Dqs annual report 2012 by Imam Abdulrahman Bin Faisal University

DIRECTORATE OF QUALITY & SAFETY ANNUAL REPORT 2012

Table of Contents

Directorate of Quality and Safety

Annual Report 2012

Messages Message from the President of UoD & Supervisor General of KFHU ........................................ 8 Message from the Director General of KFHU ........................................................................ 9 Message from the Supervisor General DQS .......................................................................... 10

Directorate of Quality & Safety - Overview ........................................................................ 11 Executive Summary ........................................................................................................... 12 Staff Profile ...................................................................................................................... 13 Units ................................................................................................................................ 14 Major Achievements (Communication) ................................................................................. 15 Major Achievements (Educational Activities) ......................................................................... 15 Major Achievements (Reporting & Data Analysis) .................................................................. 16 Major Achievements (Performance Improvement Projects) ..................................................... 16 Major Achievements (Patient Experience)............................................................................. 16 Major Achievements (Environmental Rounds) ....................................................................... 17

Strategic Planning .............................................................................................................. 18 Mission, Vision, & Values of KFHU ...................................................................................... 19 Education Meeting ............................................................................................................. 20 Draft of Departmental Strategic Planning (First) ..................................................................... 21 Initiatives .......................................................................................................................... 22 JCI Accreditation Journey .................................................................................................. 23 Summary of Accomplishments ............................................................................................ 24

................................................................................................... 26 Patient Safety ................................................................................................................... 26 Performance Improvement ................................................................................................. 26 JCI Chapters Teams .......................................................................................................... 27 Task Force & Teams ......................................................................................................... 27 Achievements of JCI Chapters (ACC) .................................................................................. 28 Achievements of JCI Chapters (AOP) .................................................................................. 29 Achievements of JCI Chapters (ASC) ................................................................................... 30 Achievements of JCI Chapters (COP) .................................................................................. 31 Achievements of JCI Chapters (FMS/IPSG) .......................................................................... 33 Achievements of JCI Chapters (MCI/GLD) ............................................................................ 34 Achievements of JCI Chapters (PCI) .................................................................................... 39 Patient Experience ............................................................................................................. 43 Introduction ...................................................................................................................... 44 Aim ................................................................................................................................. 44 Continuous Improvement

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Table of Contents

Objectives ........................................................................................................................ 44 Starting Time .................................................................................................................... 44

............................................................................................................................. 44 Method ............................................................................................................................ 45 Pilot Study ........................................................................................................................ 45 Distribution ....................................................................................................................... 46 Response Rate (OPD) ....................................................................................................... 46 Response Rate (Inpatient) .................................................................................................. 47 Recommendations ............................................................................................................ 49 Performance Improvement & Accreditation Unit ................................................................ 50 Introduction ...................................................................................................................... 51 Executive Summary ........................................................................................................... 52 Strengths ......................................................................................................................... 52 Performance Improvement Projects .................................................................................... 52 Implementation of International Patient Safety Goals .......................................................... 53 AHRQ Culture of Safety .................................................................................................. 53 Monitoring of Performance Measure ................................................................................. 54 Patient Satisfaction Survey ............................................................................................. 54 JCI Accreditation Process & Basic Concepts of Quality Improvement .................................... 55 Utilization Care Review................................................................................................... 55 Committees, Project, JCI Teams & Teams Meetings Attended ............................................. 55 Accreditation Journey ........................................................................................................ 57 Clinical Performance Measure ............................................................................................ 60 Managerial Performance Measure ....................................................................................... 65 Recommendations ............................................................................................................ 67 Utilization Care Review ....................................................................................................... 68 Summary of Avoidable Days (July-December 2012) ............................................................... 69 Extra Pre-Operative Days ................................................................................................... 70 Risk Management Unit ........................................................................................................ 72 Overview .......................................................................................................................... 73 Data & Methods ............................................................................................................. 73 OVRs related to International Patient Safety Goal .................................................................. 75 Analysis of OVRs .............................................................................................................. 77 Overstaying of Patients in ER .......................................................................................... 77 Discharged Against Medical Advice (DAMA)...................................................................... 78 Break in Skin Integrity..................................................................................................... 79 OR Cancellation ............................................................................................................ 80 Line, Tube, Drain or Catheter .......................................................................................... 81 Building Structure or Infrastructure ................................................................................... 82 Clinical Equipment, Device, Consumables ........................................................................ 83 Birth Trauma / Injury to Neonate ...................................................................................... 84 Admission Related Issue ................................................................................................ 85 Scope

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Table of Contents

Missing Patient .............................................................................................................. 86 Out on Pass .................................................................................................................. 87 Non-Clinical Equipment .................................................................................................. 88 Fall .............................................................................................................................. 89 Incorrect Name or Medical Records.................................................................................. 90 Transfer-Related............................................................................................................ 91 Fire Alarm/Fire .............................................................................................................. 92 Refused Treatment / Procedure ....................................................................................... 93 Housekeeping Issue ....................................................................................................... 94 Medication OVRs ........................................................................................................... 95 Infection Control ............................................................................................................ 96 Food Services ............................................................................................................... 97 Initiatives .......................................................................................................................... 98

Documents Control Unit ..................................................................................................... 100 Overview .......................................................................................................................... 101 Scope of Documents Control Unit ........................................................................................ 101 Controlled Documents Section......................................................................................... 101 Committees & Reports Section ........................................................................................ 101 Types of Documents ...................................................................................................... 101 Process of Documents Control Unit ..................................................................................... 102 Process of Committees & Reports Unit ................................................................................. 102 JCI Chapter Teams ........................................................................................................... 104 Committees of King Fahd Hospital of the University ............................................................... 104 Achievements of Committees & Reports Section ................................................................... 105 Achievements of Controlled Documents Section ................................................................... 106 Job Descriptions ............................................................................................................... 109 Forms .............................................................................................................................. 109 Initiatives .......................................................................................................................... 110 Environmental & Safety Unit ............................................................................................... 111 Introduction ...................................................................................................................... 112 A Situation Requiring Attention ............................................................................................ 112 Overview of Unit................................................................................................................ 112 Scope of Environmental & Safety Unit .................................................................................. 112 Environmental Safety Rounds Program ................................................................................ 112 Implementation of JCI standards on FMS ............................................................................. 116 Organize Activities of Hospital Safety Committee (HSC) ......................................................... 118 Training ........................................................................................................................... 119 Education and Training Unit ............................................................................................... 120 Overview .......................................................................................................................... 121 Scope .............................................................................................................................. 121 Activities .......................................................................................................................... 121 Performance Improvement Projects ..................................................................................... 122

2013 Goals & Plans of the Directorate of Quality & Safety Glossary

................................................. 124

............................................................................................................................ 126

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List of Tables

JCIA Accreditation Journey ................................................................................................ 23 Table 1: DQS Accreditation Activities ................................................................................... 24

Performance Improvement & Accreditation Unit ................................................................ 49 Table 1: KFHU Patient Safety Culture Priorities ..................................................................... 54 Table 2: Meetings Attended by Performance Improvement Coordinators................................... 55 Table 3: Teams ................................................................................................................. 56 Table 4: Hospital Committees ............................................................................................. 56 Table 5: Quality Improvement Project ................................................................................... 56 Table 6: Policies & Procedures............................................................................................ 57 Utilization Care Review ...................................................................................................... 68 Table 1: Summary of Avoidable Days Report ........................................................................ 69 Table 2: Extra Pre-Operative Days ...................................................................................... 70 Risk Management Unit ........................................................................................................ 72 Table 1: OVRs Related to IPSG .......................................................................................... 76 Table 2: Reasons for Overstaying ........................................................................................ 77 Table 3: Reasons for Discharged Against Medical Advice ....................................................... 78 Table 4: Type of Break in Skin Integrity ................................................................................ 79 Table 5: Causes of OR Cancellation .................................................................................... 80 Table 6: Reported Incident.................................................................................................. 81 Table 7: Building Structure or Infrastructure .......................................................................... 82 Table 8: Reported Birth Trauma/Injury to Neonate ................................................................. 84 Table 9: Reported Incidence on Admission-Related Issue ....................................................... 85 Table 10: Location of Reported Missing Patient ..................................................................... 86 Table 11: Locations of Reported Incidence about Non-Clinical Equipment................................. 88 Table 12: Locations of Reported Fall .................................................................................... 89 Table 13: Reported Incidence on Incorrect Name or Medical Record Number ............................ 90 Table 14: Reported Transfer-Related Issue ........................................................................... 91 Table 15: Reported Incidence on Refused Treatment/Procedure ............................................. 93 Table 16: Location of Reported Housekeeping Issue .............................................................. 94 Table 17: Reported Medication Occurrence .......................................................................... 95 Table 18: Infection Control Top Variances ............................................................................ 96 Table 19: Top Variances (Food Services) ............................................................................. 97

Document Control Unit ....................................................................................................... 100 Table 1: King Fahd Hospital of the University Standing Committees ......................................... 104 Table 2: Other departments submitted Policies & Procedures .................................................. 108 Table 3: List of Departments (Pending submission of Policies & Procedures) ............................ 108 Table 4: List of Departments (Non submission of Policies & Procedures)

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List of Figures

Strategic Planning .............................................................................................................. 18 Figure 1: Education Meeting for Departmental Strategic Plan .................................................. 20 Figure 2: First draft versus department response to education ................................................. 21 Figure 3: First draft versus total departments ......................................................................... 21

Patient Experience .............................................................................................................. 43 Figure 1: Response Rate – Out Patient Survey...................................................................... 46 Figure 2: Response Rate – In Patient Survey ........................................................................ 47 Performance Improvement & Accreditation Unit ................................................................ 50 Figure 1: Overall Patient Safety Culture Survey ..................................................................... 53 Figure 2: % Completed Policies & Procedures, Forms & Plans ................................................ 57 Utilization Care Review ....................................................................................................... 68 Figure 1: Summary of Avoidable Days.................................................................................. 69 Figure 2: % of Summary Avoidable Days .............................................................................. 70 Figure 3: Extra Pre-Operative Days ..................................................................................... 70 Risk Management Unit ........................................................................................................ 72 Figure 1: Number of OVRs Monthly ..................................................................................... 73 Figure 2: Top Reported Incidents 2012................................................................................. 73 Figure 3: Percentage of Top Reported Incidents 2012 ............................................................ 74 Figure 4: OVRs related to IPSG........................................................................................... 75 Figure 5: Monthly Reported – Overstaying In ER ................................................................... 77 Figure 6: Reasons for Overstaying of Patients In ER .............................................................. 77 Figure 7: Location of Reported Discharged Against Medical Advice.......................................... 78 Figure 8: Reported Pressure Ulcers ..................................................................................... 79 Figure 9: Number of OR Cancellation ................................................................................... 80 Figure 10: Location of Reported Incidents on Line, Tube, Drain Catheter .................................. 81 Figure 11: Distribution of Age for Reported Line, Tube, Drain Catheter ..................................... 81 Figure 12: Number of Building Structure or Infrastructure ........................................................ 82 Figure 13: Reported Incidence-Clinical Equipment, Device, Consumable .................................. 83 Figure 14: Reported Birth Trauma-Injury to Neonate .............................................................. 84 Figure 15: Admitted without Multidrug-Resistant Screening Result ........................................... 85 Figure 16: Reported Missing Patients ................................................................................... 86 Figure 17: Out on Pass ...................................................................................................... 87 Figure 18: Reported Non-Clinical Equipment ......................................................................... 88 Figure 19: Distribution of Age & Gender for Reported Falls ..................................................... 89 Figure 20: Number of Reported Incidents (Fall) ..................................................................... 89 Figure 21: Reported Incorrect Name or Medical Record Number ............................................. 90 Figure 22: Reported Transfer-Related Issue.......................................................................... 91 Figure 23: Locations of Reported Fire/False Fire Alarm .......................................................... 92 Figure 24: Reported Fire/False Fire Alarm ............................................................................ 92 Figure 25: Reported Refused Treatment or Procedure............................................................ 93 Figure 26: Housekeeping Issues ......................................................................................... 94

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List of Figures

Figure 27: Reported Housekeeping Issue ............................................................................. 94 Figure 28: Reported Medication OVRs ................................................................................. 95 Figure 29: Locations of Reported Sharp Injury & Blood/Body Fluid Exposure ............................. 96

Document Control Unit ....................................................................................................... 100 Figure 1: Minutes of Meetings for 2012 – JCI Chapters ........................................................... 105 Figure 2: Minutes of Meetings for 2012 – JCI Team Leaders & Joined Chapters ........................ 105 Figure 3: Minutes of Meetings for 2012 – JCI Steering Committee & Strategic Planning Task Force ............................................................................... 105 Figure 4: Finalized Control Documents for 2012 .................................................................... 106 Figure 5: Medical Services Departments Policies & Procedures ............................................... 106 Figure 6: Department of Nursing Services Policies & Procedures ............................................. 107 Figure 7: Health Information & Medical Records Department Policies & Procedures ................... 107 Figure 8: Support Services Department Policies & Procedures ................................................ 107 Environmental & Safety Unit ............................................................................................... 111 Figure 1: Areas surveyed (August – December 2012)............................................................. 113 Figure 2: Frequency of Surveys (August – December 2012) .................................................... 114 Figure 3: Department Compliance ....................................................................................... 114 Figure 4: Responses received versus reports generated ......................................................... 115 Figure 5: Common areas of deficiencies identified during the survey ........................................ 116 Figure 6: Initiatives coordinated with FMS Chapter Team ........................................................ 117 Figure 7: Initiatives Coordinated with HSC ............................................................................ 118 Figure 8: Staff Training Sessions ......................................................................................... 119 Education & Training Unit ................................................................................................... 120 Figure 1: Flowchart Interns Preparation ................................................................................ 123

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Message from the President, University of Dammam Supervisor General, King Fahd Hospital of the University

Today, King Fahd Hospital of the University (KFHU) is focusing its resources on providing the safest and highest quality care possible, with the aim of reducing, and ultimately eliminating, adverse events and outcomes. KFHU is also committed to understanding our patients’ needs relative to their direction regarding quality and patient safety initiatives. Here at King Fahd Hospital of the University, clinical quality and patient safety remain our top priorities, and we strive to be a model and leader in both of these areas.

To ensure that King Fahd Hospital of the University will continue to provide quality care and safety to all patients and employees, the Directorate of Quality & Safety (DQS) with support from the Deanship of Quality & Academic Accreditation (DQAA) is established to meet the dynamic needs and evolution of the ever changing milieu related to quality, safety and accreditation.

2012 was a year of significant accomplishment for DQS, for which I could call it as “DQS journey towards excellence.” DQS launched the ambitious Quality Improvement (QI) Plan in March 2012 in preparation for the JCI accreditation. The aim of the QI Plan is to define all strengths, weaknesses, opportunities and threats to KFHU. The KFHU Hospital Administration and the Directorate of Quality & Safety (DQS) is responsible for the implementation, monitoring and evaluation of this plan. DQS aims to accomplish this through setting standards, measuring performance, providing consultation and education where needed. KFHU aims to achieve an international recognition as a quality service healthcare provider. This will be measured by an achievement of accreditation for facilities by a recognized standards agency. By getting accredited, KFHU will highlight the image as a leading organization in the eastern region, and will strengthen the community confidence in its standard of care and competency of its staff. This will be possible with the full cooperation of all staff and DQS.

This annual report proved the achievements of the Directorate of Quality & Safety which is the first of many to be published in the years to come. A special thank you to the staff and leader of DQS for their professionalism, dedication and commitment they bring to their department each day.

DR. ABDULLAH AL RUBAISH President, University of Dammam Supervisor General, King Fahd Hospital of the University

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Message from the Vice Dean for Hospital Affairs Director General, King Fahd Hospital of the University

King Fahd Hospital of the University (KFHU) is committed to providing high quality health care through innovation and the use of the latest technology available. As KFHU expands and our plans progress, we will rely more and more on the support of validated accurate data to reflect our efficiency and project our development. The Directorate of Quality & Safety (DQS) is created to answer the needs of King Fahd Hospital of the University (KFHU) to have a comprehensive core for all functions related to quality and safety. One of the aims of the Directorate of Quality & Safety is to have King Fahd Hospital of the University to be the first academic hospital in the Eastern Province to be accredited by the Joint Commission International (JCI). DQS with its staff had the spirit of full determination and an eagerness to achieve of having KFHU accredited by JCI (Joint Commission International).

