29 of 82
KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
Utilization Care Review Report Summary of Avoidable Days Report 1. Extra Pre-operative Day Pre-operative day exceed 2 days Reasons Pre-operative preparation done as inpatient. Patient was admitted without passing Pre Anesthesia Clinic. Patient is not fit for surgery. Recommendations Pre-operative preparation (Investigations) should be done in OPD (Elective OR). All patients for surgery are required to be seen first by the Pre-operative Clinic (Anesthetist). Implementation of Clinical pathways. Implementation of length of stay during admission. 2. Thirty + Days Patient stays in the hospital for more than 30 days. Reasons
Patient is bedridden, ventilator dependent, unconscious and comatose. Patient needs special care and monitoring. Waiting Police clearance. Waiting for caregiver. No family who will take care of the patient.
Recommendations Patient and family education Social Worker Involvement and recommendations. 3. Humanitarian Stay Reasons
Long Term Patient No Caregiver at home Old age – no bed available in home for the aged Patient needs special care and monitoring No family who will take care of them. Patient is bedridden, ventilator dependent, unconscious and comatose.
Page 30 of 82
KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
Recommendations Patient and family education. Social Worker involvement and recommendations. Implementations / Action Taken: A letter sent to all Surgical Department and Admission Office not to admit patient’s for Elective Surgery without going through Pre-Anesthesia Clinic. The Pre-Anesthesia Clinic aim is to decrease the incidence of delays of surgery and cancellations by ensuring that patients are medically ready for surgery. Admission office will not accept patient’s for admission without the stamp of Pre-Anesthesia Clinic on the admission paper. Patients for surgery on next day are not allowed to go out on pass without seeing Anesthesiologist. All surgeons are encouraged to utilize the day- case unit (1C) for appropriate surgeries and patients. The purpose of encouraging all surgeons to utilize the daycase unit is to avoid the overcrowding of patients in the inpatients unit and to properly utilize the services and resources of KFHU.
Page 31 of 82
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KING FAHD HOSPITAL OF THE UNIVERSITY
Utilization Care Review Report
Table 3: Avoidable Days Report (January – December 2013) Jan
Barriers
Feb
Mar
Apr
May
June
Jul
Aug
Sept
D/C Order Delay
Oct
Nov
Dec
1
No Severity of Illness Extra Pre-operative Days Thirty +Days Other Consult Delay Patient/Family Insists Hospital Delayed Pick-up
1
No Home Care Available Humanitarian Stay
13
14
10
11
14
18
6
7
5
2
7
7
36 1
33
24
37
24
35
32
25
28
23
25
26
2
1
2
1
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
2
2
1
1
1
1
1
1
31
25
19
17
17
17
18
18
18
19
2 2
25
25
Figure 3: Avoidable Days Report (January – December 2013) 40 35 D/C Order Delay
30
No Severity of Illness Extra Pre-oerative Days
25
Thirty+Days
20
Other Consult Delay
15
Patient/Family Insists Hospital Delayed Pick-up
10
No Home Care Available
5
Dec
Nov
Oct
Sep
Aug
July
June
May
Apr
Mar
Feb
Jan
0
Humanitarian Stay
Page 32 of 82
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KING FAHD HOSPITAL OF THE UNIVERSITY
Department Urology General Surgery Pediatric Surgery Vascular Surgery Cardiothoracic Surgery Plastic Surgery Opthalmology Neurosurgery ENT Orthopedics OB Gyne
Table 4: Extra Pre-operative Days (January – December 2013) Jan Feb Mar Apr May June July Aug Sep 2 1 1
3 4 2
5 2
1 1 2 1 2
2 1 1 1 1 1 3
2 5
1
2 1
3 1
5 4
3
1
4 2
1 3 2 2
2
3
2
Oct
Nov
Dec
1
2
4
1
1
2
2
1
1 1 2
1 2 1
2
1
2
Figure 4: Extra Pre-operative Days (January – December 2013) 5
Urology
4.5
General Surgery
4
Pediatric Surgery
3.5
Vascular Surgery
3
Cardiothoracic Surgery
2.5 2
Plastic Surgery
1.5
Opthalmology
1
Neurosurgery ENT
0.5 0
Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec
Orthopedics
Page 33 of 82
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KING FAHD HOSPITAL OF THE UNIVERSITY
Figure 4a: Extra Pre-Operative Days (January – December 2012) 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 Jan
Feb
Mar
Apr
May
June
Opthalmology
July
Aug
Sept
Oct
Nov
Dec
Oct
Nov
Dec
January - December 2013
4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 Jan
Feb
Mar
Neurosurgery
Apr
May
June
July
Aug
Sept
January - December 2013
Page 34 of 82
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KING FAHD HOSPITAL OF THE UNIVERSITY
Figure 4b: Extra Pre-Operative Days (January – December 2012) 2.5 2 1.5 1 0.5 0 Jan
Feb
Mar
Apr
May
June
ENT
July
Aug
Sept
Oct
Nov
Dec
Oct
Nov
Dec
January - December 2013
2.5 2 1.5 1 0.5 0 Jan
Feb OB Gyne
Mar
Apr
May
June
July
Aug
Sept
January - December 2013
Page 35 of 82
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KING FAHD HOSPITAL OF THE UNIVERSITY
Figure 4c: Extra Pre-operative days (January – December 2013)
6 5 4 3 2 1 0 Jan
Feb
Mar
Apr
May
June
General Surgery Department
July
Aug
Sept
Oct
Nov
Dec
January - December 2013
3.5 3 2.5 2 1.5 1 0.5 0 Jan
Feb Orthopedics
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
January - December 2013
Page 36 of 82
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KING FAHD HOSPITAL OF THE UNIVERSITY
Figure 4d: Extra Pre-operative days (January – December 2013)
3.5 3 2.5 2 1.5 1 0.5 0 Jan
Feb
Mar
Apr
May
June
Vascular Surgery
July
Apr
Sept
Oct
Nov
Dec
Oct
Nov
Dec
January - December 2013
1.2 1 0.8 0.6 0.4 0.2 0 Jan
Feb
Mar
Plastic Surgery
Apr
May
June
July
Aug
Sept
January - December 2013
Page 37 of 82
KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
Page 38 of 82
KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
DOCUMENTS CONTROL UNIT Policies and Procedures: DQS has collaborated with the different departments of KFHU to develop clear policy and procedure documents on safety and quality issues. The total policies and procedures that were completed were 777. Out of this, 583 were signed and approved and some were implemented. All policies and procedures that were signed and approved were downloaded to all nursing units and departments of the hospital.
