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following basic 6 sigma method

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    quality improvement project quality improvement project Presentation Transcript

    • Saudi Ministry of Health Mental Health ServicesQuality Continuous Improvement Program Yellow Belt Six Sigma
    • Six Sigma Cycle DefineControl MeasureImprove Analyze
    • Reducing the number of reports ofpotentially harmful objects found with patients in wards Quality improvement program using six sigma Yellow belt level By Hatim banjar Risk manager Al – Amal Hospital-Jeddah
    • DefineID Opportunity Process MapExplain why & how Completes high-level,your team detailed map and identifyselected this project? quick win opportunities.Team Charter Effective Team VOC to CTQDevelop charter to Assign role and Gather/Display datainclude business case, responsibility to verifying customerproject opportunity, each team needs.goals, scope, schedule member.and team.
    • Project Title: Reducing the Number of Reports of Potentially Harmful Objects Found with Patients in Wards Business Case : Specific Problem Statement:Through (OVRs) review from 10/2010 to What : High number of reports of harmful3/2011 it was found that there were 52 cases objects found with hospitalized patientsof potentially harmful objects found with When: from 10/2010 until 3/2011hospitalized patients in Al-Amal Hospital Where: Al-Amal Hospital Jeddahwards, and that endangers the patients safety How: 9 reports/monthand security and may result in injuries or Specific Goal Statement:even casualties (God forbids). By doing this Reduce the number of reports of harmfulproject I hope to provide a safer environment objects found with hospitalized patients infor the patients and staff of Al-Amal Hospital Al-Amal Hospital wards from 9 reports per month to 3 reports per month by 10th/June/2011. In Scope: Project Scope Location of project: Al-Amal Hospital Jeddah Business: Patient Safety - Quality Management Process: Patient safety Start Point: Patient admission End Point: Patient discharge Project Charter
    • DefineProject Title : Reducing the Number of Reports of PotentiallyHarmful Objects Found with Patients in Wards Resource Plan ReviewProject Lead (YB): Review frequency :Hatim Banjar (Patient Safety Officer) weekly meeting with champion and teamChampion: membersDr.Naji Alawed (Quality Manager)Team Members: Review responsibility :Dr.Naji Alawed (Quality Manager) Dr.Naji AlawedNaif Al-Omari (Nursing Officer)Eng.Turki Al-Ghamdi (Maintenance Officer)Salim Al-Shumrani (Quality Officer) Project Charter Sign-off: Team Leader:Milestones Hatim Banjar Stages Start Date End date Champion (HOD): Dr. Naji AlawedDefine 10/3/2011 17/3/2011Measure 17/3/2011 24/3/2011Analyze 24/3/2011 1/4/2011Improve 1/4/2011 10/6/2011Control 10/6/2011 10/7/2011 Project Charter
    • SIPOC : Patient Search Start Boundary : Arrival to Hospital S I P O CSupplier Input Process Output CustomerSecurity Entrance point Search Patient get searched Admitted Nurses Routine Search Body Search Patient X - Ray Suspicions Abdominal X-Ray Family Social interaction Visitation End Boundary : Patient in ward
    • SIPOC : Maintenance Order and response Start Boundary : inform maintenance S I P O C Supplier Input Process Output CustomerDepartment s Find problem Call maintenance report Reporting receive departmentmaintenance Take complain report workers maintenance Fix problem Solve problem End Boundary : report back