The directorate will require

unyielding support from all staff of KFHU to achieve this goal. While we have made great strides over the past years, there is much more to be done, and we continue to rely on the contributions and commitment of all our physicians, nurses, healthcare workers and employees. 2012 was a very successful year for DQS. It is an enormous achievement for the directorate, with months of thorough planning and visioning.

This reports states the achievements and

progress of DQS. This report also tells KFHU journey to JCI accreditation, quality and safety. I believe that the staff of Directorate of Quality & Safety has the talent and technical skills to achieve our ambitious plans of having King Fahd Hospital of the University to be recognized as the first academic hospital in the Eastern Province in terms of excellence in quality and safety.

DR. KHALID AL OTAIBI Vice Dean for Hospital Affairs Director General, King Fahd Hospital of the University

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Message from the Supervisor General Directorate of Quality & Safety

This annual report covers March 2012 to December 2012 and focuses on the primary activities, accomplishments and achievements of the Directorate of Quality & Safety for the past nine (9) months. This report reflects the enormous effort that goes into measurement and serves as a means of conveying the directorateâ&#x20AC;&#x2122;s accomplishments in key areas. Ensuring the safety of patients is an integral part of quality health care, and our report describes the progress of several safety initiatives launched by the team of the Directorate of Quality & Safety. The reason for our initial success for the past nine months is the quality of staff. The great majority of staff are highly dedicated and motivated, many working well beyond the normal call of duty and regularly going that extra mile to improve the quality of service of the directorate. This report documents all programs, projects and activities of the Directorate of Quality & Safety in accordance with our mission of providing professional quality improvement services to improve the quality of care of King Fahd Hospital of the University and assistance in the management of systems required to meet strategic objectives and the needs of the community. This report also documents the accomplishments and projects of the units of the Directorate of Quality & Safety. Each unit of the Directorate of Quality & Safety will present their accomplishments and programs in this report. DQS continues with its commitment to support the King Fahd Hospital of the Universityâ&#x20AC;&#x2122;s mission and goals. The work and accomplishments completed in 2012 serves as a strong foundation for the strategic initiatives which lie ahead in 2013. This effort is a representative of a comprehensive quality and safety program which encompasses King Fahd Hospital of the University (KFHU) through the efforts of physicians, staff and leaders. As we take pride of our 2012 accomplishments, we also recognize that we need to continually strive to meet the needs of the employees, patients, and improve outcomes of care. DQS will help initiate more collaborative designed to help measure safety in KFHU and will also increase our interaction with all hospital staff. We will continually strive to introduce tools and techniques, principles and practices to help us better monitor, manage and improve KFHU services and DQS programs. At the same time we are inspired on strengthening a culture that values, supports and promotes continuous improvement to quality and patient safety. On behalf of the Directorate of Quality & Safety, I would like to thank His Excellency, Dr. Abdullah Al Rubaish, President of University of Dammam & Supervisor General of King Fahd Hospital of the University & Dr. Khalid Al Otaibi, Director General of King Fahd Hospital of the University for their continued support and guidance in our quest for the JCI Accreditation and to continue to provide quality of care of all patients and safety to all patients, their families and employees.

DR. AHMED AL KUWAITI Supervisor General Directorate of Quality & Safety King Fahd Hospital of the University

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Overview

Directorate of Quality & Safety - Overview

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Executive Summary

The Directorate of Quality & Safety (DQS) works in partnership with King Fahd Hospital of the University (KFHU) leadership, physicians and staff to improve care, safety and performance. The Directorate of Quality & Safety provides ongoing support and consulting services to all hospital departments to help achieve quality, identify KFHU’s mission, delineate responsibilities and authorities and enforce the teamwork concept, employee motivation and other basic elements of administrative work until they have become a daily practice of all committees, teams and task forces throughout KFHU. DQS ensures the continuous implementation of these notions to attain the KFHU’s defined objectives to maintain its international standing. The directorate’s strong commitment to continuous improvement and our no blame philosophy are important ways to assisting hospital staff, but we do recognize the very great commitment that individuals make to the success of the hospital. Overall quality, patient safety, patient experience and performance improvement outcomes demonstrated a culture dedicated to achieving and sustaining excellence. DQS provides direction and leadership in areas of quality improvement, regulatory compliance, patient safety, workplace safety, risk prevention and medical staff quality / peer review. DQS collects clinical & demographic data and organizes, analyzes and translate this data into useful information which:   

Initiates performance improvement efforts; Contributes to KFHU objectives / accomplishments; and Support the systems and processes necessary to obtain accreditation / certification and achieve regulatory compliance.

The Directorate of Quality & Safety is also responsible to provide support, education and leadership to all staff and departments at King Fahd Hospital of the University (KFHU) in the following areas:     

Quality and Performance Improvement Patient Safety JCI Accreditation Data Management System review and design

DQS role is to provide leadership and to support KFHU in delivering on its objective of providing high quality and safe services to patients and service users. This role is delivered by:      

Determining recommended practices (within the context of the JCI Standards) and systems required for quality and safe care based on best evidence. Building capacity within KFHU to deliver on the quality improvements Using data and evidence to monitor service quality Sponsoring a patient focus and service user participation Improving the sharing of information, the management of, and learning from, incidents to avoid reoccurrence. Undertaking healthcare audits to provide organizational assurance

While we are delighted of the work we have done, the objectives we have accomplished and the improvements we have introduced, we understand that quality is a journey and not a destination that we should stopped.

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Staff Profile

The Directorate of Quality & Safety is comprised of 13 full time professionals who support the mission and goals of the department. Our staff holds a variety of bachelorâ&#x20AC;&#x2122;s and masterâ&#x20AC;&#x2122;s degrees in a wide array of disciplines as well as a variety of certifications and specializations. The development of the Directorate brought staff from various functions together into new structures and working relationships. The staff of the Directorate of Quality & Safety includes specialists in quality improvement, patient safety, risk management, regulatory and accreditation, data analysis, workplace safety and patient advocacy. The culmination of these experiences and expertise has produced a team of people who have significantly contributed to the positive culture of quality and safety within KFHU. The team works closely with a number of other departments to support the overall quality agenda across a multifaceted organization.

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Units of the Directorate of Quality & Safety



Performance Improvement Unit: The quality improvement specialists’ roles are filled by registered nurses who focus on quality, performance improvement and patient safety initiatives at the hospital-wide and unit level. They participate in JCI chapters and Hospital Committees to report on this work and are key leaders for strategic initiatives such as utilization review, clinical pathways, closed record review, rapid response team, Operating Room cancellation, patient falls, etc. The Unit is also responsible for the regulatory accreditation process and oversight of the ongoing regulatory readiness activity and coordinates the JCI Accreditation program.



Risk Management Unit: The Unit is staffed by registered nurses and demonstrator who focuses on reported errors, medication safety, near-miss events and ongoing compliance to patient safety goals.



Environmental & Safety Unit: The Unit is staffed by environmental & safety specialists that coordinates KFHU emergency management and environmental safety programs.



Document Control Unit:

The Unit is staffed with responsible personnel that take overall coordination of controlled documentation, maintains tracking & archiving system of quality records. 

Education & Training Unit:

The Unit is staffed with personnel who liaise with the colleges of the University of Dammam to provide internship training and development to graduating students.

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Major Achievements of the Directorate of Quality & Safety

The Directorate of Quality & Safety exists to serve the quality and safety needs of KFHU and support ongoing improvement in patient care outcomes. DQS has been instrumental in building the infrastructure to support KFHU mission, vision and goal achievement. Quality improvement activities of DQS have taken many forms over the past nine months. DQS accomplishments during the past nine months are many, and we are very proud with the successful launch of these programs and projects. Through this effort, we placed a renewed emphasis on safety and implemented a successful programs and projects focused on quality and performance improvement. Several programs and projects came to fruition last year with our aim of continued compliance with the highest standard of patient care. COMMUNICATION The Directorate of Quality & Safety developed a system that aimed at optimizing patient outcomes by improving communications and teamwork skills among KFHU healthcare professionals and DQS. DQS established highly effective communication program that focuses on:    

Forming highly effective teams that augment the use of information, people, and resources to achieve best clinical outcomes for patients. Increasing team awareness and clarifying team roles and responsibilities. Resolving conflicts and improving information sharing. Reducing barriers to quality and safety.

DQS developed a “culture of safety” which allows hospital staff to talk freely about safety problems, minimizes blame, and assists in identifying the cause of problems and ways to avoid the same risks going forward. DQS will continue to focus on supporting all hospital departments to support practices that improve quality and safety through improved communication, team building, and a culture of safety within all departments. EDUCATIONAL ACTIVITIES In order to increase staff awareness about JCI standards and as preparation for the 2013 JCI survey, DQS conducted a JCI awareness education. DQS has hosted a number of education sessions to educate staff and physicians on quality and safety issues. Lectures conducted in 2012:  JCI Readiness  International Patient Safety Goads  Occurrence Variance Report (OVR) Overview  Focus PDCA  Utilization Review  Hand-over Communication  High-Alert Medication  JCI Chapters (Anesthesia & Surgical Care (ASC))  Rapid Response Team (RRT)

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Major Achievements of the Directorate of Quality & Safety

Interest in patient safety education through KFHU is increasing from a variety of clinical disciplines, as well as from executive leadership. The Directorate of Quality & Safety in collaboration with the Directorate of Academic Affairs & Training plans and develops a new employee orientation program that has specific learning objectives targeted to prepare a multinational workforce for quality functions at King Fahd Hospital of the University. REPORTING AND DATA ANALYSIS DQS has been using the Occurrence Variance Report (OVR) system. This tool identifies categories of adverse events and is used to drive quality improvement activities and priorities to help reduce adverse events for patients. The Risk Management Unit of DQS rollout the OVR system designed to enhance our capability to improve patient safety by capturing reported safety events, managing them, and addressing risks and opportunities for improvement. The Risk Management Unit of DQS has integrated surveillance, performance measures and data analysis. The Unit works collaboratively to support department leaders across KFHU in quality improvement. Monthly & Quarterly reports for Occurrence Variance Report were submitted and reported during the JCI Steering Committee meeting. DQS has achieved great success over the past nine months with the implementation of many quality initiatives and will continue to drive the quality agenda in KFHU. PERFORMANCE IMPROVEMENT PROJECTS Three performance improvement projects were registered during the last quarter of 2012, namely:    

Overstaying of patient in Emergency Room OR (Operating Room) Cancellation Rate Rapid Response Team Patient Fall

PATIENT EXPERIENCE (Detailed report is included in the Patient Satisfaction Survey) The Directorate of Quality & Safety undertakes ongoing surveys (inpatient and out-patient) to determine patient satisfaction. The survey is conducted with a determination to gain a clear understanding of what service patients think so that we can make changes for the better. This is the first year the survey was conducted so there is no benchmark data available from previous surveys. The aim of DQS is to enable the continuous improvement of health care services by learning from the experiences of service users and to support change necessary to drive up standards of quality. Patient survey data is also valuable as a mechanism to identify gaps in provision, and provide opportunities to develop new areas of service.

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Major Achievements of the Directorate of Quality & Safety

ENVIRONMENTAL ROUNDS (Detailed report is included with the Environment & Safety Unit) The Environmental & Safety Unit of DQS has been in operation since March 2012 and is responsible for the identification, tracking and correction of deficiencies in compliance with applicable codes, standards, policies and regulations that may present an unsafe environment for any person associated with King Fahd Hospital of the University. DQS has initiated the environmental rounds program in August 2012 with an aim to ensure that deficiencies such as housekeeping, maintenance, security, and health and safety are identified and corrected. The Directorate of Quality & Safety in collaboration with the Ministry of Health and Defense had the first “Mock Fire Exercise” last 25th of December 2012. A few other quality initiatives that DQS Team has been involved with are:   

Implementation of Safety rounds Patient Safety Culture Surveys Safety Team supports the process by leading the Programs and Teams through a structured self-assessment process, through which they identify and formalize quality plans to address opportunities for improvement.

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Strategic Planning

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Strategic Planning

The Strategic Planning Task Force was formed under the recommendation of the JCI Steering Committee with the leadership of the Vice Dean of Hospital Affairs & Director General of King Fahd Hospital of the University and collaboration with the Supervisor General of the Directorate of Quality & Safety. The Task Force was formed to document and outline the strategies of KFHU. The KFHU Strategic Planning Task Force review the KFHU’s mission, vision and values to ensure that they were in line with stakeholder’s requirements. Below are the mission, vision and values of KFHU: Mission: To provide high quality healthcare, education and training for healthcare professionals and support scientific research. Vision: To be a leading University Hospital in healthcare provision, education, and scientific research according to international standards. Values:   

Honesty Mutual Respect Teamwork

  

Transparency Responsibility Commitment

Based on the evaluation of the present situation of KFHU and the Vision and Mission, the KFHU Strategic Planning Task Force identified six Essential Strategic Issues to be focused on, which are also in line with the Strategic Plan of the University of Dammam. The Six Essential Strategic issues are: 1. Patients 2. Human Resources 3. Quality Improvement & Patient Safety 4. Management of Information 5. Finance 6. Community Affairs These essential strategic issues set the tone and provide guidance at a high level, for all major activities of KFHU. For each Domain Strategic GOALS have been identified and each Goal has been broken down into achievable OBJECTIVES with timelines and person(s) responsible. After six months of strategic planning process, the final and approved King Fahd Hospital of the University Strategic Plan was distributed to all departments on 12th of September 2012 (25 Shawwal 1433). With the distribution of the KFHU Strategic Plan, the Directorate of Quality & Safety moves to the implementation of having all KFHU departments formulate their departmental strategic plans. The Directorate of Quality & Safety in collaboration with department heads throughout the hospital arranged an education meeting to assist each department in developing their strategic and action plans in alignment with the strategic goals of KFHU.

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Strategic Planning

Letters were sent to all department heads informing them of a mutual cooperation with the Director of the Strategic Management Unit of the Deanship of Quality & Academic Accreditation in providing assistance and guidance to establish the strategic plan for each department. From June 2012 until December 2012, DQS encouraged all department heads to participate in generating their strategic plan. Continuous communication was done to encourage each department in whatever issues are encountered in formulating their strategic plan to communicate with DQS. Department-specific goals and objectives to achieve the Mission and Vision of KFHU were defined in each strategic plan. Some departments encountered issues which resulted in some challenges related to the development of their strategic plans. With this, education and meeting were provided by the Directorate of Quality & Safety to assist them in the process. At the last quarter of 2012, DQS has successfully received calls from some departments of their interest and requested the assistance of the Director of the Strategic Management Unit from Deanship of Quality & Academic Accreditation. Slowly, some of the attendees formulated their departmental strategic plan and submitted for review and revision of the Directorate of Quality and Safety. Of the total 41 departments, 25 departments responded to the call for education meeting with the Director of the Strategic Management Unit of the Deanship of Quality & Academic Accreditation, while 16 departments did not respond to the call for education.

Figure 1: Education Meeting for Departmental Strategic Plan

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Strategic Planning

From the 25 departments that responded to the call for education, 11 departments submitted the first draft of their respective departmental strategic plan.

Figure 2: First draft versus department response to education

Through the year 2012 and until the last quarter of 2012, the Directorate of Quality & Safety continues to encourage and follow-up with the department heads to formulate and established their departmental strategic plan.

Figure 3: First draft versus total departments

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Strategic Planning Initiatives

INITIATIVES 1. All strategic plans will be approved by the Strategic Planning Task Force prior to commencing the implementation of the plans. 2. All strategic plans will be aligned with the mission and vision of each department, which are also aligned with the KFHU mission and vision. 3. The Directorate of Quality & Safety will be more involved in following up the status of implementing the strategic plans, and will intervene when needed to facilitate the process and promote cooperation among departments. 4. The Directorate of Quality & Safety and its counterpart, the Director of the Strategic Management Unit of the Deanship of Quality & Academic Accreditation will continue to support and assist the development of the departments of King Fahd Hospital of the University.