Figure 1: KFHU Departments Policy & Procedure
Page 39 of 82
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KING FAHD HOSPITAL OF THE UNIVERSITY Job Description:
This year, the Documents Control Unit has completed almost 87% of the job description for KFHU. The remaining 13% represent the number of departments that has not complied with the requirements set forth by the hospital administration.
Job Description Update 13% Submitted 87%
Not Submitted
Figure 2: Job Description Update
Hospital Forms The unit also completed and re-formatted all existing forms of the hospital. There were 20 forms proponent. The total forms that were completed were 222 and 111 priority forms were printed and are now being used across the hospital.
Figure 3: Hospital Forms
Page 40 of 82
KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
Scope of Service
Figure 4: Department Scope of Service
COMMITTEES & JCI CHAPTERS Committees of King Fahd Hospital of the University # 1 2 3 4 5
6 7 8 9 10 11 12 13 14 15 16 17
KFHU COMMITTEES Hospital Executive Committee Credentialing & Privileging Committee Medico-Legal Committee Equipment Utilization & Stock Review Committee Medical Executive Committee A. Peer Review Subcommittee B. Trauma Subcommittee Hospital Safety Committee Hospital Disaster Committee Quality Management Committee Infection Control Committee Medical Records & Health Information Committee Institutional Review Board Committee Drug & Therapeutics Committee Surgical & OR Committee Tissue Review Committee Transfusion Committee Morbidity & Mortality Committee Critical Care Committee Table 1: Committees of KFHU
HEC CPC MLC EUSRC MEC
HSC HDC QMC ICC MRHIC IRBC DTC SORC TRC TFC MMC CCC
# of Meetings 9 2 7 0 3 4 1 7 6 2 4 6 7 2 3 2 7 6 1
Page 41 of 82
KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
Figure 5: KFHU Committees JCI Chapter Teams
# 1 2 3
4 5 6 7 8 9 10 11
JCI TEAM Management of Communication and Information Governance, Leadership & Direction Medication Management & Use Access to Care & Continuity of Care Assessment of Patient Care of Patient Patient and Family Education Patient and Family Right Anesthesia & Surgical Care Quality and Patient Safety Prevention & Control of Infection Facility Management and Safety International Patient Safety Goal Staff Qualification and Education Human Subject Research Program Medical Professional Educational
# of Meetings 2 MCI/GLD MMU ACC AOP COP PFE PFR ASC QPS PCI FMS IPSG SQE HRP MPE
2 4 5 1 1 1 3 2 0 4 2 5 6 4
Table 2: JCI Chapter Teams
Page 42 of 82
KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
Figure 6: JCI Chapter Teams JCI Joint Chapter Team
# 1 2 3 4 5 6
JCI TEAM Management of Communication and Information Governance, Leadership & Direction Staff Qualification and Education Access to Care & Continuity of Care Assessment of Patient Care of Patient Facility Management and Safety International Patient Safety Goal Patient and Family Education Patient and Family Right JCI Team Leaders JCI Steering Committee
# of Meetings MCI/GLD ACC AOP COP FMS IPSG PFE PFR
0 0 7 3 1 3
Table 3: Joint JCI Teams
Figure 7: Joint JCI Teams
Page 43 of 82
KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
TEAMS
# 1 2 3 4 5 6 7 8
Teams Closed Record Review Code Blue Environmental & Safety Failure Mode & Effect Analysis - FMEA Forms Patient Satisfaction Rapid Response Utilization Review
# of Meetings 2 0 0 4 3 1 2 1
Table 4: KFHU Teams
Figure 8: KFHU Teams TASK FORCES # TASK FORCE 1 Laboratory Supply 2 Strategic Planning Table 5: Task Forces
# of Meetings 2 3
Figure 9: Task Forces
Page 44 of 82
KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
Page 45 of 82
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KING FAHD HOSPITAL OF THE UNIVERSITY
ENVIRONMENTAL & SAFETY UNIT Scope of Environmental & Safety Unit: The Environmental Health & Safety Unit (ESU) coordinated to establish a structured Environmental & Safety monitoring program at KFHU that is focused at continuous quality improvement. The unit was also involved in establishing administrative and internal departmental policies & procedures with regard to Facility Management System (FMS) chapter of JCIA in coordination with the FMS Chapter Committee. The broad areas of department functions include: 1. Environmental Safety Monitoring Program 2. Implementation of JCI standards on FMS 3. Facilitate initiatives of Hospital Safety Committee & Hospital Disaster Committee 4. Orientation & Training Environmental Safety Monitoring Program: Each environment of care poses unique risks to the patients, the employees and medical staff who use and manage it, and to others who enter the environment. The environmental elements and issues can contribute to positively or negatively influencing patient outcomes, satisfaction, and patient / staff safety. Objective: Proactive risk assessment and management Environmental Safety Rounds (ESR) Program: A periodic appraisal to warrant that all KFHU facilities are maintained in a clean, safe, and sanitary manner which includes mechanisms to identify evident risks within environment of care at KFHU. All areas at KFHU were subjected to unannounced monitoring rounds using a predefined checklist periodically as per an established schedule. Figure 2 illustrates the areas surveyed during the report period (January to November 2013) and Figure 3 indicates the frequency of surveys. A multidisciplinary focus group that consists of select representatives from the patient service and support departments with primary and collaborative responsibility for providing a safe, secure, and comfortable environment to facilitate patient care effectively collaborated to the success of the environmental safety monitoring program. Figure 1: Process for risk reduction