    • Patient search Functional Deployment Mapdepartment Patient Security Psychiatry X Ray Nursing OPD Ward Internal activity Home ,work nursing Pass and referralprocessAdmission New Search and Admission Chest x Ask P.T for Internal yes yes admission metal properties ray activity to hospital detector Pass no Take no P.T to P.T returns Search Search activityInternal from referralSearch or pass Finish activity yes Suspicions search No Receive P.T in Abdominal ward Take P.T x ray to ward Discharg e Give P.T Take P.T properties to OPD leave ReferralDischargeP.T = patient
    • Maintenance Order and Response Functional Deployment Map departmentprocess Reporting department MaintenanceCall Answer and take complain t Call maintenanceReport Ask for complaint details Record complaint Give complaint a job order and number Record job order number, Give the caller the order number and end call date and timeProcess Give the job order to the appropriate department Give the job order to the technician Take tools Go to ward and chick problemRepair Show the problem to technician Report to complaining department charge yes Chick wear house for parts Need parts Parts available no no yes Go back to ward no Fix problemEnd yes Sign job order by department charge Give the job order to reporting department charge Report to department
    • Quick Win Analysis for Maintenance Order and ResponsePotential Quick Easy to Fast to Cheap to Within the teams Easily Implementwin opportunity Implement Implement Implement control reversible (Yes/No)Tools should Y Y Y Y Y Yalways be carriedin a tool boxA maintenance N Y Y Y Y Nsupervisor shouldgo with thetechnician andsupervise the workTool box should be Y Y Y N Y Nchecked beforeand after bymaintenancesupervisor on shiftCharge of Y Y Y Y Y Yreportingdepartment mustcheckmaintenance sightbefore signing joborderOnly tools that r N Y Y Y Y Nneeded for thatspecific taskshould be taken inthe tool box
    • Quick Win Analysis for Patient Search Potential Quick win Easy to Fast to Cheap to Within Easily Implement opportunity Implement Implement Implement the reversible (Yes/No) teams control Search PT every time he N Y N Y Y N get out from OPD before admissionDo abdominal X-Ray for all Y Y N N N N admissions Have portable metal N N N N N N detecting machineActivate pt transfer policy Y Y Y Y Y Y for nursing correctlyDo not allow pt to get out Y Y Y Y Y Yof nursing sight or mingle with other PT after final search in OPD
    • Quick Wins Opportunity for Harmful Objects Found with Al-Amal Hospital Inpatients Program Quick Win Opportunity Action WhenTools should always be carried Provide tool boxes One month from in a tool box 1/4/11Charge of reporting department Activate role of ro department One weak frommust check maintenance sight charge in maintenance 1/4/11 before signing job order Do not allow pt to get out of Educate OPD nursing staff One month from nursing sight or mingle with 1/4/11 other PT after final search in OPD Activate pt transfer policy for Monitor nursing behavior One month from nursing correctly 1/4/11 Goal Accomplishment Current Actual (collect 2-4 weeks data) 3 reports/month 9 reports/month 7 reports/month Did the quick wins meet the goal statement? Yes
    • Measure Process PerformanceID Key IndicatorsTo identify the key IPO Display the data in graphic andindicators that relate to project calculate current Processgoals. Sigma Capability.Measure Plan MSADetermine Operation Verify ourDefinition, Data OperationalCollection Plan Definition and measurement system.