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JCI Accreditation Journey

Directorate of Quality & Safety Annual Report 2012

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JCI Accreditation Journey

Our JCI Accreditation journey started with the formation of the JCI Steering Committee. The JCI Steering Committee is the responsible body in ensuring compliance of KFHU with the JCI standards. A total of 14 JCI chapters had been distributed with approved team leaders. Meetings are conducted monthly, or as required to assess, plan and implement compliance with JCI Standards and evaluate progress. All meetings are documented. Minutes of Meetings are kept at the Directorate of Quality & Safety to be used to monitor any problems and to be reported to the JCI Steering Committee for action. Summary of Accomplishments: 1. Education on International Patient Safety Goal (IPSG) and Patient & Family Education (PFE) were almost done. Policy and Procedures were done and ready for implementation and monitoring. 2. Policy and Procedure for each department were done and submitted for review and approval of concerned departments. 3. Re-designing and re-typing of forms were done and completed. Submitted for the final approval of the proponent before printing and implementation. 4. Once forms were reviewed and approved by the Forms Team, target time for implementation is on the 3rd week of February 2013; Closed Record Review will be launched and implemented. KING FAHD HOSPITAL OF THE UNIVERSITY "ACCREDITATION ACTIVITIES" 2012 1 2

4 5 6 7 8

9 10 11

Activities Formation of JCI Steering Committee Development of Quality Improvement Plan Educational sessions on Quality Improvement Plan JCI Accreditation Awareness Campaign Formation of JCI Teams Practicum Training on JCI Standards Assessment of current situation Gap analysis in comparison to JCI standards, designing solutions to close gaps Communication of JCI standards to KFHU staff Implementation of Quality Improvement Plan Monitoring process

Jan

Feb

Mar

Apr

May

June

Jul

Aug

Sept

Oct

Nov

Dec

Table 1: DQS Accreditation Activities

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JCI Accreditation Journey

Task Force and Teams were formed in collaboration with the Directorate of Quality & Safety. Each task force and team will identify a set of initiatives, objectives and realistic actions to achieve the assigned goal. Each task force and team will leverage their knowledge and determine their own processes which include: gathering of information and reviewing best practices, then they will make recommendations to the JCI Steering Committee. The following highlights the accreditation journey of the Directorate of Quality & Safety:

To prepare for the demanding survey, DQS assist all staff to familiarize themselves with the JCI standards, relevant hospital policies and standard operating procedures. All healthcare professionals were guided to demonstrate consistent, fluent and sound clinical methodology in healthcare practices. DQS supported staff development to enhance their skills as JCI standards require monitoring of core competencies, continuous education and training, credentialing for adequate skills, as well as leadership and management skills training. In the process of attaining the accreditation, employeesâ&#x20AC;&#x2122; thoughts and opinions were sought and their satisfaction levels were measured through the Patient Safety Culture Survey. Various efforts were made to improve employee safety and security. Opportunities were created for staff to be involved in quality activities. The lines of authority and accountability were made clearer, and importantly, the whole process promoted teamwork among all the staff. And for the patients, DQS had made the patientâ&#x20AC;&#x2122;s rights more visible to assure the patients that their rights and privacy are respected and protected. Patient education has been enhanced and the communication channels are more effective. Medical staff was encouraged to involve patients in care decisions and care processes.

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JCI Accreditation Journey

The accreditation preparation gave KFHU and staff the knowledge and tools for measuring and sustaining developments in the areas of continuous improvement, patient safety, and performance improvement: Continuous Improvement 

Developing complete, patient-centered processes throughout King Fahd Hospital of the University



Launching a structured and transparent process to monitor continuous compliance to the International Patient Safety Goal (IPSG) and various types of risk management activities



Improving interdisciplinary communication



Upgrading documentation of processes to ensure care continuity, patient safety and continuous improvement

Patient Safety 

Adhering to the International Patient Safety Goals to generate a culture of safety for staff and patients



Implementing a comprehensive approach to involve patients, families, staff, and visitors



Establishing a transparent reporting system for complaints and suggestions from employees, patients and families

Performance Improvement 

Developing a quality management system based on the JCI Standards



Improving monitoring systems and processes to measure enhancements to quality and patient safety in clinical and managerial areas



Establishing a periodic review of data analysis to sustain quality improvements



Designing an effective and efficient surveillance system to monitor, analyze and address data-driven, sustainable improvements in infection control

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JCI Accreditation Journey

Below are the JCI chapters, task force and teams of the Directorate of Quality & Safety:

JCI CHAPTERS TEAMS 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

MCI GLD MMU Team ACC AOP COP PFE PFR ASC QPS PCI FMS IPSG SQE

TEAMS & TASK FORCE 1. 2. 3. 4. 5. 6. 7. 8.

Code Blue Team Rapid Response Team Forms Team Patient Satisfaction Team Closed Record Review Team Utilization Review Team Environmental Safety Team Strategic Planning Task Force

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Accomplishments of JCI Chapters

Access to Care & Continuity of Care (ACC): STANDARD ACC.1 ME 1-2-5

ACCOMPLISHMENTS - Patient Triage In ER - Nursing Routines Common to All OPD - Admission of Surgical Patient

ME 1-2-4-5

ACC.1.1.1

- Admission, Discharge & Transfer Criteria

ACC.1.1

OPD Registration Process of Inpatient Admission Holding Patient in ER Emergency Room Standard of Nursing Care Management of Census When Beds are Limited

ME 1 ACC.1.1.2

- Criteria for Referring In-Patient to Physiotherapy

ME 2 ACC.1.1.3

- Treatment Delays

ACC.2

ACC.3.1

ACC.3.2

- Discharge Summary Form

ACC.3.3

- Significant Data Sheet

ACC.3.4

- Appointment for Discharged Patient - Appointment Card - Appointment & Registration Process

ACC.4

ME 1-2 ACC.3 ME3-5

ACC.5

Referral & Request for Consultation P&P Referral & Request for Consultation Form Referral to Social Services Transfer and Transport of Patient Between Services Discharge of Patient Discharge Order and Instruction Form Out on Pass P&P Out on Pass Form Discharge Plan

Transfer of Patient to Other Facilities Patient Transfer Summary Ambulance Service P&P Transport Medication Checklist Ambulance Request

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Accomplishments of JCI Chapters

Assessment of Patients (AOP): STANDARD AOP.1

ACCOMPLISHMENTS - Assessment and Reassessment of Patient P&P

ME 1 & 2 AOP.1.1 ME1

AOP.1.1 ME 4 AOP.1.3.1 AOP.1.4 ME1-4 AOP.1.5

- Physicians Admission History And Physical Assessment Form – Adult - Physicians Admission History And Physical Assessment Form – Pediatric - Physicians Admission History And Physical Assessment Form – Obstetrics - Nursing Initial Assessment Form – Adult - OPD Charting P&P - Outpatient Clinic Treatment Record Form -

ER Assessment Form – Physicians ER Assessment Form – Nursing Delivery of Care P&P Verification of Assessment & Report from Other Hospital P&P

- Nursing Documentation P&P

ME.3 AOP.1.6

- Nutritional Assessment P&P

ME 3 AOP.5.1

- Laboratory Safety Manual

AOP.5.3

- Turnaround Time P&P

AOP.5.6

ME1-4

- Specimen Collection, Handling And Transportation Manual - Safety Requirements for Staff P&P - Safety Requirements for Patients P&P - Infection Control and Waste Disposal P&P

AOP.6.3

- Radiology Report P&P

AOP.6.2

ME.4 AOP.6.8

- Quality Control Program

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Accomplishments of JCI Chapters

Anesthesia & Surgical Care (ASC): STANDARD

ACCOMPLISHMENTS

ASC.1

- Minimal Sedation/Analgesia in Day Surgery and Endoscopy P&P

ASC.2

- Procedural Sedation/Analgesia – Moderate & Deep P&P

ASC.3

- Procedural Sedation/Analgesia – Moderate & Deep P&P

ASC.4

- Patient Management in Recovery Room/PACU P&P - Pre Anesthesia Clinic

ASC.5

- Pre, Peri and Post-Operative Assessment Form

ASC.5.3

- Pre, Peri and Post-Operative Assessment Form

ASC.6

- Pre, Peri and Post-Operative Assessment Form - Recovery Room Observation Record Form

ASC.7

- Physician’s History & Physical Assessment Form – Adult - Physician’s History & Physical Assessment Form – Pedia - Clinical Pathways

ASC.7.1

- Consent for Surgery/Procedure Form

ASC.7.2

- Operative Notes Form - Perioperative Record - General

ASC.7.3

- Pre, Peri and Post-Operative Assessment Form

ASC.7.4

- Post-Operative Orders Form

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Accomplishments of JCI Chapters

Care of Patient (COP): STANDARD COP.2.1 ME.5 COP.2.2 ME.1

ACCOMPLISHMENTS - Physician’s Order Form - Hospital Approved Abbreviations.

COP.3.1 COP.3.2 COP.3.3 COP.3.4 ME.1-2 COP.3.5 ME.1-2 COP.3.6

COP.3.6

COP.3.7 COP.4 ME1-5

- Administration of Blood and Blood Components. - Administration Reaction of Blood Transfusion - Care of Patient on Life Support and Who are Comatose - Care of Unconscious Patient - Pressure Ulcer Mgmt. Guidelines - Care of Patient With Communicable Disease - Care of Immunocompromised Patient Dialysis P&P  Cannulation of Arterial Fistula/AV Graft to Initiate HD  Care of AV Fistula AV Graft  Dialysis Laboratory Work in Dialysis Unit  Employee Infection Control  External Cleaning of Hemodialysis Machine  Fistula Arm Exercise  Mgmt. of Anticoagulation  Management of Patient with AV Fistula/AV Graft  Management of Cardiac Arrest During Dialysis  Management of Patient with Aneurysm  Prevention and Control of Hepatitis in Dialysis Unit  Prevention and Control of Infection in Dialysis Unit  Transplant Work Up For Recipient  Transporting Patients from the Ward for Dialysis - Safety Guidelines for Restraint Use - Nutritional Analysis of Patient Menu - Menu Planning P&P - Charting in Medical Record P&P - Nutritional Screening & Policy - Initial Nutritional Assessment Form - Outside Food for Patient P&P

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Accomplishments of JCI Chapters

Care of Patient (COP): STANDARD COP.4.1 ME1-5

COP.4.1 ME1-5

COP.5 ME.1-3

ACCOMPLISHMENTS -

Food Quality Standard P&P Food Preparation and Handling P&P Use of Disposable Gloves P&P Thawing of Meat P&P Thawing of Frozen Food P&P Use of Color Coded Cutting Board P&P Storage and Temperature Control of Food P&P Refrigerator Freezer Temperature Monitoring Form Food Production Sheet P&P Labeling of Food P&P Waste Disposal P&P Disposal and Handling Infectious Waste P&P Product Write-Off & Disposal P&P Nutritional Screening P&P Nutritional Assessment Form Monitoring of Patient Dietary Intake P&P 24-Hour Dietary Intake Record Form

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Accomplishments of JCI Chapters

Facility Management & Safety / International Patient Safety Goal (FMS / IPSG): STANDARD IPSG.1

ACCOMPLISHMENTS  Patient Identification Policy & Procedure

ME1-ME4 IPSG.2 ME1-ME3

IPSG.3

 Verbal/Telephone Order Policy & Procedure  Reporting Critical Test Result Policy & Procedure (hospital wide)  List of Critical Value Results that need to be reported (attachment)  High Risk/High Alert Medication P&P

ME1-ME4 IPSG.4 ME1-2

IPSG.5 ME1-2 IPSG.6 ME1-ME2

 Surgical Site Verification/Site Marking/Time-Out Pre-Procedural Patient Safety (Site Verification; Laterality; Time Out-Process)P&P  Pre-Op Checklist P&P  Pre-OP Patient Preparation P&P  Patients Walking to the Operating Room/Procedure Room P&P  Operating Room List P&P  Recovery Room Observation Record Form  Perioperative Record – General Form  Surgery Schedule Request Form  Calling Patient from Inpatient Unit to OR Form  Surgery Schedule Request Form  Intra Operative Form  “Time Out” process Form  Site Markings Form  Infection Control Program  CDC Guidelines  Hand Hygiene P&P  Falls Policy & Procedure  Falls Prevention Program Scale/Humpty Dumpty)

Directorate of Quality & Safety Annual Report 2012

(Falls

Morse

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Accomplishments of JCI Chapters

Facility Management & Safety / International Patient Safety Goal (FMS / IPSG): STANDARD FMS.1-3 ME1-4

FMS.4 ME1-3 FMS.5 ME1-3 FMS.6 ME1-3 FMS.7 ME1-3 FMS.8 ME1-3 FMS.9-10 ME1-3

ACCOMPLISHMENTS - Facility Management & Safety Plan - Laws & Regulations, Building Codes - Hospitalâ&#x20AC;&#x2122;s License to Operate and/or Registration: Royal Command issued for the Hospital to be a part of Dammam University as a University Hospital - Formation of the Environmental & Safety Team - P&P relating to mandatory working permit from Infection Control - Hospital Safety Codes - Security Plan - Environmental Checklist Form - Environmental Data - P&P for Disposal of Hazardous Materials - Material Safety Data Sheet -

Psychiatry Evacuation Plan Laboratory Safety Manual Fire Safety Manual Hospital Disaster Drill P&P for Fire Alarm System and Fire Fighting System Fire Safety Plan/Program Fire Evacuation Routes Smoking P&P Biomedical Department P&P Medical Equipment Plan Staffing Plan Job Description Utility System P&P Utility System Emergency Protocol Utility System Management Plan Scope of Service

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Accomplishments of JCI Chapters

Management of Communication & Information / Governance, Leadership & Direction (MCI / GLD): STANDARD MCI.1 ME1 ME2 ME3 ME4 MCI.2 ME1 ME2 ME3 MCI.3 ME1-ME2

ACCOMPLISHMENTS -

KFHU Mission/Vision Statement Strategic Assessment Report MCI Plan Community Outreach Program

- Multidisciplinary Patient and Family Education Form

Community Resource List Screening Process P&P Sample and list of Patient and Family Information (PFI) and Patient and Family Education (PFE) materials/videos

ME3 MCI.4 ME1

ME2 ME3 ME3

ME4

- Staff Communication P&P - Newsletter â&#x20AC;&#x201C; Asdaf Al Jama - Memos - Departmental meeting - Morning Report - Various mode of communication - Committee meetings, surveys - Transfer & Transport Between Services P&P - Referral/Transfer/ Discharge & Follow-up P&P - Transferring Patient from Other Facilities P&P - Request for Medical Information - Verification of Assessments and Reports from Other Facility - Discharge Planning and Tracking - Education Record - Multidisciplinary meeting minutes - Transfer Policy and Form - Transfer summary guidelines

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Accomplishments of JCI Chapters

Management of Communication & Information / Governance, Leadership & Direction (MCI / GLD): STANDARD

ACCOMPLISHMENTS - General

ME5

Orientation

Program/

Departmental

Orientation Program, Training Program, - Communication Boards, books in each unit

MCI.5

- Scope of Service

ME1 - PACS for Radiology ME2

- Critical Value Results P&P (Hospital-wide) - Overhead Paging for CODE Activation

ME3 MCI.6 ME1-4 MCI.7

- Staff communication thru memorandum - Progress Notes, Patient Transfer Summary (internal), shift report - Patient Transfer Summary Checklist/Form - Confidentiality of Patient Information P&P

ME1 ME2

- Confidentiality of Patient Medical Records P&P

MCI.8

- Transfer of Patient Between Services P&P

ME1-7

- Transfer of Patient to Another Facility P&P

MCI.9

- Staff Communication P&P

ME1-4 MCI.10

- Confidentiality & Restricted Documents P&P

ME1 - Confidentiality of Patient Information P&P ME2

- Ethics Plan - Medical Staff Bylaws

ME3

- Hospital P&P to be available in the server. To activate the Hospital Intranet

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Accomplishments of JCI Chapters

Management of Communication & Information / Governance, Leadership & Direction (MCI / GLD): STANDARD MCI.11 ME1-5 MCI.12 Me1-3 MCI.13 ME1-5 MCI.14-15 ME1-4 MCI.16 ME1-2 MCI.17 ME1-3

GLD.1

GLD.1.1

GLD.1.2

ACCOMPLISHMENTS -

Data Security P&P Privacy and Monitoring P&P User Name and Password/ Access Control P&P Archiving of Health Records P&P Retention of Health Records P&P ICD-9 Code used in the hospital

- Data collected must be monitored and used to improve hospital services

ď&#x201A;ˇ Ongoing education of IT Department as part of the Hospital Orientation Program - Formation of the Hospital Executive Committee with minutes of meeting - Hospital By-laws/Medical By-laws - Medical Staff Rules & Regulations - Nursing By-laws - Mission/Vision Statement - Minutes of the Steering Committee approving the mission/vision of the hospital - Governance P&P approval - Departmental Strategic Plans, Policies and Procedures - Measuring tools to be added in the P&P

GLD.1.3 GLD.1.4 GLD.1.5 GLD.2 ME1-6 GLD.3 ME4

Appointment letter for the organizationâ&#x20AC;&#x2122;s senior managers or directors - Reporting of the QPS Program to the President - Job Description - Risk Management Report - How to Develop Policies and Procedures (P&P - Copy of the Hospital Executive Committee meeting minutes - Environmental rounds report - Tracer activities monitor

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Accomplishments of JCI Chapters

Management of Communication & Information / Governance, Leadership & Direction (MCI / GLD): STANDARD GLD.3.1 ME3-4 GLD.3.1 ME3-4

ACCOMPLISHMENTS - Strategic and Operational Planning - Minutes on approval of the organization’s strategic and management plans - Inspection report from MOH, Civil Defense to be provided and the hospital’s reply to inspection report - Academic Affairs calendar of activities - Educational brochures on health promotion and disease prevention.