Risk Identification Communication of identified risks to Action plan respective department to reduce the Follow up to risks resolve pending issues
Risk Reduction
Page 46 of 82
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KING FAHD HOSPITAL OF THE UNIVERSITY
Communication on department compliance to safety requirements, identified risks and follow-up monitoring rounds by the unit has helped to determine closure of issues reported to the respective departments. Figure 3 illustrates the compliance range obtained by some departments. Figure 2: Areas surveyed (January – November 2013)
Figure 3: Frequency of surveys (January – November 2013)
Areas Surveyed Jan-13
Feb-13
Mar-13
Apr-13
Pharmacy
CCU
Ophthalmology
Blood bank
Radiology
OR
Dermatology
EHS
OPD
ENT
Kitchen(1)
Day Surgery
PT
Peritoneal Dialysis
ER
IT May-13
Jun-13
Jul-13
Aug-13
Medical Store
LAB (500)
Gen.Store
ICU
Psychiatry
Roof Top
O&M Millipore
Burn Unit
O&M Mechanical
Kitchen(2)
Sep-13
Oct-13
December-13
MRD
Housing
Medical Waste Transportation O&M Workshops FAMCO
BLD.500
4A-4B-4C-4D4E
Frequency Surveys December November October September August July June May April March February January
0
5
10
3A-3B-3C3D-3E 2A-2B-2C-2D CCU Security & Mosque
Page 47 of 82
15
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KING FAHD HOSPITAL OF THE UNIVERSITY
Figure 4: Department compliance (January – November 2013)
Department Compliance - 2013 90% 80% 70% 69%
60% 50%
57%
58%
60%
65%
69%
65%
70%
70%
74%
69%
80%
79% 70%
69%
73%
54%
54%
40%
45%
51%
44%
30% 20% 10% 0%
The departments’ enthusiasm to implement the identified action plan focused at reducing safety risks within their area is evident from the following graphs. There has been notable increase in the responses compared to earlier period. Figure 5 illustrate the ratio of responses received from departments against the reports generated. Table 1: Responses received vs reports generated DEPARTMENT Physical Therapy Transportation OR (Anesthesia) Biomedical Engineering Blood bank Dermatology Diagnostic laboratories Diatery Department ENT Department ER Department FAMCO IT Department Medical supply Ophthalmology Pharmacy Department Psychiatry Department Radiology Department Stores Administration
SENT 1 1 1 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1
RECEIVED x x x x x x x x x x x x x x
Figure 5: Action Plan Reports Received
Action Plan Reports Received 2013 Sent
Received 32
31
31 27
24 14
13
Houskeeping Nursing Department Department
16
Operation & Safety Maintenance Department
Page 48 of 82
KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
SOME OF THE SIGNIFICANT ACHIEVEMENTS: 1. We have done proactive risk assessment for all parts of the hospital such as inpatient and outpatient areas, support services, FAMCO, roof top and more. 2. Our report have guided department to reduce their safety hazards. 3. We have collaborated with departments to implement patient safety initiatives for example a. Ensure patient emergency call bell system in all toilets. b. Daily temperature monitoring for all medication refrigerators. 4. We facilitated to implement fire extinguisher& fire hose maintenance program. 5. We coordinated to make safety signage in all hospital in Arabic and English. a. No smoking sign b. Elevator safety sign ( in case of fire don’t use elevator use stairs) c. Emergency call bell inside patient toilet (pull the cord if you need assistance). 6. Storage and use of hazardous materials in the hospital were regulated according to the newly established procedure. Eg: Secured storage of flammable liquids and chemicals, specially designed storing facility for radioactive material, MSDS folders were made available in all the wards, leak proof containers were introduced for housekeeping staff to keep their supplies on while on the trolley, etc 7. Comprehensive emergency management procedures were formulated for the hospital with regard to disasters, fire, bomb threat, child abduction, large chemical spills and violence management. 8. We closely work with disaster & safety committee to address a safety issue in the hospital and to organize training on disaster management through mock drills. 9. JCI-FMS Documentation: a. 7 FMS plans were developed – Safety, Security, Hazardous Material Management, Biomedical Equipment Management, Utility Systems Management, Fire Safety and Emergency Management. b. Approximately 120 policies were developed for meeting the standard requirements. 10. The Unit coordinated to organize disaster & fire mock drills within the hospital including various communications between departments, training programs, resource identification & department preparedness. 11. During healthcare quality week we establish our own booth for environmental health & safety which we utilized for making staff aware of various aspects of safety in the hospital by distributing brochures, asking questions and using interesting & educative tools to attack staff attention and response was overwhelming . 12. Training: The Unit conducted numerous training sessions, including mandatory lectures and general orientation program for various groups of staff as illustrated in Figure 6.
