Health, Care, Quality, improvement, Introduction Gamal Soliman 24-2010

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This is a brief introduction, to essential elements for implementing health care quality improvement,
The responsibility taken by the health care providers, should stimulate them to find out better way , to be applied specifically and appropriately,
to reach better than expected for the patient and family

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Health, Care, Quality, improvement, Introduction Gamal Soliman 24-2010

  1. 1. 08/01/13 Prepared By: Dr Gamal Soliman Health Care,Health Care, Not only qualityNot only quality But also improvementBut also improvement Rule # OneRule # One No Blame But RewardNo Blame But Reward
  2. 2. 08/01/13 Prepared By: Dr Gamal Soliman Health Care Quality ManagementHealth Care Quality Management Introduction And PrinciplesIntroduction And Principles
  3. 3. 08/01/1308/01/13 Prepared By: Dr Gamal SolimanPrepared By: Dr Gamal Soliman Today’s AgendaToday’s Agenda 24-05-201024-05-2010
  4. 4. 08/01/13 Prepared By: Dr Gamal Soliman 1.1. Criteria for Performance Excellence.Criteria for Performance Excellence. 2.2. Eight Disciplines Problem Solving.Eight Disciplines Problem Solving. 3. Accreditation Decisions. 4.4. Ten Survey Strategies to Remember.Ten Survey Strategies to Remember. 5.5. Quality Management StandardsQuality Management Standards Flow of informationFlow of information 5-1 Plan For Implementation.5-1 Plan For Implementation. 5-2 Patient Safety Initiative. 5-3 Internet Resources
  5. 5. 08/01/13 Prepared By: Dr Gamal Soliman Part1Part1 Criteria for Performance ExcellenceCriteria for Performance Excellence  To help improve organizationalTo help improve organizational performance practices, capabilities andperformance practices, capabilities and resultsresults  To facilitate communication and sharing ofTo facilitate communication and sharing of information on best practices.information on best practices.  A working tool for, understanding,A working tool for, understanding, managing performance, for guidingmanaging performance, for guiding planning and opportunities for learningplanning and opportunities for learning
  6. 6. 08/01/13 Prepared By: Dr Gamal Soliman The seven categories of the CriteriaThe seven categories of the Criteria areare 1. Leadership1. Leadership 2. Strategic Planning2. Strategic Planning 3. Customer Focus3. Customer Focus 4. Knowledge Management4. Knowledge Management 5. Workforce Focus5. Workforce Focus 6. Process Management6. Process Management 7. Results7. Results
  7. 7. 08/01/13 Prepared By: Dr Gamal Soliman Results to be achieved:Results to be achieved:  delivery of ever-improving value todelivery of ever-improving value to patients& owners, contributing topatients& owners, contributing to organizational sustainabilityorganizational sustainability  improvement of overallimprovement of overall organizational effectiveness andorganizational effectiveness and capabilitiescapabilities  organizational and personal learningorganizational and personal learning
  8. 8. 08/01/13 Prepared By: Dr Gamal Soliman Part2Part2 Eight Disciplines Problem SolvingEight Disciplines Problem Solving
  9. 9. 08/01/13 Prepared By: Dr Gamal Soliman 1-Define the Problem1-Define the Problem 2-Use a Team2-Use a Team 3-3- Implement and verify InterimImplement and verify Interim ActionsActions 4-4- Identify and Verify Root CausesIdentify and Verify Root Causes 5- Choose and verify Permanent5- Choose and verify Permanent Corrective Actions (PCAs)Corrective Actions (PCAs)::
  10. 10. 08/01/13 Prepared By: Dr Gamal Soliman 6-Implement and validate PCAs6-Implement and validate PCAs 7-Prevent recurrence7-Prevent recurrence: Modify the: Modify the management systems, operationmanagement systems, operation systems, practices and proceduressystems, practices and procedures to prevent recurrence of this and allto prevent recurrence of this and all similar problems.similar problems. 8-Congratulate your Team8-Congratulate your Team
  11. 11. 08/01/13 Prepared By: Dr Gamal Soliman Part3 Accreditation Decisions
  12. 12. 08/01/13 Prepared By: Dr Gamal Soliman   Accredited   Provisional Accreditation   Conditional Accreditation   Preliminary Denial of Accreditation   Denial of Accreditation   Preliminary Accreditation
  13. 13. 08/01/13 Prepared By: Dr Gamal Soliman Part4Part4 Ten Survey Strategies to RememberTen Survey Strategies to Remember
  14. 14. 08/01/13 Prepared By: Dr Gamal Soliman  1. Be confident - you are the expert not the survey team!  2. Anticipating the survey is more stressful than the actual survey  3. You will pass by meeting regulatory requirements,  4. Preparation for the survey includes documentation, organization - effectively communicating what you know.
  15. 15. 08/01/13 Prepared By: Dr Gamal Soliman  5. Show the surveyors completed risk assessments, “RCA’s” and :FOCUS  6. First impressions are extremely important;  7. “Closing the loop” on identified problems can be more important than the problem itself!  8. Facts not documented, don’t exist!
  16. 16. 08/01/13 Prepared By: Dr Gamal Soliman  9. Prepare for the survey by organizing the required planning documents, practicing interview and pre-planning the building tour  10. If you disagree with a surveyor, tactfully uncover their perspective, - - - - - -------Relax! Resource: www.ahrq.org