GLD.3.2 ME 1 GLD.3.2.1 ME 2 GLD.3.3 ME1-5 GLD.3.3.1 ME1-3 GLD.3.4

GLD.3.5

– Formation of Equipment Utilization & Stock Review Committee -

Biomed Equipment contracts (warranty) Housekeeping/Food Service/ Landscaping contract Laboratory/Radiology Equipment contract Patient Satisfaction Survey Key Performance Measures: sample indicators for Lab/ Radiology - PI Projects -

SBAR for medical staff Formation of Quality Management Committee Staffing Plan Staff Retention Plan Checklist for Personnel file review Orientation Program/checklist CME Annual Mandatory Training BLS/ACLS/NRP/PALS

GLD.4

GLD.5 – 5.5

GLD.6

- Job Description - Departmental Strategic Plan - Policies and Procedures - Quality Indicators - Employee Performance Appraisal Program (EPAP) Code of Ethics

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Accomplishments of JCI Chapters

Prevention & Control of Infection (PCI): STANDARD PCI 1

PCI 2

PCI 3

PCI 4

PCI 5

PCI 5.1

ACCOMPLISHMENTS The Infection Control Department is directed by professor in infectious disease and 3 infection control practitioner who attend several educational activities and receive training in infection control(two had pass already the certification in infection control and one is in the preparation).CV and certification are included in the file of ICT. Job description available There is an infection control committee who had member from (laboratory ,internal medicine, infection control, pediatric, nursing, quality ,pharmacy ,surgery who met regularly Collaboration between infection control department and other hospital department (e.g. housekeeping, dietary, laboratory, maintenance, etc.) The data of infection is being discussed in the meeting and it is distributed to the units through the infection control representatives. Sources such as CDC,MOH in the kingdom and WHO is being used as the references for the guidelines and recommendations GCC and APIC 2006 manual are available in the infection control department The Infection Control Department have total of 4 Staff: Infection Control Chairperson, 3 Infection Control Practitioner. -Infection control policy and procedure are available which cover all the main aspects in the hospital (infection control program, isolation, employee health, aseptic tech, hand hygiene, immunization, OUTBREAK INVESTIGATION, etc.) Attached is the policy. -infection control department statistical data for HAI is being compared with the NHS benchmark -Infection control policy and procedure are available which cover all the main aspects in the hospital (infection control program, isolation, employee health, aseptic tech, hand hygiene, immunization, OUTBREAK INVESTIGATION, etc.)

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Accomplishments of JCI Chapters

Prevention & Control of Infection (PCI): STANDARD PCI 6

PCI 7

PCI 7.1

PCI 7.2

PCI 7.3

ACCOMPLISHMENTS -Infection control program, Infection control committee, policy on surveillance for HAI ,Policy on isolation precaution, ongoing educational activity, OVR Process, Environmental round, - Action and recommendation is being discussed and done according to the result of the statistics and the incidences The infection control department in collaboration with the DQS identifies the risk through infection control data and finding. Policy and procedure is being prepared according to the risk that need action(e.g. MDROs policy like: MRSA, Acinetobacter policy ,Immunization policy) ALL Policies related to cleaning and disinfection and sterilization are with CSSD -cleaning and disinfection of toys policy is available - Infection control policy for laundry prepared and submitted to the concern department for feedback but not respond yet. ME 1. Need further clarification with the medical supply store By the policy of CSSD single used items canâ&#x20AC;&#x2122;t be resterilized. Educational activities has been conducted regarding the safe handling and disposing of waste especially medical waste and sharps waste Spills kit has been provided for each housekeeper and they were trained by the infection control team in the proper way of utilizing it when cleaning blood and body fluids spills. Infection control policy for mortuary care is provided .several reports sent to the concerned department regarding morgue issues. Puncture resistant container are wall mounted in each patients room and in other areas of the units as required Housekeeping policy still in progress ,the hospital is contracting with a company to deal with the waste

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Accomplishments of JCI Chapters

Prevention & Control of Infection (PCI): STANDARD PCI 7.4

PCI 7.5

PCI 8

PCI 9

PCI 10 PCI 10.1

ACCOMPLISHMENTS Policy and procedure for infection control in dietary services is prepared and reviewed The dietary department has their own policy regarding food preparation, sanitations and maintenance. The policy is approved and submitted to the hospital committee. Infection control policy for construction and renovation is prepared and discuss with the maintenance company for the implementation Maintenance department are still working on their policy and procedure concerning ventilation and air conditioning, water supply system, Policy on isolation precaution is available and approved, isolation room for contact precaution and airborne precaution is available Hepa- filter machine has been provided to manage patients with airborne precaution for short period when negative pressure room is not available.(policy prepared Educational activity has been provided for all HCW regarding the isolation precautions. Isolation precaution policy is provided which contain the use of PPE Current CDC guideline for the isolation is being implemented, MOH rules regarding influx of infectious diseases (e.g. avian flu, swine flu, TB etc.) is being implemented. Educational activity has been provided to all HCW regarding the use of PPE Hand hygiene policy is prepared and approved Posters for handwashing technique and using alcohol hand rub is prepared Hand hygiene policy is adapted from WHO and CDC guideline Infection control program There is a continuous surveillance for HCAI ,(rate is being communicated regularly)

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Accomplishments of JCI Chapters

Prevention & Control of Infection (PCI): STANDARD PCI 10.2

ACCOMPLISHMENTS Infection control Department is collaborating with the quality department for the performance improvement strategies.

PCI 10.3

PCI 10.4 PCI. 10.5

PCI 10.6

Isolation precaution policy, hand hygiene policy, employee health program policy Plans for improvement in collaboration with quality improvement coordinator Rate of HCAI is compared to the NHS benchmark. The results of HCAI reports are communicated regularly to the unit head nurses, infection control committee and other committee as required. Infection control department report to the MOH all cases require reporting, policy and procedure available, list of disease and reporting criteria available from MOH

Directorate of Quality & Safety Annual Report 2012

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Patient Experience

Directorate of Quality & Safety Annual Report 2012

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Patient Experience (Patient Satisfaction Survey)

Introduction Patient satisfaction survey in KFHU is an essential element (factor) in improving the quality of care provided to patients in any healthcare setting. It provides an important or needed feedback of patient experience in his/her journey in the hospital either good or bad. KFHU intend to focus more on the negative aspect of patients experience for improvement. Measurement of patient satisfaction performed world-wide, especially for those hospitals who intend to acquire JCI certification, or those who share patients and their relatives in resulting to posting their institute especially when there is a competition market system. Continues monitoring of patient satisfaction is part of quality management department activities. Distribution of patient satisfaction questionnaires for inpatients and outpatient were performed on daily basis. Aim To identify area of deficiencies experienced by patients and their relatives who use KFHU as a resource of their health care delivery. Objectives 

To identify the level of patient satisfaction in relation with different aspect of in-patient care



To identify the level of patient satisfaction in relation with different aspect of outpatient clinics (OPD) care



To develop a system that will allow for comparison of patient’s satisfaction on quarterly basis and as well with other well recognized high health care quality provider hospital

Starting time Patient satisfaction survey process started on May 2012 with an aim to satisfy JCI standard, where by patient satisfaction considered as an essential part of quality improvement in health care. It started with choosing valid and reliable questionnaire, used by well recognized hospital with an aim to compare KFHU with that hospital. Two questionnaires selected one for in patients and the other for out-patients. Second step was started by translating the questionnaires into Arabic and modification performed so that they can be applied for KFHU culture. Scope Both questionnaires to be distributed to all patients attending KFHU OPD, and all in-patients, except those who were critically ill. Those patients who cannot read or write the questionnaire given to the member of the family and asked to fill the questionnaire with the patient, and if relatives not present or not cooperative, the social worker will help the patient in filling questionnaire.

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Patient Experience (Patient Satisfaction Survey) Method Questionnaire A valid and reliable in-patient and out-patient questionnaires were selected and used after translating them into Arabic and removing questions or dimensions for unavailable services. Outpatient questionnaire consist of 43 items in which the patients asked to score on 5 point Likert scale from strongly agree to strongly disagree. Pilot study Before wide distribution of the questionnaire, a pilot study was performed on a small number of patients. The questionnaires were distributed and patient point of view regarding the questionnaire content was documented, then minor changes were performed in order to satisfy patients without influencing the validity and reliability of the questionnaire. The Out Patient Department (OPD) questionnaire is composed of 43 items grouped into the following dimensions: - Background questions - New file initiation/registration - Reception - Appointment - Facility - Patient treatment - Patient test - Patient personal issues - Overall assessment Comment space added at the end of each dimension

12 items 3 items 2 items 4 items 3 items 5 items 6 items 3 items 5 items

The inpatient questionnaire is composed of 62 items grouped into the following dimensions: - Background questions - Admission - Room - Meals - Nurses - Tests - Treatment - Visitors and family - Physician - Discharge from hospital - Personal issues - Overall assessment Comment space added at the end of each dimension

Directorate of Quality & Safety Annual Report 2012

10 items 2 items 10 items 4 items 9 items 3 items 3 items 2 items 6 items 3 items 7 items 3 items

Page 45 of 128

Patient Experience (Patient Satisfaction Survey)

Distribution The social health worker distributes the questionnaire on daily basis, by giving the questionnaires to those who attend outpatient clinic and those patients who are discharged from the hospital. Then the questionnaire entered into the EXCEL sheet, and then analysis was performed using SPSS Statistical Software. At the beginning, the analysis was performed on monthly basis, and was later on performed on quarterly basis. Department reports Initially, a report was prepared at the end of each month. It was later consolidated and prepared as quarterly report. Response rate The response rate was not considered. For patients who could not fill the questionnaire, they were helped and assisted by the social worker. In the future, the response rate will be included as a mandatory data for the accuracy of the information. Results

The OPD, number of questionnaires 349

- Overall reception satisfaction rate

90.8%

- Overall registration/file initiation satisfaction rate

86.1%

- Overall appointment satisfaction rate

84.3%

- Overall assessment satisfaction rate

83.2%

- Overall treatment satisfaction rate

82.8%

- Overall test satisfaction rate

82.1%

- Overall facility satisfaction rate

76.3%

- Overall personal issues satisfaction rate

74.4%

Figure 1: Response Rate (Out Patient Survey)

The results for OPD shows that the majority of dimensions below 90%, only overall reception satisfaction rate is above 90%.

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Patient Experience (Patient Satisfaction Survey)

Two dimension, overall facility satisfaction rate and overall personal issues satisfaction rate are below 80%. The inpatient number of questionnaires 409 - Overall physician satisfaction rate

89.7%

- Overall admission satisfaction rate

89.2%

- Overall assessment satisfaction rate

88.2%

- Overall treatment satisfaction rate

85.8%

- Overall discharge satisfaction rate

85.2%

- Overall Nurses satisfaction rate

83.8%

- Overall privacy satisfaction rate

83.7%

- Overall room satisfaction rate

81.1%

- Overall visitors and family satisfaction rate

81.0%

- Overall tests satisfaction rate

80.6%

- Overall meals satisfaction rate

71.5%

Figure 2: Response Rate (Inpatient Survey)

For the inpatient survey, it shows that all dimensions within 80%, while only overall meals satisfaction rate is 71.5%.

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Patient Experience (Patient Satisfaction Survey)

Questionnaires improvement A subcommittee has been set to look for an area to improve the questionnaire contents to overcome patients and social worker difficulties. The main improvement       

adding information part to patients at the beginning of questionnaires increase the size of font correct some wordings adding “Not Applicable” to scores removing comment space below each dimension, and having one common at the end of each questionnaire combining new file initiation/registration, reception, and appointment dimensions into one making the questionnaire forms well-arranged and more attractive

The OPD questionnaire composed of 39 items, these items grouped into the following dimensions - Background questions - New file initiation/registration/reception/appointment - Facility - Patient treatment - Patient test - Patient personal issues - Overall assessment Comment space added at the end of the questionnaire

13 items 3 items 3 items 6 items 6 items 3 items 5 items

The inpatient questionnaire composed of 61 items, these items grouped into the following dimensions - Background questions - Admission - Room - Meals - Nurses - Tests - Treatment - Visitors and family - Physician - Discharge from hospital - Personal issues - Overall assessment Comment space added at the end of the questionnaire

Directorate of Quality & Safety Annual Report 2012

10 items 2 items 9 items 4 items 9 items 3 items 3 items 2 items 6 items 3 items 7 items 3 items

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Patient Experience Recommendations

To improve response rate and to reduce the Social Worker waiting, changes were incorporated in the questionnaire distribution system by having boxes for filling questionnaire collection.

One box will be placed in the Reception Area and the

Receptionist will give the Out-Patient Department questionnaire to the patients. The patient will be asked to fill the questionnaire while waiting for physicianâ&#x20AC;&#x2122;s appointment. For inpatients questionnaires, a box is to be placed in each ward and ask the nurse to give the questionnaire to those patients who have been discharged on the same day, to fill the questionnaire before leaving the hospital. 2.

The new process to be piloted.

A new Patient Relation Office has been established at the ground floor of the hospital building, with recruitment of new staff that have expertise in this filed.

Directorate of Quality & Safety Annual Report 2012

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Performance Improvement & Accreditation Unit

Directorate of Quality & Safety Annual Report 2012

Page 50 of 128

Performance Improvement & Accreditation Unit Introduction

The Quality Improvement and Patient Safety is an important element of Joint Commission International Accreditation. Quality Improvement in Healthcare is a roadmap for improving the delivery of health care services, patient health outcomes, and population health. The Quality Improvement initiative is intended to align the priorities and efforts of hospital leaders and stakeholders in improving the quality and reducing the cost of health care. The Directorate of Quality and Safety has collaborated with stakeholders across the entire organization that observed overwhelming consensus that everyone can play a role in improving the quality and reducing the cost of health care. In order to facilitate reporting and share the lessons learned, we strive to improve quality improvement system and proper data analysis so as to identify clinical risk, formulate quality improvement initiatives to tie in with resources, transform healthcare environment and provide a safer and more efficient healthcare to our patients. This report provides an update on the Quality Improvement and Patient Safety initiatives that has occurred in 2012, and the activities currently underway.

Directorate of Quality & Safety Annual Report 2012

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Performance Improvement & Accreditation Unit Executive Summary

With the support of KFHU Leaders, Directorate of Quality and Safety Department launched the Joint Commission International Accreditation in January 2012. The hospital leaders formulate a team based on the 14 standards of JCI manual. The main objectives of the teams are to establish the infrastructure of accreditation process, assess the feasibility of implementing and to be compliant to the standards. The accreditation was launched with intensive engagement and training programs which have substantially enhanced the awareness and support to JCI accreditation. We identified strengths and opportunities for improvement related to the clinical and managerial performance measures; clarification with the data owner is made in some variations. We discussed these areas for improvement with the responsible data owner of who agreed with our suggestions to start a quality improvement project using FOCUS PDCA methodology. STRENGTHS Started the following activities: 1. Performance Improvement Projects a. Rapid Response Team (RRT) – The opportunities of improvement is the increase in number of Code Blue outside the Critical Care Unit. The project start last June 2012, the team composes of Assistant Director of Nursing, Intensivist, Respiratory Therapist, Critical Care Nurse and CCU/ICU Supervisor. RRT Policy and procedures, Forms, training and education for all employees were done. The Rapid Response Team Code will start in February 2013. b. Patient Overstaying in Emergency Room – The increase in number of patient in emergency room more than 6 hours cause overcrowding in ER. The increase in trend identified through Occurrence Variance Report. The project started in 29th December 2012. The existing policies and procedures reviewed and revised such as Timely Completion of Consultation in EMD, and OPD Admission. Implementation of Admission Request Form to monitor the Length of stay, Information Technology Department (ITD) is involved to monitor the Turn Around Time of diagnostic laboratory and radiology. c. Patient Falls – The increase in number of inpatient falls were identified through Occurrence Variance Report (OVR). Falls Prevention Policy revised and implemented, Humpty Dumpty fall prevention policy adopted, and Environmental checklist, Signage and stickers were developed which are to be included to the policy and procedure as an attachment. Morse Fall scale for adult and Humpty Dumpty for pediatric are used as an assessment tool. d. Operating Room Cancelation – The increase in operating room cancelation rate identified through OVR.