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DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KING FAHD HOSPITAL OF THE UNIVERSITY
International Patient Safety Goals (Physicians & Allied Health Professionals)
10 Lectures
International Patient Safety Goals Code Pink Code Mr. Strong
5 Train the Trainer (Nurses)
General Safety Practices Electrical Safety Medical Devise Safety Emergency Codes @ KFHU HAZMAT Management International Patient Safety Goals
10 General Orientations
Overview on Healthcare Quality Principles of Healthcare Quality Overview of Environmental Health & Patient Safety Patient Safety HAZMAT Management Emergency preparedness Utility System Management
2 Orientations – Interns (HIMT)
Figure 6: Staff trainings sessions
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
RISK MANAGEMENT UNIT OVERVIEW This report provides a comprehensive overview on the Occurrence Variance Reports (OVRs). It covers all the incidents received by the Risk Management Unit for 2013. Data was collected and thoroughly analyzed and presented here in a simple format. The aim of this report is to highlight the identified opportunities for improvement and come up with solutions for the system and process failures. This report provides an assessment of the actual and potential risks in KFHU in addition to recommendations on how to lessen these risks in the future. This report consists of the following elements: • • • • •
Top 5 Clinical reported OVRs. Top 5 Non-Clinical reported OVRs. Top reporting departments. IPSG related OVRs. 2014 Goals of Risk Management
“Risk is like fire, If controlled, it will help you; if uncontrolled it will rise and destroy you” - Theodore Roosevelt
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DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KING FAHD HOSPITAL OF THE UNIVERSITY INTRODUCTION
The total number of reported OVRS from January to December 2013 is 7986. An increase in reporting was noted each month except July with was the month of Ramadan. Total number of OVRs in 2013 in the 3rd and fourth quarter increase by 10% and 25% compared to 2012 respectively. Only 73 reported incidents were classified as non-OVR. There was a total of 4 sentinel and 3 near messes. Figure 1: Total Number of OVRs for 2013
Total Number of OVRs for 2013 2012 OVRs
2013 OVRs
900 800 700 600 500 400 300 200 100 0
Comparison between the 3rd and 4th quarter 2012
2013
2500
Open OVR 9%
OVR STATUS
close OVR 91%
2000 1500 1000
Figure 3: OVR Status
500 0
1671 1837 3rd Quarter
1849 2314 4th Quarter
Figure 2: Comparison between the 3rd & 4th Quarters
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DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KING FAHD HOSPITAL OF THE UNIVERSITY
TOP CLINICAL OVRS
Top 5 clinical OVRS for 2013 1800 1600 1400 1200 1000 800 600 400 200 0
1617 1166
1131
474
Overstyaing of patient
DAMA
Break in skin integrity
OR cancellation
382
Line, tube, drain or catheter
Figure 4: Top 5 Clinical OVRs for 2013
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DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KING FAHD HOSPITAL OF THE UNIVERSITY
TOP CLINICAL OVRS Patient overstaying in ER (20%) Overstaying of patient in ER refers to the cases where patients stay in Emergency Room for 6 hours or more. This category is the highest reported OVRs with a percentage of 20% from the total number of OVRS reported for 2013. There’s no significant improvement in the 3rd and 4th quarter compared to 2012. The highest reason for overstaying is medical re-evaluation which represent 55% of the total variances and this is due to the complexity of the patient’s pre-existing condition and natural course of treatment (e.g. CT scan, further referral to another service for consultations). Bed unavailability is another top reason of patient overstaying in ER. Figure 5: Patient Overstaying in ER
Patient Overstaying in ER 250 200 150
160
151
126
153
143
123
102
100 94
50
108
120
113
110
113
121
158
155
144
202
2012 2013
0
Reasons for overstaying of patient in ER no isolation bed available
7
patient refused to leave
9
Admission process
9
Non-eligible patients in ER
waiting for relatives
10
Discharge process
13
patient for blood transfusion
21
no ICU bed available not eligible
discharg ed 38% admitte d 62%
38 87
no bed available medical re/evaluation
Figure 7: Non-eligible patients in ER 523 894
Figure 6: Reasons for overstaying of patient in ER Page 55 of 82
KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
TOP CLINICAL OVRS DAMA (15%) Discharged Against Medical Advice stands for the cases where patients of their families refused health advices or decide to leave the hospital contrary to the judgment of healthcare team personnel. Discharged Against Medical Advice is the second highest reported OVR for 2013. 62% of reported DAMA were from ER and 38% were reported by in-patient units. Although it is acknowledged that refusing treatment is one of the patient’s rights, KFHU healthcare providers make all possible efforts to convince the patients to stay and not to take such decision.