  17. 17. 08/01/13 Prepared By: Dr Gamal Soliman 5-1 Quality Management Standards5-1 Quality Management Standards Plan For ImplementationPlan For Implementation
  18. 18. 08/01/13 Prepared By: Dr Gamal Soliman  1-A sufficient staff to QM1-A sufficient staff to QM committee,committee,  2-QM2-QM Mission, Vision, Value, scope ofMission, Vision, Value, scope of services, Organizational Chart andservices, Organizational Chart and job descriptions Templatesjob descriptions Templates MethodMethod: This week templates of: This week templates of designs for each department,designs for each department,
  19. 19. 08/01/13 Prepared By: Dr Gamal Soliman 3-Define high problem prone areas.3-Define high problem prone areas.  3- 1 Invasive procedures.3- 1 Invasive procedures.  3-2 High risk procedures.3-2 High risk procedures.  3-3 unusually expensive3-3 unusually expensive medications.medications.  3-4 All high risk medications.3-4 All high risk medications.
  20. 20. 08/01/13 Prepared By: Dr Gamal Soliman  MethodMethod: Flow of information to head: Flow of information to head departments,departments, Print and give high problem pronePrint and give high problem prone areas PFR-16 teaching file,areas PFR-16 teaching file, To be modified accordingly.To be modified accordingly.
  21. 21. 08/01/13 Prepared By: Dr Gamal Soliman 5-2 Patient Safety Initiative
  22. 22. 08/01/13 Prepared By: Dr Gamal Soliman  Assign individuals (team)  Scope of program activities  Safety culture Focus to improve patient safety processes, No blame No punishment against staff making errors But correct them and reward the competent  Components of program Description of how Al-Rashid Hospital integrates safety elements into wide effort
  23. 23. 08/01/13 Prepared By: Dr Gamal Soliman  Adverse Events (medical errors) Plan provides for: Procedures for immediate response. 1- Care of the affected patients 2- Containment of risk to others 3- Preservation of information for subsequent analysis  Definition of the systems in place for internal and external reporting of information  Definition of mechanisms in place for responding to unexpected clinical events including sentinel events-SE, root cause analysis-RCA, Plan Do Check Act-PDCA and FOCUS
  24. 24. 08/01/13 Prepared By: Dr Gamal Soliman  Measurement and analysis  Corrective actions for high-risk processes  Resourced allocation 1-A good design of adequate parameters 2-Assignment of competent personnel 3-Provision of information systems and data management process 4-Leadership assessment
  25. 25. 08/01/13 Prepared By: Dr Gamal Soliman 5-5-Barriers and solutions to:  Effective communication,  Analysis of major adverse events  Knowledge-based systems
  26. 26. 08/01/13 Prepared By: Dr Gamal Soliman 6- Information analysis on: A-Confirmed transfusion reactions B-Significant adverse drug reactions C-Significant medication errors and hazardous conditions D-Major discrepancies between pre- and postoperative diagnosis E-Adverse events associated with anesthesia
  27. 27. 08/01/13 Prepared By: Dr Gamal Soliman 7-Identification of staff roles and7-Identification of staff roles and responsibilities.responsibilities. 8-Quality concepts and Risk8-Quality concepts and Risk Management.Management. 9-Problem identification, information9-Problem identification, information gathering, implementing actions, andgathering, implementing actions, and evaluation.evaluation.
  28. 28. 08/01/13 Prepared By: Dr Gamal Soliman 10- Data measurements, analysis and10- Data measurements, analysis and implementation evaluationimplementation evaluation 11- Quality improvement projects11- Quality improvement projects prioritization, teams reports and flowprioritization, teams reports and flow of information to all staffof information to all staff 12- Quality plans approval by the QM12- Quality plans approval by the QM and the Hospital Directorand the Hospital Director 13- Annual plans’ revisions by GM13- Annual plans’ revisions by GM
  29. 29. 08/01/13 Prepared By: Dr Gamal Soliman MethodMethod QM supplies hard and soft P&P thisQM supplies hard and soft P&P this week to all committees of the next:week to all committees of the next:
  30. 30. 08/01/13 Prepared By: Dr Gamal Soliman  Checklist for Patient SafetyChecklist for Patient Safety  Template for Developing Your Quality ManagemTemplate for Developing Your Quality Managem  The Focus: PDCA MethodologyThe Focus: PDCA Methodology  Action Minutes TemplateAction Minutes Template  Indicator & PDCA WorksheetIndicator & PDCA Worksheet  Organizational QI PlanOrganizational QI Plan  Application Form For PDCA ProjectsApplication Form For PDCA Projects  Quality Management PlanQuality Management Plan
  31. 31. 08/01/13 Prepared By: Dr Gamal Soliman 6-3 Internet Resources:6-3 Internet Resources: www.cbahi.orgwww.cbahi.org www.jointcommissioninternational.orgwww.jointcommissioninternational.org www.ahrq.orgwww.ahrq.org www.apic.orgwww.apic.org
  32. 32. 08/01/13 Prepared By: Dr Gamal Soliman ENDEND Primo Non NocerePrimo Non Nocere == Before All No ObstaclesBefore All No Obstacles

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