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Performance Improvement & Accreditation Unit Executive Summary

2. Implementation of International Patient Goals – The JCI Chapter team of International Patient Safety Goals (IPSG) developed a policies and procedures for the six IPSG. Training and Education to all healthcare providers were completed. A letter from Dr. Khalid Al Otaibi was sent to all Head of each service for implementation. Monitoring for compliance will be monitored by the Quality Improvement Coordinator of each unit in collaboration of the Directorate of Quality and Safety. 3. AHRQ Culture of Safety – Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture were conducted. The survey form was issued to all employees in July 2012. It was designed to assess hospital staff opinions about patient safety issues, medical errors, and event reporting. The survey includes 42 items that measured 12 areas, or composites, of patient safety culture: a) Teamwork within units, b) Supervisor / Manager Expectations and Actions Promoting Patient Safety, c) Org. Learning – Continuous quality improvement d) Management support for patient safety e) Overall perception of patient safety f) Feedback of communication error g) Frequency of events reported h) Communication openness i) Teamwork across units j) Staffing k) Handoffs and transitions l) Non-punitive response to error The survey also includes two questions that ask respondents to provide an overall grade on patient safety on their work area/ unit and to indicate the number of events they reported over the past 12 months. The survey was completed anonymously and employees put their response in the drop boxes located in every nursing station and hospital lobby. Most of the survey’s items ask respondents to answer using 5-point responses categories in terms of agreement (strongly agree, agree, neither, disagree, strongly disagree) or frequency (always, most of the time, sometimes, rarely, never) KFHU overall patient Safety culture rate is given below (56%) compare to AHRQ (60%). Overall Patient Safety Culture Survey

p Good

100% 75%

56.0%

60.0%

KFHU

AHRQ

50% 25% 0% Figure 1: Patient Safety Culture Survey

Directorate of Quality & Safety Annual Report 2012

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Performance Improvement & Accreditation Unit Executive Summary KFHU Patient Safety Culture Priorities: Patient Safety Culture Composite

KFHU

AHRQ

Non punitive Response to Error

24.1%

40%

Staffing

26.6%

53%

Communication Openness

39.5%

60%

Handoffs and Transitions

56.1%

40%

Supervisor /Manager Expectations and Actions Promoting Patient Safety

56.2%

72%

Table 1: Patient Safety Culture Composite

4. Monitoring of Performance Measures – Performance Measures were identified in compliance to JCI chapter Quality Improvement and Patient Safety, QPS.3 The measures selected related to the important clinical areas include: a. Patient assessments; b. Laboratory services; c. Radiology and diagnostic imaging services; d. Surgical procedures; e. Antibiotic and other medication use; f. Medication errors and near misses; g. Anesthesia and sedation use; h. Use of blood and blood products; i. Availability, content, and use of patient records; j. Infection prevention and control, surveillance, and reporting; and k. Clinical research. The measures selected related to the important managerial areas include: a. The procurement of routinely required supplies and medication essential to meet patient needs; b. Reporting of activities as required by laws and regulations; c. Risk management; d. Utilization management; e. Patient and family expectations and satisfaction; f. Staff expectations and satisfaction; g. Patient demographics and clinical diagnoses; h. Financial management; and i. Prevention and control of events that jeopardize the safety of patients, families, and staff. 5. Patient Satisfaction Survey – The cost of providing health care is escalating at an alarming rate. With challenges ranging from rising malpractice costs to physician turnover, medical practices and must maximize resources. It is precisely these challenges that make improving patient satisfaction so critical. Goal of Patient Satisfaction:  Reduce malpractice  Decrease patient defections  Decrease negative word–of-mouth advertising  Increase patient referrals

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Performance Improvement & Accreditation Unit Executive Summary

6. Joint Commission International Accreditation Process and Basic Concepts of Quality Improvement – Introduction of JCI Accreditation process and basic concepts of Quality Improvement process were included in the General Orientation Program for the new employee. 7. Utilization Care Review – This is to ensure the effectiveness and efficiency of hospital facilities and services, through the use of an on-going monitoring program designed to identify patterns of inappropriate utilization. 8. Hospital Committees, JCI Chapter Teams, Performance Improvement Project Teams, and Team meetings attended by Quality Improvement Coordinators – In order to assess, evaluate and learn about the organization, the Performance Improvement Coordinator attended various meetings.  155 JCI Chapter Team and Quality Improvement Projects as meetings attended as Facilitator  21 Committee meetings attended as Secretary S/N 1 2 3 4 5 6 7 8 9 10 11 12 13 14

JCIA Chapters Access to Care & Continuity of Care (ACC) Assessment of Patient (AOP) Care of Patient (COP) ACC/AOP/COP Anesthesia & Surgical Care (ASC) Facility Management and Safety (FMS) International Patient Safety Goal (IPSG) FMS / IPSG Joint chapter meeting Governance Leadership and Direction (GLD) Management of Communication & Information (MCI) Staff Qualification and Education (SQE) MCI/SQE/GLD Joint chapter meeting Medication Management and Use (MMU) Prevention and Control of Infections (PCI) Patient and Family Rights (PFR) Patient and Family Education (PFE) PFE/PFR Joint chapter meeting Quality Improvement and Patient Safety (QPS) JCIA Chapter Team Meetings Total

# of Meetings 13 13 13 2 10 11 8 15 13 11 3 1 7 3 11 5 1 3 2 145

Table 2: JCI Chapters (meetings Attended by Performance Improvement Coordinator)

Directorate of Quality & Safety Annual Report 2012

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Performance Improvement & Accreditation Unit Executive Summary

Table 3: Teams (Meetings attended by Performance Improvement Coordinator)

S/N

Teams

# of Meetings

Rapid Response Team

Forms Team

Patient Satisfaction Team

Code Blue Team

Utilization Care Team

Close Record Review Team â&#x20AC;&#x201C; waiting for the forms

0 Total

Table 4: Hospital Committees (Meetings attended by Performance Improvement Coordinator)

S/N

Hospital Committees

# of Meetings

Credentialing and Privileging Committee (CPC)

Hospital Safety Committee (HSC)

Quality Management Committee (QMC)

Infection Control Committee (ICC)

Medical Records and Health Information Committee (MRHIC)

Drug and Therapeutics Committee (DTC)

Surgical and Operating Room Committee (SORC)

Morbidity and Mortality Committee (MMC)

Critical Care Committee (CCC)

1 Total

Table 5: Performance Improvement Project (Meetings attended by PI Coordinator)

S/N

Performance Improvement Project

#of Meetings

Rapid Response Team

OR Cancelation

Over staying patient in ER

Patient Falls

1 Total

Directorate of Quality & Safety Annual Report 2012

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Performance Improvement & Accreditation Unit Executive Summary

9. Accreditation Journey – The journey begin in January 2012 by presenting Joint Commission International Accreditation to all KFHU employee in Hospital Auditorium. The 14 chapter team’s review, revise, and developed policies and procedures, forms and plans. Table 6: JCI Chapters Statistics of Total Number of Policies & Procedures # #Required Completed Completed Completed % Standard Required # Plans Forms P&P Forms Plans Completed P&P IPSG 6 6 6 6 100% ACC

100%

ASC

100%

PFE

100%

QPS

100%

MMU

98%

COP

96%

PFR

AOP

GLD

MCI

SQE

FMS

91% 89%

88%

73%

57% 40%

PCI

MPE

10% 0%

HRP

Figure 2: Percentage of Policies & Procedures completed by JCI Chapters

Directorate of Quality & Safety Annual Report 2012

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Performance Improvement & Accreditation Unit Executive Summary

Opportunities for Improvement The opportunities for improvement identified 

Monitoring and data collection of the following Performance Measures:  Medical History and Physical Assessment Completed within 24 Hours  Nursing Initial Assessment within 2 hours of admission  Pain assessment upon admission  Radiology Report TAT  Repeat exposure  Unnecessary X-ray  Surgical antibiotic cases with prophylactic antibiotic administration 550 mins before surgery  Surgical Cases with appropriate selection of prophylactic antibiotics  Use of relievers of children inpatient asthma (JCI Library of measure)  % of pre-anesthesia assessment completed  Compliance to Anesthesia Consent (Conscious or Deep Sedation  % of Compliance completion of medical records JCI criteria  Approved abbreviation  Completed significant data sheet  Completed Informed Consent  Informed consent completed before clinical research  Monitoring of complete of requested documentation before research approval  % of Life Saving Medication below minimal level  % of expired warehouse Supplies  % Patient Satisfaction  Patient complaints  Staff Satisfaction  Staff Turn over  Top 10 Surgical Procedures  Top 10 discharge diagnosis  Annual hospital budget  Allocation of operational budget  % compliance to patient Identification  % compliance to Newborn Identification Policy  % compliance to verbal & telephone order policy  % Compliance to P&P of Critical Value Reporting  % Compliance to storage of high alert medication P&P  % Compliance to patient verification  % Compliance to patient surgical marking  % Compliance to Time-out  % of hand hygiene compliance  Falls Rate  % of compliance to Falls assessment policy (JCI library of measure)

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Performance Improvement & Accreditation Unit Executive Summary

    

Blood stream infection rate is above the mean Operating Room cancelation rate is above the target Average length of stay is above the AHRQ average length of stay 4.5 Evidence of compliance to the JCI standards and implementation of the policies and procedures, forms and hospital plans. Data collection process

Directorate of Quality & Safety Annual Report 2012

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Performance Improvement & Accreditation Unit Clinical Performance Measure

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. Julia / CCU

60% 40% 20% 0%

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Target

2012

Blood Culture Contamination Rate

â&#x2013;ź Good

3.0 2.0 1.5

Number of cultures contaminated (i.e., with species listed under the graph) in a month

Data Owner: Ms. Sausan, Clinical Laboratory

1.0 0.5 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Target

2012

â&#x2013;ź Good

Blood Product Wastage Rate 6%

Analysis: The graph indicates the decreased the rate of contaminated culture in the last quarter of 2012 and it was below the CAP benchmark.

Numerator:

Number of units of blood or blood products that were discarded within their expiry date in a month Denominator: Number of units of blood or blood products that were transfused and discarded within their expiry date in a month

4% 2% 0%

Numerator:

Denominator: Number of blood cultures in a month

2.5

0.0

Analysis: The graph indicates KFHU compliance to the JCI library of measures. Patients received aspirin within 24 hours before or after hospital arrival

Data Owner: Ms. Sausan, Clinical Laboratory Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Target

Directorate of Quality & Safety Annual Report 2012

2012

Analysis: Although there were 2 spikes April and July 2012 due to preparation and cancelation of surgery, blood product wastage decreased in the last quarter of 2012 below the CAP benchmark 3%

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Performance Improvement & Accreditation Unit Clinical Performance Measure

BSI Incidence per 1000 device days

▼ Good

25.0 20.0

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

15.0

Denominator: patient days

10.0 5.0 0.0

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Mean

Data Owner: Ms. Samia, Infection Prevention and Control

2012

Analysis: The graph shows Blood Stream Infection rate is above the 2011 mean Note: the statistics include all critical areas ▼ Good

Hospital Acquired Healthcare Associated Infection 6.0

Number of healthcareassociated infections. Denominator: number of inpatient.

5.0 4.0

Data Owner: Infection Prevention and Control

3.0 2.0 1.0 0.0

Numerator:

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Mean

2012

▼ Good

MRSA 5.0

Analysis: No data submitted in the last quarter of 2012. The graph indicate HCAI below the mean although there is an increased in trend in 3rd quarter of 2012 due to an increase blood stream infection rate in ICU in spite of hand washing awareness campaign.

Numerator:

Number of healthcareassociated MRSA infections in a month Denominator:

4.0 3.0

Data Owner: Samia, Infection Prevention and Control

2.0 1.0 0.0

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Target

Directorate of Quality & Safety Annual Report 2012

Analysis:

2012

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Performance Improvement & Accreditation Unit Clinical Performance Measure

▼ Good

JCI ILM Cesarean Deliveries 50%

Numerator:

Number of nulliparous patients delivered of a live term singleton newborn in vertex presentation by Cesarean section

40%

Denominator: Number of nulliparous patients delivered of a live term singleton newborn in vertex presentation

30% 20% 10% 0%

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec WHO Target

Data Owner: Labor and Delivery Unit

2012

Analysis: The graph indicates an increase of nulliparous patient delivered of a live a singleton newborn in vertex presentation by cesarean section in Sept. Oct. and Nov. 2012 it is more than 10% above WHO ▼ Good

OR Cancelation Rate

Numerator: Number of surgery cases cancelled on the same day of surgery in a month.

20%

Denominator: Number of surgery cases scheduled in a month.

15% 10%

Data Owner: Daliah, Operating Room

5% 0%

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Target

2012

Analysis: Data collection started in June 2012, the graph shows surgical cancelation rate on the day of the procedure is above the target. Surgical cancelation is due to unavailability of bed, blood and some investigation was not complete Note: Quality Improvement Project started.

UTI Incidence per 1000 device days

▼ Good

15.0

Numerator:

Number of urinary tract infection in a month Denominator: device days

12.0

Data Owner: Ms. Samia, Infection Prevention and Control

9.0 6.0 3.0 0.0

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Mean

Directorate of Quality & Safety Annual Report 2012

2012

Analysis: The graph shows urinary tract infection rate 3 data point is above the 2011 mean.

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Performance Improvement & Accreditation Unit Clinical Performance Measure

▲Good

% of Venous Thromboembolism Prophylaxis 100% 95% 90% 85% 80%

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Target

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. Denominator: Patients directly admitted or transferred to ICU who is at least 18 years of age.

2012

Data Owner: Adult Critical Care Analysis: Data gathered from April 2012 in Adult Critical Care Unit show the compliance rate ranging from 88% to 100%. ▼ Good

Specimen Rejection Rate

Numerator: Number of specimens rejected (in accordance with criteria above) in a month

5.0

Denominator: Number of specimens received in a month

4.0 3.0

Data Owner: Ms. Sausan, Clinical Laboratory

2.0 1.0 0.0

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Target

2012

▼ Good

Wrong identification

Analysis: The graph shows specimen rejection rate range from 0.5 to 2.8 and it is below the benchmark.

Numerator: Number of specimen received with wrong identification in a month.

5.0

Denominator: Number of specimen received in a month.

4.0 3.0 2.0

Data owner: Ms. Sausan, Clinical Laboratory

1.0 0.0

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Target

Directorate of Quality & Safety Annual Report 2012

2012

Analysis: 7 specimens with wrong identification out of 48165 specimens received.

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Performance Improvement & Accreditation Unit Clinical Performance Measure

Medication Error per 10,000 Items Dispense

â&#x2013;ź Good

Number of medication

errors in a month Denominator:10,000 medication items dispensed in a month

5 4 3

Data Owner: Elizabeth Zipagan, Risk Management Unit

2 1 0

Numerator:

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2012

Directorate of Quality & Safety Annual Report 2012

Analysis: The graph indicates a decreased in medication error rate in the last quarter of 2012 after the in-service training on medication administration

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Performance Improvement & Accreditation Unit Managerial Performance Measure

Average Length of Stay

â&#x2013;ź Good

Numerator: Total number of inpatient services for a given period of time Denominator: Total number of days in the same period Analysis: The graph shows the average length of stay in 2012 is above the AHRQ length of stay in 2009

AHRQ

2011

2012

â&#x2013;ź Good

LAMA per 100 Admission

Numerator: Number of LAMA submissions Denominator: Number of admission X 100

Analysis:

Jan

Feb

Mar

OVR admission per 100 Admission

Numerator: Number of inpatient OVR submissions Denominator:100 patient days Data Owner: Elizabeth Zipagan, Risk Management Unit Analysis: Data collection started second quarter of 2012

Feb

Mar

Directorate of Quality & Safety Annual Report 2012

Apr

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.