Location of reported DAMA In-pt 38% ER 62%
Figure 8: Location of reported DAMA
Reasons for DAMA Refused investigation
19
Out on pass
31
Refused to wait for… Refused…
44 293
Refused admission
373
Refused to stay in-… 0
403 100 200 300 400 500
Figure 10: Reasons for DAMA
Figure 9: Refusal of Admission / Treatment Form
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DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KING FAHD HOSPITAL OF THE UNIVERSITY TOP CLINICAL OVRS Break in Skin Integrity (14%)
Table 1: Type of Break in Skin Integrity
Skin integrity is of outmost importance as hospital-acquired pressure ulcer, skin tears and infections are associated with pain, reduced mobility, increased risk of complications and prolonged length of stay in the hospital. A total of 1189 were reported incidents pertaining of Break in Skin Integrity for 2013. Top five reported type of Break in Skin Integrity are Hematoma (51%), Peeling (15%), Redness (14%), Blister (8%) and Pressure ulcer (6%). Blood extraction is the highest reason why a patient obtains a hematoma which is related to the patient existing condition or the extractors’ individual performance. Warm or cold compress are given to patients to relieve or make the hematoma subside.
Type of Break in Skin Integrity Number Hematoma 605 Peeling 182 Redness 162 Blister 95 Pressure ulcer 66 Ecchymosis 25 Wound 21 Swelling 20 Bruises 7 Diabetic foot 2 Burn 2 Abrasion 2 Grand Total 1189
Figure 11: Causes of Hematoma
Causes of Hematoma 350 300 250 200 150 100 50 0
Pressure ulcer
322 173 55
6
7
5
21
14
Develo ped 38%
Admitt ed 62%
Figure 12: Pressure Ulcer
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DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KING FAHD HOSPITAL OF THE UNIVERSITY TOP CLINICAL OVRS
Table 2: Causes of OR Cancellation
OR Cancellation (6%) A cancelled operation can cause waste in time and money. Eliminating OR cancellation reduces rework and maximize the flow of patients in OR. For year 2013, OR cancellation remains to be one of the top reported variances. The top three reasons for OR cancellations are Patient’s condition (unfit for surgery) 36%, Lack of time 19% and Patient didn’t come 18%.
Line, Tube, Drain or Catheter (5%) Type of Line, tube, drain or catheter IV infiltration Central Line ETT Feeding tube Foley catheter Wound drain Peg tube Dialysis catheter Others Epidural catheter Drain IV line EVD Chest tube Total
Number 171 25 24 18 15 9 8 8 8 5 4 4 3 2 304
Cause of OR cancellation Patient’s condition Lack of time Patient didn’t come Bed not available (post-op) Patient refused Consultant/Staff unavailable Equipment failure or unavailable Pre-operative guideline not followed Change of procedure Others Grand Total
Regular checking of patient’s IV lines, wound drains, feeding tubes (NGTs, gastrostomy, Jejunostomy, etc.), catheters and dialysis catheter as well as its patency prior to use is very important. For 2013 Line, tube, drain or catheter is one of the top reported clinical variance. The top three most reported variance are IV infiltration 56%, followed by Central line and Endotracheal tube (ETT) with a percentage of 8% each and Feeding tube 6%.
Table 3: Type of Line, Tube, drain or catheter
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Number 147 78 73 53 21 11 11 6 5 4 409
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KING FAHD HOSPITAL OF THE UNIVERSITY
TOP NON-CLINICAL OVRS Non-Clinical OVRs include risk associated with: occupational health and safety, Maintenance services, Communication, support services (housekeeping, laundry and food services).
Top 5 Non-clinical OVRS for 2013 180 160
154
153 134
140 120
92
100
76
80 60 40 20 0 Missing patient or other person
Non-clinical equipment
Building Gas, power, Housekeeping structure or water or issue infrastructure heating faliure
Figure 13: Top 5 Non-clinical OVRs for 2013
“Managing risk is not just about assessing and monitoring all the things that could go wrong. Rather it is about understanding all the things that needs to go right for an organization to achieve its mission and objectives.”