Page 65 of 128

Performance Improvement & Accreditation Unit Managerial Performance Measure

Numerator: Number of inpatient days in a month

Occupancy rate

Denominator: 100%

Data Owner: Mr. Sadiq

80%

Analysis: The graph show the occupancy rate is below compare to AHRQ / CDC (74%) It is conflicting to the Increased in ALOS

60% 40% 20% 0%

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec CDC

2011

Number of Sharps Injury

2012

â&#x2013;ź Good

Numerator: Number of reported sharps injuries in a month Denominator:

10 8

Data Owner: Elizabeth Zipagan, Risk Management Unit

6 4

Analysis: Data collection started in June 2012

2 0

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2012

Directorate of Quality & Safety Annual Report 2012

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Performance Improvement & Accreditation Unit Recommendation

One of the primary purposes of the quality improvement system is to build a hospital-wide consensus on how to measure quality. As we undertake the challenge of improving health care quality, our efforts must be driven by reliable data that the stakeholder agrees encompasses the best and most relevant measures, without creating an undue burden of collection. The following are the strategic opportunities to accelerate system-wide improvement:

Develop a hospital-wide strategy for data collection, measurement, and reporting that supports performance measurement and improvement efforts.

Develop an infrastructure at the department level that assumes responsibility for improvement efforts, resources for the department to benchmark and compare performance, and mechanisms to identify, share, and evaluate progress.

Develop a process of implementing and monitoring of new forms, policies and procedures, clinical pathways.

Promote Quality Improvement Project Methodology (FOCUS-PDCA) through education.

Continue the existing quality improvement project, and celebrate the success.

Increase manpower to develop and revise hospital forms.

Directorate of Quality & Safety Annual Report 2012

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Utilization Care Review

Directorate of Quality & Safety Annual Report 2012

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Utilization Care Review

Utilization review ensures the effectiveness and efficiency of hospital facilities and services, through the use of an on-going monitoring program designed to identify patterns of inappropriate utilization. After staff education, utilization review screening started July 2012. Results shown: Table 1: Summary of Avoidable Days Report: July 2012- December 2012

BARRIERS Discharge Order Delay No severity of illness Extra pre-operative day Thirty + days Transfer delay X-ray delay Laboratory delay OR delay Discharge Planning Delay Social Services delay Patient/Family Insist Hospital Delayed Pick-Up No home care available Humanitarian Stay

JULY 1 28 45

AUG

9 44

SEPT

20 40

1 3

3 25

2 22

3 29

OCT 4 8 25 1 1

1 1 2 26

NOV 1 17 34 1

2 3 3 2 29

DEC 1 1 26 33 1 1 1

2 1 2 2 30

Figure 1: Summary of Avoidable Days (July-December 2012)

Directorate of Quality & Safety Annual Report 2012

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Utilization Care Review Figure 2: Percentage of Avoidable Days

Table 2: Extra Pre-Operative Days

EXTRA PRE-OPERATIVE DAYS Urology General Surgery Pediatric Surgery Vascular Surgery Cardiothoracic Surgery Plastic Surgery Ophthalmology Neurosurgery ENT Orthopedics

JULY 11 7

AUG 4 3

4 2 2 1

1 1

SEPT 6 7 5

OCT 1

NOV 3

DEC 7 3

3 2 1

3 6 1

3 4 1

Figure 3: Extra Pre-Operative Days

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Utilization Care Review

Extra Pre-operative day  Pre-operative day exceed 2 days Reasons:  Pre-operative preparation done as an inpatient. Recommendations:  Pre-operative preparation should be done in outpatient clinic. ( Elective OR)  Patient should not be admitted if not cleared by the Anesthetist.  Implementation of Clinical Pathways.  Implementation of length of stay during admission. Thirty + days Reasons:  Patient is bedridden, ventilator dependent, unconscious, and comatose.  Patient needs special care and monitoring.  Waiting for police clearance.  Waiting for caregiver. Recommendation:  Patient and family education. Humanitarian Stay Reasons:  Long term patient  No caregiver  Old age – no bed available in home for the aged  Patient needs special care and monitoring  No family  Patient is bedridden, ventilator dependent, unconscious, and comatose. Recommendation:  Patient and family education.

Directorate of Quality & Safety Annual Report 2012

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Risk Management Unit

Directorate of Quality & Safety Annual Report 2012

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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 from July to December 2012. 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: Data & Methods

The total number of OVRs from July to December 2012 has reached 3,520. An increase in reporting was noted each month except for the month of October because of Eid Al Adha. Figure 1: Monthly OVR Received

Figure 2: Top Reported Incidents 2012

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Risk Management Unit Overview

Figure 3: Percentage of Top Reported Incidents 2012

Top reported incidents were “Overstaying of patient in ER” (784) followed by “Discharged Against Medical Advice” (587) then “Break in Skin Integrity” (504). “OR Cancellation was the fourth highest reported incident (210) followed by “Line, Tube, Drain, or Catheter” (125) and “Building Structure and Infrastructure” (94),“Clinical equipment”(80), “Birth trauma/Injury to Neonate”(71), “Admission-related issue” (66), “Missing patient or other person”(58). Also on top list were, “Out on pass (51)”, “Nonclinical equipment” (50), “Fall” (47), “Incorrect name or Medical Record number”(44), “Transfer-related issue”(41), “Fire alarm or Fire”(34), “Refused treatment/procedure”(31), and “Housekeeping issue”(30).

Directorate of Quality & Safety Annual Report 2012

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Risk Management Unit OVRs Related to International Patient Safety Goal IPSG is one of the requirements for implementation by JCI. Its purpose is to promote specific improvements in patient’s safety. The goals of IPSG are: 1. 2. 3. 4. 5. 6.

Identify patients correctly Improve effective communication Improve the safety of high-alert medications Ensure correct site, correct procedure, correct patient surgery Reduce the risk of health-care associated infections Reduce the risk of patient harm resulting from falls

Some of the highlighted problems on reported incidents from July to December 2012 were related to IPSG.   

 

Communication (5.7%) – Due to ineffective communication there were patient care delay, procedure delay, OR cancellations, delay in admissions and delay in transfer of patients. Patient Identification (2.9%) – Errors noted were incorrect name or Medical Record number, incorrect demographics and incorrect labels. Health associated infections (1.7%) –Infection prevention and control are challenging in a health care settings. Reported variances were about non-compliance to Personal Protective Equipment (PPE), admission of patients in the unit without and with incomplete multi-drug resistant organism screening and break in skin integrity. Falls (1.3%) - 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. High Alert Medications (0.1%) – The most effective means to reduce or to eliminate these occurrences is to develop a policy and procedure in managing high-alert medication.

Figure 4: OVRs Related to International Patient Safety Goals (IPSG) Directorate of Quality & Safety Annual Report 2012

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Risk Management Unit OVRs Related to International Patient Safety Goal

Table 1: OVRs related to International Patient Safety Goals (IPSG)

Directorate of Quality & Safety Annual Report 2012

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Risk Management Unit Analysis of OVRs (Overstaying of Patients in ER)

Figure 5: Monthly Reported

Figure 6: Reasons for Overstaying

Table 2: Reasons for Overstaying of Patients in Emergency Room

Overstaying of patient in ER refers to the cases where patients stay in Emergency Room for 6 hours and more. This category is the highest reported OVRs with a percentage of 22%. The reasons for overstaying are either patient related or system related. Medical re-evaluation represents 57% of the total variances and this is due to the complexity of the patientâ&#x20AC;&#x2122;s condition and natural course of treatment (e.g. CT scan, further referral to another service for consultations). No bed available is another top reason of patient overstaying in ER.

Directorate of Quality & Safety Annual Report 2012

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Risk Management Unit Analysis of OVRs (Discharged Against Medical Advice)

Table 3: Reasons for Discharged Against Medical Advice (DAMA)

Figure 7: Location of Reported DAMA

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 from July to December 2012. 66% of reported DAMA were from ER and 34% were reported by in-patient units. Although it is acknowledged that refusing treatment is one of the patientâ&#x20AC;&#x2122;s rights, KFHU healtcare providers make all possible efforts to convince the patients to stay and not to take such decision.

Directorate of Quality & Safety Annual Report 2012

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Risk Management Unit Analysis of OVRs (Break in Skin Integrity)

Table 4: Type of Break in Skin Integrity

Figure 8: Reported Pressure Ulcers 2012

Skin integrity means whole, intact and undamaged skin. Maintaining skin integrity is important because hospital acquired pressure ulcers, skin tears and infections are associated with pain, reduced mobility, increased risk of in-hospital complications and increased health care costs due to prolonged length of stay. Break in skin integrity is the third most frequently reported occurrence from July to December 2012 with a total of 504 cases (14%). Hematoma was the highest reported case due to needle pricks, cannulation, patient factors (e.g. low platelets, patient on anticoagulant) and blood extraction. 48 cases of Pressure ulcers were reported, of which 28 were upon admission to hospital and 20 cases developed upon patientâ&#x20AC;&#x2122;s stay in the unit. Stages of hospital acquired pressure ulcers were not defined because of the absence of pressure ulcer scoring system.

Directorate of Quality & Safety Annual Report 2012

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Risk Management Unit Analysis of OVRs (OR Cancellation)

Table 5: Causes of OR (Operating Room) Cancellation

Figure 9: Number of OR (Operating Room) Cancellation

OR Cancellation is consistently one of the top most reported incident from July to December 2012. Cancelled operations are waste of resources and time. They bring the additional administrative burden of re-scheduling appointments. They are distressing, inconvenient for patients, and when the hospital themselves cancel operations, these will be difficult for the hospital. The three types of cancellations identified from submitted OVRs were: 1. Hospital non-clinical: bed not available, staff unavailable, overlapping of schedule, no consent 2. Hospital clinical: surgery no longer required, pre-operative guidelines not followed, patient arrived with illness and pre-existing medical condition, needs more diagnostic examinations, 3. Patient: did not show up on the scheduled day of surgery

Directorate of Quality & Safety Annual Report 2012

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Risk Management Unit Analysis of OVRs (Line, Tube, Drain or Catheter)

Figure 11: Distribution of Age for Reported Line, Tube, Drain, Catheter Figure 10: Location of Reported Incidents (Line, Tube, Drain or Catheter)

Table 6: Reported Incident (Line, Tube, Drain, Catheter)

Central line, IV lines, NGTs, catheters, drains must regularly be checked for proper placement and make sure that itâ&#x20AC;&#x2122;s working properly prior to use. Incidents like infiltrations, dislodged lines, accidental removal and removal of line by patient was reported and came as fifth of the top reported incidence from July to December 2012. 35% of reported incidence happened to children below 10 years of age.

Directorate of Quality & Safety Annual Report 2012

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Risk Management Unit Analysis of OVRs (Building Structure or Infrastructure)

Table 7: Building Structure or Infrastructure

Figure 12: Number of Building Structure or Infrastructure

This incidence is associated to basic physical structures/facilities needed for operation. A big percentage of incident reported on building structure or infrastructure was about damaged ceiling tiles (24%) due to water leak from HVAC. The peak of this incidence was noted during summer time. Other reported incidents were leaking AC, malfunction AC, broken window, malfunction call bell, leakking faucets, cracked wall, broken door, broken drinking fountain, elevator malfunction, damaged floor tiles, open electrical outlet, oxygen leakage, damaged vinyl tiles, and broken wall.

Directorate of Quality & Safety Annual Report 2012

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Risk Management Unit Analysis of OVRs (Clinical Equipment, Device Consumables)

Figure 13: Clinical Equipment, Device, Consumables

This incidence is associated about equipment occurrences that are related to clinical equipment like thermometer, sphygmomanometer, etc. It also includes occurrences about hospital supplies that are important to provide care like masks, syringes, hand gel and much more. Occurrences about Clinical Equipment, Device and Consumable are the seventh most reported incident from July to December 2012. Reported incidence were about breakage (42%), malfunction (41%), material management-out of stock (10%), device or equipment not available (3%), poor quality consumables (3%) and inadequate supply of materials (1%).

Directorate of Quality & Safety Annual Report 2012

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Risk Management Unit Analysis of OVRs (Birth Trauma / Injury to Neonate)

Table 8: Reported Birth Trauma/Injury to Neonate

Figure 14: Reported Birth Trauma / Injury to Neonate

Injuries to the infant that result from mechanical forces during the birth process are categorized as birth trauma. Most birth traumas are self-limiting and have a favorable outcome. Scratches, forceps marks, hematoma, vacuum mark, redness, weakness on right arm, abrasion, peeling and wound were reported as birth trauma secondary to vacuum, forceps, Caesarean section, vaginal breech delivery and normal vaginal delivery. Recognition of trauma necessitates a careful physical and neurologic evaluation of the infant to establish whether additional injuries are present. Symmetry of structure and function should be assessed, the cranial nerves should be examined, and specifics such as individual joint range of motion and scalp/skull integrity should be evaluated.

Directorate of Quality & Safety Annual Report 2012

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Risk Management Unit Analysis of OVRs (Admission-Related Issue)

Table 9: Reported Incidence on Admission-Related Issue

Figure 15: Admitted in the Unit without Multidrug-Resistant Screening Result

Admission is the process of accepting patients for care and /or treatment. Any variance in the admission process are considered incidence and needs to be reported. No Multidrug-resistant screening result is the highest reported variance in admission-related issue, with reported cases of 45 (68%). Of the reported â&#x20AC;&#x153;No Multidrug-resistant screening result, 84% of reported cases were transferred from other hospital to KFHU while reported cases admitted in our hospital without multidrug-resistant screening result was 16%.

Directorate of Quality & Safety Annual Report 2012

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Risk Management Unit Analysis of OVRs (Missing Patient)

Table 10: Location of Reported Missing Patient

Figure 16: Reported Missing Patients

All patients noted to be absent from the ward or department without prior arrangement must be treated as missing patient. When a patient goes missing, this should be reported as an incident. The biggest number of missing patient was reported by ER, followed by 3D, 3C, 3A,3E, 3B, 2C, 4E, 4B, 5A, 1C and 2D. It was noted that a big number of reported in-patient missing patient happened in third floor of hospital.

Directorate of Quality & Safety Annual Report 2012

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Risk Management Unit Analysis of OVRs (Out on Pass)

Figure 17: Out on Pass

Out on pass enable the patient to leave the hospital premises for a period of time for personal reason. Any non-compliance with the existing out on pass policy is an incident that needs to be reported. A total of 51 out on pass incidents were reported from July to December 2012 of which 23 (45%) didnâ&#x20AC;&#x2122;t come back and 28 (55%) came back on or before 48 hours. It was reported that some patients were allowed to be out on pass with femoral catheter, Hickman catheter, IV cannula, PICC line, pigtail drain, saline lock and wound drain.

Directorate of Quality & Safety Annual Report 2012

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Risk Management Unit Analysis of OVRs (Non-Clinical Equipment)

Table 11: Locations of Reported Incidence about Non-Clinical Equipment

Figure 18: Reported Non-Clinical Equipment

Non-clinical equipment and device refers to miscellaneous equipment and device that is not used in direct patient care treatment. Reported incidence were about broken and malfunction equipments like table, refrigerator, cabinets, doors, soap dispenser, sink, call bell, computer, telephone, etc. 25% of the reported incidents were from 5A and 5B, a psychiatry unit.

Directorate of Quality & Safety Annual Report 2012

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Risk Management Unit Analysis of OVRs (Fall)

Figure 19: Distribution of Age & Gender

Figure 20: Number of Reported Incidents without injury

Table 12: Locations of Reported Fall

A fall is an unplanned descent to the floor with or without injury to the patient. A total of 47 cases were reported of which 81% were without injury while 19% of reported incidents were with sustained injuries like swelling of the injured part, cut wound, head injury and hematoma. 45% of reported cases belong to ages 50 and above.