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KING FAHD HOSPITAL OF THE UNIVERSITY
TOP NON-CLINICAL OVRS Missing patient or other person The highest reported non-clinical OVR is missing patient or other person, which pertains to a patient who left the hospital premises without permission. A total of 154 reported incidents concerning a patient who left without informing the staff or healthcare member. The chart showed the locations where such case happened. The top three locations wherein a patient is missing are Emergency Room (ER) 67%, 3C (Male Medical Ward) 8% and 3D (Male Medical Ward) 6%. Figure 14: Location of reported missing patient
103
ER
Location of reported missing patient
12
10
9
7
3
3
2
2
1
1
1
3C
3D
3B
3E
2C
3A
4C
4D
1D
4E
5A
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
TOP NON-CLINICAL OVRS Table 4: Non-clinical equipment
Non-clinical equipment Call bell Door Bed Computer network Telephone Cabinet Computer Refrigerator Copier machine Sink Sterilizer machine Air-conditioning Fire extinguisher Printer Sealer machine Weighing scale Light bulb Toilet Windows Emergency light Floor polisher Ice maker Keys Venetian blind Others Grand Total
Number 16 14 9 9 9 8 8 7 5 5 5 4 4 4 4 4 3 3 3 2 2 2 2 2 19 153
Non-clinical Equipm ent Non clinical equipment refers to different device that is not used in direct patient care treatment. The top three most reported with variance are the Call bell (10%), Door (9%), and bed, computer network and telephone, which tied up in (6%). Other reported Non-clinical equipment were malfunction or breakage of the drain, bidet, blanket warmer, exhaust fan, faucet, wall clock and television.
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DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KING FAHD HOSPITAL OF THE UNIVERSITY
TOP NON-CLINICAL OVRS Building structure or infrastructure For the year 2013 Building structure or infrastructure are one of the top reported variance. The most reported is the Condensing water 25% which was reported during the months of September – November. Next is the Malfunctioning of the electronic door 18% in the Psychiatry unit, which happens almost monthly Figure 15: Electronic Exit Doors Malfunction in Psychiatry Unit
Electronic Exit Doors Malfunction in psychiatry Unit 8 6 4 2 0
6 3
4 2
2
3 1
3
Type of Building structure or infrastructure
Number
Air-conditioning Ceiling tile Condensing water Door Electronic door Elevator Floor Floor tiles Fungal infection Glass door Glass window MRI Layout Negative pressure Oxygen outlet Suction outlet Wall Water leak Water pipe Window Grand Total
17 20 33 5 24 2 1 5 1 1 1 1 3 2 1 8 6 2 1 134
Table 5: Type of Building Structure or Infrastructure
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DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KING FAHD HOSPITAL OF THE UNIVERSITY
TOP NON-CLINICAL OVRS Gas, Power, Water or Heating Failure A total of 92 OVRs were reported about Gas, Power, Water, or Heating failure. The most frequent reported type of failure in the year 2013 is the “Power Shutdown” which comprises 62% of the total reported OVRs in this category. Followed by “Water Shutdown” 26% and “Unavailability of Hot Water” 7% respectively.
Type Power shutdown Water shutdown Hot water unavailable No hot water supply No treated water supply Medical air Grand Total
Number 57 24 6 2 2 1 92
Table 6: Gas, Power, Water or Heating Failure
Housekeeping Services (1%) A total of 76 reported OVRs are inrelation to Housekeeping. No housekeeper available (34%) is the most reported variance followed by Poor Housekeeping service (28%), which includes waste bin not replaced, room not clean or tidied up. The third most reported is No transporter available in the unit (18%) which is also important as they are the one sending laboratory samples or help the nurse if a patient is to be discharged or transferred to another unit or service.
Reported OVRs related to Housekeeping 30 25 20 15
26 21 14
10
7
5 0
no poor no housekeeper housekeeping transporter services
5
3
utility room floor polish inadequate unavailable out of order No. of housekeepers
Figure 16: Reported OVRs related to Housekeeping
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DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KING FAHD HOSPITAL OF THE UNIVERSITY
T O P R E P O R T I N G U N I T S A N D D E PA R T M E N T S Occurrence Variance Reporting System at King Fahd Hospital of the University started last May 2012. Top reporting departments Nursing Medical Infection Control Laboratory Pharmacy Medical Records Physiotherapy Housekeeping Medical DQS Medical Store Radiology Safety Maintenance Dental Dietary Total`
Count 7822 26 24 21 20 13 12 11 11 9 5 4 3 3 1 1 7986
Table 7: Top Reporting Departments
Rate 98% 0.32 % 0.30 % 0.26 % 0.25 % 0.16 % 0.15 % 0.14 % 0.14 % 0.11 % 0.06 % 0.05 % 0.04 % 0.04 % 0.01 % 0.01 %
For the year 2013 a total of 7986 OVRs were received hospital-wide. Majority of the reported OVRs are from Nursing Department (98%), followed by Medical Department (0.32 %) and Infection Control (0.30 %).
Figure 17: Medical Reporting Departments
Medical Reporting Departments 1 1 1 1
Rheumatology clinic ENT General Surgery Anesthesia
2
3 3
4
OB Gyne
Reporting Departments Others 11% ER 36% In-pt 53%
Figure 18: Reporting Departments
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5 5
KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
I N T E R N AT I O N A L PAT I E N T S A F E T Y G O A L S
Figure 19: IPSG-Related Reported OVRs for 2013
Figure 20: Number of Reported IPSG-Related OVRs per month for 2013
Our focus is to collect and analyze data, evaluate care processes in order to reduce risk and initiate preventive actions especially with regards to the following international patient safety goals:
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
I N T E R N AT I O N A L PAT I E N T S A F E T Y G O A L S IPSG 1: Identify Patient Correctly Patient identification and the matching of a patient to an intended treatment is an activity that is performed routinely in all care settings. Risks to patient safety occur when there is a mismatch between a given patient and components of their care, whether these components are diagnostic, therapeutic or supportive. A total of 97 cases were reported as Patient Identification. 30% of the variances were reported as incorrect name or medical record number. Followed by 25% for incomplete demographic. For the ID band OVRs a total of 14 cases were reported (15%) as cut of ID band, and 13% as unreadable ID band.