Directorate of Quality & Safety Annual Report 2012

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Risk Management Unit Analysis of OVRs (Incorrect Name or Medical Record)

Table 13: Reported Incidence on Incorrect Name or Medical Record Number

Figure 21: Reported Incorrect Name or Medical Record Number

Patient Identification OVRs are incidents that have to do with lack of compliance to the hospital of using two patient identifiers; full name and medical record number. A total of 44 cases (1%) were reported as Incorrect Name of Medical Record Number. Almost 55% of the variances are related to wrong spelling of name. Other variances reported were wrong motherâ&#x20AC;&#x2122;s name 25%, wrong fatherâ&#x20AC;&#x2122;s name 7%, wrong MR number 7%, different name with old and new file 5% and wrong age 2%.

Directorate of Quality & Safety Annual Report 2012

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Risk Management Unit Analysis of OVRs (Transfer-Related)

Transfer-related issues are incidents that have to do with transfer of patients from one unit to another. A total of 41 cases (1%) were reported. Reported variances were no bed available in critical area 44%, poor endorsement 20%, no isolation bed available 17%, patient/relative refused to tansfer to another unit 12% and no bed available in non-critical area 7%. Table 14: Reported Transfer-Related Issue

Figure 22: Reported Transfer-Related Issue

Directorate of Quality & Safety Annual Report 2012

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Risk Management Unit Analysis of OVRs (Fire Alarm / Fire)

Figure 23: Locations of Reported Fire/False Fire Alarm

Figure 24: Reported Fire/False Alarm

Fire alarm system is used to alert all staffs that a fire exists. A total of 34 incidents were reported from July to December 2012 of which 30 (88%) were about false fire alarm and 4 cases (12%) were about fire that happened in accommodation site 2, OR and CSSD. All reported fire were easily respondedand immediately controlled.

Directorate of Quality & Safety Annual Report 2012

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Risk Management Unit Analysis of OVRs (Refused Treatment / Procedure)

Table 15: Reported Incidence on Refused Treatment/Procedure

Figure 25: Reported Refused Treatment or Procedure

Informed refusal must be an integral part of the hospital informed consent process because it is protective and beneficial to both patient and healthcare workers. It is protective and beneficial to patients because it helps to reduce patient morbidity and mortality and improve patient safety and treatment outcomes. It is also protective and beneficial to healthcare workers because it can reduce their risks of being sued and improve their ability to defend themselves.

Directorate of Quality & Safety Annual Report 2012

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Risk Management Unit Analysis of OVRs (Housekeeping Issue)

Figure 26: Housekeeping Issues

Figure 27: Reported Housekeeping Issue

Table 16: Location of Reported Housekeeping Issue

General care, cleanliness, orderliness plus some porter issues are covered by the Housekeeping Department. A total of 30 incidents were reported from July â&#x20AC;&#x201C; December 2012 affecting Housekeeping Department. Reported Housekeeping issues were inadequate number of housekeepers 54%, poor housekeeping service (dirty bathroom, no enough paper towels, wet floor) 43% and work ethic 3%.

Directorate of Quality & Safety Annual Report 2012

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Risk Management Unit Analysis of OVRs (Medication OVRs)

Table 17: Reported Medication Occurrence

Figure 28: Reported Medication OVRs

Medication occurrences are those incidents related to medication error and medication-related incidents. 87% of reported Medication Occurrences were medication related incidents and 13% were medication errors. Medication interaction or reaction (19%) was the top most reported incident followed by Medication not available (17%). Most of the medication not available was non-formulary. A reported wrong drug was a case of high alert medication. Reported expired medicines were BCG vaccines and Human AHF 1X. Reported cases of missed dose were due to staff performance (forgot to give the medicine on due time, physician didnâ&#x20AC;&#x2122;t fill up narcotic form) and patient factor (no IV line).

Directorate of Quality & Safety Annual Report 2012

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Risk Management Unit Analysis of OVRs (Infection Control)

This category is associated with aspects related to infection control especially situations when there is risk of acquisition and transmission of healthcare associated infections. It account to 1% of total reported occurrence from July to December 2012. For admitted cases with incomplete and without multi-drug resistant screening (MRSA, Acinetobacter, etc) which was categorized under admission-related issues, Infection Control was made aware through correspondence. Table 18: Infection Control Top Variances

Figure 29: Locations of Reported Sharp Injury & Blood/Body Fluid Exposure

Directorate of Quality & Safety Annual Report 2012

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Risk Management Unit Analysis of OVRs (Food Services)

FOOD SERVICES

Food service OVRs are incidents that have to do with the delivery and serving of ready to eat foods. Variances reported were diet not served on time, foreign material (hair, staple wire, and insects) on food served, not well-cooked food and expired food item.

Table 19: Food Services Variances

Directorate of Quality & Safety Annual Report 2012

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Risk Management Unit Initiatives

Item Risk Management Process

Reporting Occurrence Variances

Overstaying of Patient in ER

OR Cancellation

DAMA Refusal of Treatment / Procedure

Initiative APP DQS 07-010 Occurrence Variance Reporting System was developed to disseminate the process of reporting and managing OVRs in a clear and simple manner in order to facilitate and encourage reporting incidents by KFHU staffs.  Education about OVRs for non-reporting departments was conducted to facilitate more reporting of incidents.  Risk Management became a part of the General Orientation program for newly hired staffs in KFHU so as to give new staffs more information of what Risk Management is. Overstaying of patient in ER was consistently the topmost reported incident. Overstaying of patient in ER can cause the emergency department to be crowded and this is not ideal because it will be difficult for the healthcare workers to do their best to provide privacy and the best quality of care. Incidents about overstaying of patient in ER were handed over to Performance Improvement Unit for a PI project to improve the flow process in ER. OR Cancellation was one of the top most reported incidents. Cancelled operations are waste of resources and time. They bring the additional administrative burden of re-scheduling appointments. They are distressing, inconvenient for patients, and when the hospital themselves cancel operations; these will be difficult for the hospital. The three types of cancellations identified from submitted OVRs are: 1. Hospital non-clinical 2. Hospital clinical 3. Patient Surgical cancellation incidents were handed over to Performance Unit for a PI project so as to cut down the number of cancelled surgeries. Informed refusal must be an integral part of the hospital informed consent process because it is protective and beneficial to both patient and healthcare workers. It is protective and beneficial to patients because it helps to reduce patient morbidity and mortality and improve patient safety and treatment outcomes. It is also protective and beneficial to healthcare workers because it can reduce their risks of being sued and improve their ability to defend themselves. A “Refusal of Admission/Treatment/Release from Hospital Against Medical Advice” form was developed and for final approval.

Directorate of Quality & Safety Annual Report 2012

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Risk Management Unit Initiatives

Item Pressure Ulcer Missing patient Food Service

Medication issues

Directorate of Quality & Safety Annual Report 2012

Initiative Hospital acquired pressure ulcers were not graded because of the absence of scoring system. A Braden Scale for predicting and scoring pressure ulcers was shared to Nursing Department. Installation of accessed door to all in-patient units was recommended. Implementation on recommendations about extra careful in handling and handling of foods was strongly stressed because of the illness or injury that may occur to the patient with the reported variances.  Medication wastage Due to an incident of “Medication wastage”, a policy and a flow chart was developed for patients receiving treatment in short stay unit.  Wrong medication Medication container is on the process of procurement Medication Administration Policy (NPP-02-02-00-50) was updated and recommendations given by Risk Management were included.  Medication given without physician’s order A Memorandum from Vice-Dean of Clinical Affairs requiring strong compliance was circulated stating that “Medical interns are not give any written orders without consulting the Residents or Consultants on duty” and “Interns are not allowed to enter orders into the computer system using the Consultant’s or Resident’s password”.

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Document Control Unit

Directorate of Quality & Safety Annual Report 2012

Page 100 of 128

Document Control Unit Overview

The Documents Control Unit of the Directorate of Quality & Safety was commissioned last April 2012. Documents Control Unit is vitally important to any organization. The Documents Control Unit (DCU) of the Directorate of Quality & Safety of King Fahd Hospital of the University provides the means to disseminate correct information and documents at the right time. DCU facilitate consistency and quality of documents through standardization. The Documents Control Unit is composed of two sections:  Controlled documents section  Committees & Reports section

Scope of Documents Control Unit: Controlled Documents Section: The Controlled Documents Section of the Documents Control Unit is responsible in the preparation, release and distribution of policies & procedures, job descriptions, forms and other controlled documents. The Controlled Documents Section controls the issuance of documents, including changes, and assures that documents, including changes, are reviewed for adequacy and approved for release. Duties of this section are as follows:    

Responsible for the process of page layout, print type and size and page numbering. Responsible for the process of approval of the document, evidenced by signing and dating by the responsible personnel. Development and tracking of records of documents. Provide the list of personnel to send all the controlled documents, i.e. policies & procedures, job descriptions, scope of service and forms.

Committees & Reports section: The Committees & Reports section of the Documents Control Unit is responsible to provide assistance and attend all JCI chapters meetings and standing committees to define the requirements and to track their functions, meetings and action taken, receive and review all departmental reports. The Committees & Reports section keeps track of all documentation, specifications and processes. The section ensures that all hospital professionals use the correct and most current processes and specifications.

Types of Documents: The Documents Control Unit handles the following:    

Policy – document the KFHU’s position or intention for its operation Procedure – responsibilities and processes for how KFHU operates to comply with its policies Job Description – step-by-step instructions for a specific job or task Forms – recorded information demonstrating compliance with documented requirements

Directorate of Quality & Safety Annual Report 2012

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Document Control Unit Process

Process of Controlled Documents Section: 1. Creation of the following documents according to the approved format: a. b. c. d.

Policies & Procedures Job Descriptions Scope of Service Forms

2. Approval of Documents: All revised, re-formatted and finalized documents will be send to the appropriate personnel for signature, and for approval of the hospital administration before implementation. 3. Indexing of documents 4. Distribution of documents 5. Archiving, storing and retention of documents

Process of Committees & Reports Section: It is the responsibility of the Committees & Reports Section to document proceedings of meetings and the distribution of minutes to all members of the JCI chapters and committees. This section has to review and approve both the accuracy and the completeness of the documentation of different quality management activities in KFHU. Types of Documentation:  

Minutes of Meetings Committees’ Meetings

Definition: Minutes of Meetings: are documentation of the meetings held by teams and committees delegated to consider, investigate, take action on or report on some matter related to KFHU operations or patient care. Document: Printed or written material which can be depended on as a source of reliable information. Report A formal presentation of facts. Purpose To establish a standard formats for documentation and reporting quality improvement activities.

Directorate of Quality & Safety Annual Report 2012

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Document Control Unit JCI Teams & KFHU Committees

JCI CHAPTERS TEAMS 1. MCI/GLD Team 2. MMU Team 3. ACC/AOP/COP Team 4. PFE/PFR Team 5. ASC Team 6. QPS Team 7. PCI Team 8. FMS / IPSG Team 9. SQE Team COMMITTEES of KING FAHD HOSPITAL OF THE UNIVERSITY 1. Hospital Executive Committee 2. Credentialing & Privileging Committee 3. Medico-Legal Committee 4. Equipment Utilization & Stock Review Committee 5. Medical Executive Committee 6. Hospital Safety Committee 7. Quality Management Committee 8. Infection Control Committee 9. Medical Records and Health Information Committee 10. Institutional Review Board 11. Surgical & OR Committee 12. Drug & Therapeutics Committee 13. Tissue Review Committee 14. Blood Review Committee 15. Morbidity & Mortality Committee 16. Critical Care Committee The Committees & Reports Section is an integral part of the Documents Control Unit of the Directorate of Quality and Safety. Planning and coordinating the preparation, translation of minutes of meetings, printing and distribution of all documents are some of the essential tasks of the Section.

Directorate of Quality & Safety Annual Report 2012

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Document Control Unit JCI Teams & KFHU Committees

The section has produced 166 minutes of meetings since February 2012 for all JCI Chapters. The Committees & Reports is also responsible to send notices of meeting via email to all JCI Chapters Team Leaders and Members. The section is tasked with archiving and monitoring of all standing committees of King Fahd Hospital of the University. The section has recorded and monitored meetings held by the King Fahd Hospital of the University standing committees. Below are the activities recorded by the Committees & Reports Section in reference to the meetings held during the year 2012: Table 1: King Fahd Hospital of the University Standing Committees S/N

HOSPITAL COMMITTEES

# OF MEETINGS

Hospital Executive Committee (HEC)

Credentialing & Privileging Committee (CPC)

Medico Legal Committee (MLC)

Equipment Utilization & Stock Review Committee (EUSRC)

Hospital Safety Committee (HSC)

Quality Management Committee (QMC)

Infection Control Committee (ICC)

Medical Records & Health Information Committee (MRHIC)

Institutional Review Board Committee (IRBC)

Drug & Therapeutics Committee (DTC)

Medical Executive Committee (MEC)

Surgical & OR Committee (SORC)

Tissue Review Committee (TRC)

Blood Review Committee (BRC)

Morbidity & Mortality Committee (MMC)

Critical Care Committee (CCC)

11*

*These committees had started their meeting before the new Committee Formation Order for the new committee structure was sent out in December 2012 as a continuation of the old structure. Some members of these committees remained the same, but some members were also changed. The minutes of meetings for these committees were requested from the secretary of the committees to be hand-over to the Directorate of Quality & Safety for safe keeping as part of the JCI Accreditation process.

Directorate of Quality & Safety Annual Report 2012

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Document Control Unit Achievements of Committees & Reports Section The following indicated all Committees & Reports activities for 2012: Figure 1: Minutes of Meetings for 2012 – JCI Chapters

Figure 2: Minutes of Meetings for 2012 – JCI Team Leaders & Joined Chapters

Figure 3: Minutes of Meetings for 2012 – JCI Steering Committee & Strategic Planning Task Force

Directorate of Quality & Safety Annual Report 2012

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Document Control Unit Achievements of Controlled Documents Section

The following indicated all controlled document activities for 2012:

Figure 4: Finalized controlled documents for 2012

Policies & Procedures The following graphs & tables show the department that had complied with the requirements of updating, revising and re-formatting of policies and procedures in preparation for the JCI accreditation:

Figure 5: Medical Services Departments Policies and Procedures

Directorate of Quality & Safety Annual Report 2012

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Document Control Unit Achievements of Controlled Documents Section

Figure 6: Department of Nursing Services Policies and Procedures

Figure 7: Health Information & Medical Records Department Policies and Procedures

Figure 8: Support Services Department Policies and Procedures

Directorate of Quality & Safety Annual Report 2012

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Document Control Unit Achievements of Controlled Documents Section Table 2:

Other departments that have submitted their policies and procedures: Department

Number of P/Ps

Dietary

Directorate of Quality & Safety

Housekeeping

Infection Control

Information Technology

Table 3:

Below is the list of departments that have submitted their policies and procedures but not in the approved format and some are still pending for submission. Department

Administration

Academic Affairs & Training

Sections

Number of P/Ps

Human Resources & Personnel

Finance & Cashier

Communication

Housing

General Stores

Supplies & Inventory

Purchasing

Training & Continuing Medical Education

Health Education

Audiovisual & Classrooms

Medical Photography

Translation

Medical Library

Basic Life Support Care

Dentistry

Unformatted

ENT

Needs e-copy

Laboratory Medicine

In CAP format

Patient Relations & Rights Respiratory Therapy

X Unformatted

Security Services

Social Services

Most of the policies & procedures that were submitted were signed and approved, and ready for implementation.

Directorate of Quality & Safety Annual Report 2012

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Document Control Unit Achievements of Controlled Documents Section

Job Descriptions Most of the departments had formulated and submitted the job descriptions for each member of staff. The Documents Control Unit of the Directorate of Quality & Safety had re-formatted and coded all job descriptions. Each member of staff for each department / area had signed their final job descriptions. Table 4:

The following list is the departments who had not submitted their formatted job descriptions: S/N 1 2 3 4 5 6 7 8 9 10 11 12 13

Department Administration Academic Affairs & Training Dermatology Dietary Emergency Room ENT FAMCO Information Technology Biomedical Engineering Housing Out Patient Department Ophthalmology Psychiatry

Status / Remarks None For formatting For signature For signature For signature Awaiting submission None None None None For signature For signature Awaiting submission

Forms Hospital-wide forms were revised, coded and re-formatted. These forms were submitted to the Forms Committee for final review and approval. Once the committee had approved the forms, all forms will be given to the University of Dammam Printing Press for pilot printing and distribution to all areas of the hospital for implementation.