Figure 21: Classification of OVRs related to IPSG 1
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DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KING FAHD HOSPITAL OF THE UNIVERSITY
I N T E R N AT I O N A L PAT I E N T S A F E T Y G O A L S IPSG 2: Improve effective communication A total number of 13 reported incidents were related to IPSG 2, 6 OVRs were about Critical Value not relayed to physician and 4 OVRs were due to poor endorsement upon admission or transfer. IPSG 3: Improve the safe of high alert medication 2 OVRs were reported in relation to IPSG 3 which are related to the administration and storage of High-Alert Medication. IPSG 4: Ensure patient surgery
correct-site,
correct
procedure,
correct
No reported incidents related to IPSG 4 for the year 2013. IPSG 5: Reduce the risk of healthcare associated infection Infection prevention and control are challenging in a health care settings. Reported variances were about non-compliance to PPE, admission of patients in the unit without and with incomplete multi-drug resistant organism screening and unavailability of isolation bed.
Figure 22: Classification of OVRs related to IPSG 5
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
I N T E R N AT I O N A L PAT I E N T S A F E T Y G O A L S IPSG 6: Reduce the risk of falls A significant portion of injuries in hospitalized patients is about falls. The organization should evaluate its patients’ risks for falls and take action to reduce the risk of falling and reduce the risk of injury if fall occurs. Total number of falls for 2013 is 85. A recommendation is to implement a Fall Risk Assessment to indicate patient with a chance of fall due to the patient condition or medication.
Figure 23: Distribution of Age and Gender among Reported OVRs
Figure 24: Falls in 2013
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
2014 GOALS
For 2014, Risk Management Unit aims to: Improve the occurrence variance reporting system thru:
Launching of Electronic OVR System Broaden the scope of reporting departments Strengthening by education that OVRs are non-punitive and not to point fingers at anybody. Instead, identify the gaps in the existing process and improve it to avoid re-occurrence of the same incidents. Reporting monthly to every reporting department or unit.
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
EDUCATION & TRAINING UNIT Introduction The Education & Training Unit (ETU) a part of the Directorate of Quality & Safety (DQS) grasps that education and training are important in order to give the employees of King Fahd Hospital of the University (KFHU) the necessary knowledge to bring about quality improvement and safety across the hospital. Through its constant collaboration and partnership with the different departments of KFHU, ETU continued to provide educational opportunities developed specifically to educate the hospital employees on different Joint Commission International standards with special emphasis on patient centered care and employees’ safety. 2013 has been another excellent year for Education & Training Unit of DQS. We increased the educational and training activities for the staff at every level to be able to take up educational opportunities to broaden their skills and competencies in relation to quality and safety. The Unit’s innovative and flexible approaches have continued to ensure that we have highly competent staff consistently delivering high quality care. Activities of ETU:
Coordinates interns from Health Information Management & Technology Program (HIMT) of the College of Applied Medical Science of the University of Dammam Interns training activities.
Organizes and coordinates DQS Training for Trainers.
Prepare and send letters of invitation for lectures conducted.
Documents all the educational activities conducted in the hospital.
Assists with JCI mock survey such as helping with the distribution and compiling the JCI manuals.
Provides continuous support for professional development in KFHU and creates awareness on life-long learning.
Significant accomplishment for 2013 DQS has had a very successful Healthcare Quality Week (September 8 – 12, 2013) that highlighted the outstanding quality and patient safety work being done across the KFHU. This was an opportunity for staff and physicians to celebrate their accomplishments.
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DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
KING FAHD HOSPITAL OF THE UNIVERSITY
Healthcare Quality Week is another opportunity to educate staff and physicians on the issues. During the week of celebration, lectures were conducted and were well attended:
Lectures Conducted during Healthcare Quality Week 57 50
44
Emergency Preparedness
44
International Patient Safety Goals
JCI Survey Process
Prevention & Control of Infection
Figure 1: Lectures Conducted during Healthcare Quality Week
Over the past year ETU worked diligently to collaborate education sessions with other departments of KFHU. Outlined below are some of the highlights and accomplishments achieved by the department in 2012-13. Educational activities conducted in year 2013:
Lectures Conducted in 2013 & Attendees
SQE
PFR / PFE
IPSG
IPSG 4
Hand Hygiene Campaign
GLD
FOCUS-PDCA (OR PI Project)
COP
Code Pink & Mr. Strong
ASC
AOP
Adverse Drug Reaction…
700 600 500 400 300 200 100 0
Figure 2: Lectures Conducted in 2013 & Attendees
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
Figure 3: 2013 Calendar of Activities / Campaign / Lectures / Training
Interns Training One of the DQS mission is to continuously provide the graduates of the HIMT with concrete learning and training in diversified quality improvement aspects. It is also the DQS aim to provide them with updated quality trends to challenge modern quality management advances and responsibilities and to provide an outstanding quality care for the community. The objectives of the DQS Internship Training Program are: •
To enhance their knowledge, skills and competency in the quality practice.