Directorate of Quality & Safety Annual Report 2012

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Document Control Unit Initiatives

As a part of the Directorate of Quality & Safety to improve its internal processes, the Document Control Unit will develop systems to closely monitor and track all controlled documents by: 1. Establishing an excel-based sheet Policy Tracker. This will keep track of incoming and outgoing documents that are related to the controlled documents (i.e. policies & procedures, job descriptions and forms). 2. Determining the volume of policies approved for a specified period of time. 3. Determining the policies that will soon lapse. 4. Identifying the policies affected when a form is revised and re-formatted.

Directorate of Quality & Safety Annual Report 2012

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Environmental & Safety Unit

Directorate of Quality & Safety Annual Report 2012

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Environmental & Safety Unit

INTRODUCTION The Environmental and Safety Unit strives to promote an institutional culture that will develop the KFHU medical system into the safest environment possible for patients, staff and visitors. A SITUATION REQUIRING ATTENTION: In this Report, the analysis presented pertains to a short period (August 2012 â&#x20AC;&#x201C; December 2012) prior to complete implementation of JCI standard requirements. With regard to timely responses of certain departments to identified deficiencies, reflects an improvement in the reporting culture. In parallel, the effectiveness of the safety oversight at KFHU is identified as a concern, which indicates a prime need for support and collaboration from all departments of the hospital. OVERVIEW OF UNIT: The Environmental & Safety Unit (ESU) commenced its operations from March 2012 limiting its functions to establishing the policy requirements as per JCI guidelines. Since August 2012, the unit has actively coordinated to establish a structured Environmental Safety Rounds program in KFHU, which finally took off in November 2012. The unit is also involved in establishing administrative and internal departmental policies & procedures with regard to JCI chapter on Facility Management & Safety (FMS) in coordination with the FMS Chapter Team. As part of the Hospital safety Committee, this unit has coordinated to conduct a Fire Drill in the hospital on December 25th, 2012. This two member unit attempts to ensure compliance to FMS and IPSG standards specified by JCI that is focused at continuous quality improvement at KFHU. SCOPE OF ENVIRONMENTAL & SAFETY UNIT: ESU strives to achieve the lowest potential for hostile impact on the environment of care with regard to safety of patients, staff, and other at KFHU facilities. The broad functional areas are: 1. Environmental Safety Rounds Program 2. Implementation of JCI standards on FMS 3. Organize activities of Hospital Safety Committee 4. Training ENVIRONMENTAL SAFETY ROUNDS 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, patient /staff safety. Environmental Safety Rounds (ESR) Program is the periodic appraisal to warrant that all KFHU facilities are maintained in a clean, safe, and sanitary manner. This program includes mechanisms to identify environment of care risks within the organization.

Directorate of Quality & Safety Annual Report 2012

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Environmental & Safety Unit

Although this program was unstructured at the beginning, fixed schedules, survey toolkits and an enthusiastic team were established in November 2012 which has effectively contributed to the success of this program. All areas of KFHU shall be subject to unannounced inspections periodically as per the established schedule. Follow-up inspections are conducted as indicated by the seriousness of the deficiencies noted during the initial inspection. Figure 1 illustrates the areas surveyed during the report period (August 2012 â&#x20AC;&#x201C; December 2012) and Figure 2 indicates the frequency of surveys. Figure 1: Areas surveyed between August 2012 â&#x20AC;&#x201C; December 2012 Month Surveyed Area

Aug-12 Burn Unit Morgue

Directorate of Quality & Safety Annual Report 2012

Sep-12 CSSD Diagnostic Lab ER Laundry Lithotripsy OPD(Main building) OPD(New Block) Pharmacy Radiology

Oct-12 Day Surgery

Nov-12 ICU Burn Unit Cafe 88 Cath Lab IC ID

Dec-12 2C 2A 2B - Nursery 2D 3A 3B

Respiratory Therapy

3C 3D 3E 4A 4B 4C 4D 4E Building 510 Maintenance Neurology

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Environmental & Safety Unit

Figure 2: Frequency of surveys (August â&#x20AC;&#x201C; December 2012)

Number Of Surveyed Areas 20 18 16 14 12 10 8 6 4 2 0 Series1

41122

41153

41183

41214

41244

ESRs are intended to identify deficiencies in the environment of care on the bases of JCI standards. A detailed checklist was developed with focus on General Safety, Hazardous Materials & Waste Management, Patient Safety, Environmental Health, Security& Emergency Management, Infection Control, Utilities Management, Life Safety and Biomedical Equipment Management. The deficiency data collected is further analyzed to generate a compliance score in percentage for each department. Figure 3 illustrates the compliance range obtained for each department. Figure 3: Department compliance

Department Compliance 80% 70% 60% 50% 40% 30% 20% 10% 0%

74%

71% 51%

Directorate of Quality & Safety Annual Report 2012

67%

69% 58%

61%

60%

67%

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Environmental & Safety Unit

Such deficiencies identified are being communicated, with evidence whenever available, to the respective Directors of the area along with recommendations for improvement for their information and management. As it is imperative for every department to address the deficiencies, the departments are encouraged to forward an action report to DQS which is used a follow up tool to track various implementations. Excepting a few departments, others are enthusiastic to participate in these improvement initiatives and succeed in bring about appropriate changes to accommodate the JCI requirements. Figure 4 illustrate the ratio of responses received from departments against the reports generated. Figure 4: Responses received vs reports generated

Ratio of Report Received 20 18 16 14 12 10 8 6 4 2 0

Sent Received

Houskeeping department

Operation & Maintenance

Safety department

Nursing department

Department Biomedical

Sent 1

Received X

Catheterization Lab

Diagnostic Lab

ENT department

Infection Control Morgue Pharmacy

1 1 1

1 1 X

Radiology Respiratory department

2 1

1 X

CafĂŠ 88

Analysis of the survey findings reflects deficiencies relating to common areas namely cleanliness, hazardous materials management, facility maintenance and equipment maintenance among others. Figure 5 illustrate the common areas of deficiencies identified during the survey that have been clustered department wise.

Directorate of Quality & Safety Annual Report 2012

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Environmental & Safety Unit

Significant observations from the ESR rounds are as follows: 

Medical devices did not have evidence on preventive maintenance/ calibration



Inspection due date of most fire extinguishers had expired.



Standardization not noted in fixing of fire extinguishers.



Lapse in standard operating procedures for Housekeeping noted



Cluttered & disorganized storage rooms/ cabinets



Low staff awareness on safety aspects, especially housekeeping staff



Lack of infrastructure maintenance in certain areas

Figure 5: Common areas of deficiencies identified during the survey

Safety department

Operation & Maintenance

Nursing department

Houskeeping department

IMPLEMENTATION OF JCI STANDARDS ON Facility Management & Safety (FMS): ESU functions as the main vehicle to drive the JCI – FMS & IPSG implementations in the hospital by coordinating with a fully integrated Team (FMS/ IPSG Chapter Committees) with key stakeholders, at all levels and dimensions, who are responsible for safety standards, collaborate in moving towards clinical and organizational effectiveness for environmental & patient safety. Various initiatives coordinated by ESU are illustrated in Figure 6.

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Environmental & Safety Unit

Figure 6: Initiatives coordinated with FMS Chapter team.

INITIATIVES FMS Plans

Utilities and Equipment Management Policy and Procedure Manual developed

Safety & Security

Smoking Policy in KFHU Facilities (ADM-Gen 01-009 ) established Security & related Safety Plan being reviewed

Facility Inspection & Risk

Environmental & Safety Team established.

Reduction

Quarterly rounds commenced from 27th August, 2012 coordinated by ESU.

HAZMAT Management

P&P formulated

Emergency Management

Emergency management plans and policies are being reviewed.

Medical Equipment

P&P for Equipment Management (IPP Bio 19-101- IPP Bio 19-113)

Management

established

Utility Systems

P&P for Utility System (IPP OM 23-101 - IPP OM 23-131) established

Management

+ Utility System's Emergency Protocols (IPP OM 23-301 - IPP OM 23314)

Staff Education

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Process review

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Environmental & Safety Unit

ORGANIZE ACTIVITIES OF HOSPITAL SAFETY COMMITTEE (HSC): Following its reconstitution, the HSC held its first committee meeting on November 14th, 2012 and announced the forthcoming mock fire exercise. Members collaboratively accomplished all requirements identified for this exercise. ESU coordinated to organize this exercise within the hospital including various communications between departments, training programs, resource identification & department preparedness. Figure 7 illustrates various activates coordinated at KFHU as part of HSC. Figure 7: Initiatives coordinated with HSC.

INITIATIVES Emergency Management



Disaster Management Plan review

Program



Review of P&P for emergency situations (Code Pink, Code Mr. Strong, Code Red, Code White, Code Yellow, Code Orange & Code Green)



Mock Emergency Drill Evaluation form was revised and redesigned by ESU.

Training on DMEP

ESU & few members of HSC received certification from the American College of Surgeons on’ Disaster Management & Emergency Preparedness’ for having attended the one-day course organized at KFHU (site 1).

Mock Fire Exercise



Announced mock fire drill (limited evacuation – horizontal &vertical) organized on 25th December 2012.



A detailed scenario was developed in collaboration with stakeholders over multiple committee meetings.



Training sessions were conducted for doctors/ nurses/ paramedical staff/ telephone operators/ maintenance/ volunteers.



Hospital safety committee members evaluated the staff responses to the mock emergency along with trained volunteers (medical interns) using specially designed evaluation form.



The analyzed data contributed to identify pitfalls in the disaster management plan.

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Environmental & Safety Unit Training

TRAINING ESU actively involves in various training activities aimed at improving staff awareness and capability building in handling environmental & safety issues. Numerous training session have been conducted for various groups of staff as illustrated in Figure 8. Figure 8: Staff trainings sessions

TRAINING TYPE

SESSIONS

General Orientation - new staff

          

General Safety Practices Electrical Safety Medical Devise Safety Emergency Codes @ KFHU HAZMAT Management International Patient Safety Goals General Safety Practices Electrical Safety Medical Devise Safety Emergency Codes @ KFHU HAZMAT Management International Patient Safety Goals

      

Overview on Healthcare Quality Principles of Healthcare Quality Overview of Environmental Health & Patient Safety Patient Safety HAZMAT Management Emergency preparedness Utility System Management International Patient Safety Goals

Orientation – Medical Interns

Orientation – Physicians & Allied Health Professionals Orientation – Interns (HIMT)

Train the Trainer (Nurses)

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Education & Training Unit

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Education & Training Unit Overview & Scope

The Education & Training Unit of the Directorate of Quality & Safety (DQS) introduces the students to total quality management and departmental functions, quality assessment and performance improvement. The Education & Training Unit oversee the in-house training for interns from the Department of Health Information Management and Technology of the College of Applied Medical Sciences. The Unit is responsible for coordinating training of HIMT interns for the purpose of completing their graduation requirements.

Scope of Education & Training Unit: 

Manage education activities related to quality improvement and accreditation.



Assist in accreditation of KFHU activities.



Facilitate and oversee internship activities at KFHU.



Conduct and supervise related education and training activities and quality assurance activities.



Oversee the process of managing and coordinating routine activities related to HIMT Interns and training



Facilitate KFHU scholarship application process of DQS staff members



Provide general competencies training and specialized programs designed according to specific requirements of departmental needs to equip employees with essential quality improvement skills.

Activities of Education & Training Unit: Since September 2012, the Education & Training Unit has trained three (3) HIMT students. The training program last for at least three months. This provides a great opportunity for the interns to put into practice the skills and knowledge learned in class. In our strong commitment to providing the highest quality of internship training, performance improvement projects were given to the interns. The interns participated in data gathering by doing hospital and attending meetings in order for them to gather data by scientific inquiry. Interns’ role and participation in the activities of the Directorate of Quality & Safety are:   

Planning, organizing, and facilitating Performance Improvement Project. Providing assistance in typing and translating Arabic forms for policies and procedures. Provides assistance in translating Arabic letters from Housekeeping, Dietary and Transportation Departments.

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Education & Training Unit Performance Improvement Project

The interns were involved in two Performance Improvement projects to help them gain experience in healthcare, and specifically in process improvement. They were exposed to KFHU operations management, operations consulting and performance improvement methodology. They have the opportunity to interact with clinicians and administrators. This was a great experience for them to get a first-hand understanding of hospital operations.

Definition: Performance Improvement (PI) is a method for analyzing performance problems and setting up systems to ensure good performance. Importance of Performance Improvement Projects (PIPs): PIPs provide a structured approach to measuring performance, implementing change to improve performance, and measuring the resulting outcomes. Changes that lead to favorable sustained results become permanent standards, practices, or procedures. Changes that are not successful should be revised and re-measured so that improvements are made.

Process of the Performance Improvement project: The interns write reports, conduct data analysis, create and interpret data displays that support performance improvement projects. This will include:    

Collecting data from various sources and analyzing data for trends and variances to support performance improvement decision making. Collaborating with concerned personnel, areas, and others engaged in improvement initiates to develop methods to monitor and report process improvement. Preparing reports defining and evaluating problems and recommending solutions. Develop presentations and documents that articulate a compelling story line through the effective use of data.

The interns were supported by the Performance Improvement Coordinator in the planning, setup, execution, and follow-up of Performance Improvement projects. For this semester, the selected Performance Improvement projects presented were:  

Overstaying of Patients in Emergency Room Rapid Response Team

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Education & Training Unit Performance Improvement Project

Figure 1: Flowchart Internsâ&#x20AC;&#x2122; Project Presentation Preparation

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Directorate of Quality & Safety Goals & Plans for 2013

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Goals & Plans of Directorate of Quality & Safety

The Directorate of Quality & Safety’s major goal for next 12 month is to achieve JCI accreditation. This will be achieved through the following activities: 

Develop an action plan to meet the standard requirements.



Assist all departments to develop or review the policies based on the standards, intent statements and measurable elements’ requirements.



Highlight the new standards required in the 4th Edition (Expanded).



Ensure hospital policies are implemented by all departments and initiate new policies.



Assess the level of staff knowledge on policies related to their department.



Discuss the need of all the existing departments’ policies.



Check staff compliance to policies through tracers and OVR reports.



Provide coaching to all departments in developing Strategic Plans.



Focus on Staff Development.



Continuous educational campaign on: o

Occurrence Variance Repor (OVR)

Rapid Response Team

Utilization Review



Conduct the Healthcare Quality Week for KFHU 2013.



Continue to train interns from Health Information Management & Technology , University of Dammam



Arrange visits to different institution to apply process and re-engineering on the healthcare setting and to learn from their success stories and avoid their failures.



Conduct training, education and awareness on topics of Performance Improvement tools to all KFHU staff.

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Glossary

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Glossary

ACC

Access to Care & Continuity of Care

AHRQ

Agency for Healthcare Research & Quality

AOP

Assessment of Patients

ASC

Anesthesia & Surgical Care

CCC

Critical Care Committee

COP

Care of Patients

CPC

Credentialing & Privileging Committee

Computed Tomography

DAMA

Discharged Againist Medical Advice

DCU

Document Control Unit

DQS

Directorate of Quality & Safety

DTC

Drug & Therapeutic Committee

ENT

Ear-Nose-Throat

Emergency Room

ESR

Environmental Safety Rounds

ESU

Environmental & Safety Unit

FAMCO

Family & Community Medicine

FMS

Facility Management & Safety

FOCUS

Find, Organizae, Clarify, Understand, Select

GLD

Governance, Leadership & Direction

HSC

Hospital Safety Committee

ICC

Infection Control Committee

IPSG

International Patient Safety Goal

JCI

Joint Commission International

KFHU

King Fahd Hospital of the University

MCI

Management of Communication & Information

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Glossary

Measurable Element

MMC

Morbidity & Mortality Committee

MMU

Medication Management & Use

MRHIC

Medical Records & Health Information Committee

MRSA

Methicillin-Resistant Staphylococcus Aureus

OPD

Out Patient Department

Operating Room

OVR

Occurrence Variance Report

P&P

Policy & Procedure

PCI

Prevention & Control of Infection

PDCA

Plan, Do, Check, Act

PFE

Patient & Family Education

PFI

Patient & Family Information

PFR

Patient & Family Rights

PIU

Performance Improvement Unit

PPE

Personal Protectice Equipment

QMC

Quality Management Committee

QPS

Quality & Patient Safety

RRT

Rapid Response Team

SORC

Surgical and Operation Room Committee

SQE

Staff Quailification & Education

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