•
To provide them an insight particularly in the major areas of quality improvement.
•
To be involved in research projects that can motivate them to show their innovative ideas and develop their writing abilities.
•
To awaken their interest in pursuing graduate studies and continuing medical education.
•
To excel in verbal communication and usage of visual aids by gaining skills in formal lectures and seminar presentations.
•
To maximize their views on latest programs in quality through community involvement.
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
The DQS Internship Training Program is administered by the Education and Training Unit and requires interns to participate in different quality improvement rotations for a period of 3 months, which is divided into two major aspects: •
Quality Improvement Activities (data collection, analyzing, encoding)
•
Didactic Activities
The Unit has trained five (5) interns from the Health Information Management & Technology (HIMT) Program of the College of Applied Medical Science of the University of Dammam. The interns from HIMT were trained in different units of DQS. Lectures on specific topics related to quality and safety is also given on a daily basis. Practical applications of the lectures and other educational materials are being applied once the interns were allocated to the different units of the directorate. Performance Improvement Projects (PIPs) The purpose of performance improvement projects (PIPs) is to evaluate and improve processes, and thereby outcomes, of care. To be able to start a project to achieve real improvements in care, and to have confidence in the reported improvements, PIPs must be designed, conducted and reported in a methodologically sound manner. Structure of PIPs Topics selected for the project must reflect the KFHU enrollment in terms of demographic characteristics, prevalence of disease and the potential consequences (risks) of the disease. All PIPs should target improvement in relevant areas of clinical care and non-clinical services. The interns will be given a performance improvement project (PIP) where they will be guided by the Coordinator of the PI & A Unit is collecting data to be able to formulate their report and present the PIP at the end of the internship period. Each intern will work and supervised by the Coordinator in preparing and presenting a performance improvement project. The PIP topic is usually selected by the Coordinator and carried out under the supervision of the PI & A Unit. Selection of the topic is usually done at the beginning of the internship. This is mainly to give the Intern the chance in familiarizing the topic and to start exploring the internet to be resource guidance in the completion of the project during the training program. Objectives of a PIP:
To cultivate the ability of the intern in designing and writing a report and presentation. To encourage and acquaint the intern to do literature research and use the available database for this purpose.
PIPs conducted from last quarter of 2012 to 2013 Overstaying in Emergency Room Rapid Response Team Operating Room Procedures Cancellation Falls Hand Hygiene Compliance ICU Infection Rate Interns were evaluated according to their performance in the directorate. Final evaluation reports were submitted to the Director of the HIMT program. Page 74 of 82
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DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
Education & Training Activities (in picture):
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DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
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DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
DECISION SUPPORT UNIT Decision Support Unit (DSU) is working under Directorate of Quality and Safety. DSU Staff are specialist in Management Information Technology and Statistics. The DSU activities are monitored through more than 50 selected hospital areas/sections. This unit collects and analyzes the data relevant to the service provided to the patient in King Fahd Hospital of the University. Also DSU monitor and manage the hospital manpower. The statistical outcomes supported and represent via tables, graphs and diagrams, and forwarded to the higher administration of the hospital and University of Dammam in forms of weekly, monthly, and yearly reports or according to their requests. Copies from these reports are sent frequently to the Ministry of Health and the Ministry of Finance according to the Planning & Budgeting Department of University of Dammam.
Table 1: Decision Support Unit Activities & Tasks Table During the Year 2013
Description
No. of Statistics Reports Inside Hospital No. of Statistics Reports Outside Hospital Graphs No. Done No. of data statistics forms collected from hospital departments No. of data statistics forms collected hospital electronic medical system Researches Statistics reports Other statistics reports
No. 82 22 1788 4105 3256 177 302
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DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
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KING FAHD HOSPITAL OF THE UNIVERSITY
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
The major goals for 2014 of the Director of Quality & Safety include the following:
Implementation and continuous monitoring of all JCI standards to ensure compliance
Highlight the new standards required in the 5th Edition (Joint Commission International Hospital Standards)
Training & Education for all JCI chapters by the external consultants
Monitoring of hospital-wide key performance indicators (KPIs)
Conduct the Healthcare Quality Week for KFHU 2014
Continue to assist all departments to develop or review the policies and procedures based on the standards & findings of the external consultants, intent statements and measurable elements’ requirements.
Train interns from Health Information Management & Technology, University of Dammam
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DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
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KING FAHD HOSPITAL OF THE UNIVERSITY
CS
Cesarean Section
DCU
Documents Control Unit
DQS
Directorate of Quality & Safety
ESU
Environmental & Safety Unit
ETU
Education & Training Unit
FAMCO
Family & Community
HQW
Healthcare Quality Week
HRP
Human Subject Research Program
IPSG
International Patient Safety Goals
JCI
Joint Commission International
KFHU
King Fahd Hospital of the University
MPE
Medical Professional Education
OVR
Occurrence Variance Report
PI&AU
Performance Improvement & Accreditation Unit
QPS
Quality Improvement & Patient Safety
DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2013
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