    • Measurement Plan for Reducing the Number of Reports of Potentially Harmful Objects Found with Patients in Wards ProjectPerformance Operational Data Sample Who Will When to How to Other Data thatMeasure Definition Source & Size Collect the Collect the Collect the Should be Collected Location Data Data Data at the Same TimeNumber of The number OVRs in 6mon Hatim 20/3/2011 Excel sheet Define the source ofharmful this incident TQM the object 10/2010-Objects happen (internal/external/ 3/2011 type )Number of Incidents with OVRs in Dr.Naji 20/3/2011 Systematic Define the source ofIncident by source of the TQM review the objectInternal object from (internal/external/Sources inside the type ) wardNumber of Incidents with OVRs in 52 Naif 20/3/2011 Systematic Define the source ofIncident by source of the TQM review the objectExternal object was (internal/external/Sources from outside type ) the wardNumber of What is the OVRs in 52 Hatim 20/3/2011 SystematicExternal source of the TQM reviewSources external objectNumber of What is the OVRs in 52 Dr.Naji 20/3/2011 SystematicInternal source of the TQM reviewSources internal object
    • Sources of Harmful Objects Found with Hospitalized atientsSources No Sources Main Sources No Sources Main Sourceo NExternal 31 External Smuggling 20 Internal Lights 10Internal 21 External staff 2 Internal Furniture 2 External Barber 2 Internal WC 1 External Maintenance 6 Internal Frames 4 External catering 1 Internal Garden 3 Internal nursing 1
    • AnalyzeID Potential ProblemsIdentify area to focus for theimprovement using Pareto Update Data Collectionor SOV stratification Plan Modify data collection plan and collect data to most probable root causes Regression Analysis Draw statistical and practical conclusionsAnalyze Potential Root on whether the XCauses factors areIdentify potential root causesusing Fishbone diagram, 5- significantWhy’s, Cause & Effect Matrix Comparative Methodsor FMEA Use hypothesis testing to validate root cause
    • C & E DIAGRAM FOR SMUGGLINGIshikawa Diagram (Cause and Effect Diagram) Major Categories of Causes of Problem Statement Machine (Generic Material (Generic Environment Category) Category) (Generic Category)no metal scanersx-ray machine is not working no property window in gates a lot of hiding places in wards and OPD no search rooms at ward doorsmetal detectors are not set for low amount smugglers mostly smuggles lighters location of metal detectors smuggling smuglers use inter body cvities smugglers use privet body partsdoctors are not always present in clinics smugglers cover things in tapeno clear searching PP for securityin wards A & B no punishment for smugglers smugglers use nilon wrapingsecurity are not trained in searching methodsno united searching method searching is not always the final step in OPDother PT praise smugglers People (Generic Method (Generic Category) Category)
    • C & E DIAGRAM FOR LIGHTS.Ishikawa Diagram (Cause and Effect Diagram) Major Categories of Causes of Problem Statement Machine (Generic Material (Generic Environment Category) Category) (Generic Category)light switches are inside the roomslight tubes are long lights are made of easley broken glass lights are not high enoghlights covers are easily broken no barriers for lights protection lights brake by handnursing rounds are not done right use hard objectmaintenance staff some times keep lights uncoveredpatients donot fear elctricity People (Generic Method (Generic Category) Category)
    • C & E DIAGRAM FOR MAINTENANCEIshikawa Diagram (Cause and Effect Diagram) Major Categories of Causes of Problem Statement Machine (Generic Material (Generic Environment Category) Category) (Generic Category)tools are not counted no comunication between maintenance and house keepingto many tools are taken to ward sometimes low quality tools are used high work load maintenanceno policy for location cleaningno policy for tool counting not always use tool boxmaintenance staff are not safety orinted problem is not always cheiked before taking toolsno supervisionlow number of staff for the job orderno policy for equipment supervision Method (Generic People (Generic Category) Category)
    • C & E DIAGRAM FOR FRAMESIshikawa Diagram (Cause and Effect Diagram) Major Categories of Causes of Problem Statement Machine (Generic Material (Generic Environment Category) Category) (Generic Category) use of incorect scrwes use of woden framessome frames are rusty some frames are easely broken framesmaintenance staff are not safety orinted some frames are not fixed properly Method (Generic People (Generic Category) Category)
    • C & E DIAGRAM FOR GARDENSIshikawa Diagram (Cause and Effect Diagram) Major Categories of Causes of Problem Statement Machine (Generic Material (Generic Environment Category) Category) (Generic Category) leaves durt stikslight stands stones windows neting damged gardenssport equipments are left with no supervision Method (Generic People (Generic Category) Category)
    • Cause & Effect Matrix For Smuggling Smuglling Output Indicator Input/Process Indicators 10 Importance Location of metal detectors 0 0 X-Ray machine is not working 9 No metal scanners 0 0Searching is not always the final step in OPD before admission 9 90A lot of hiding places for restricted objects in wards and OPD 3 30 Metal detectors are not set for low amount 3 30 Security are not trained in searching method 9 90 No united searching method 3 30 Smugglers use privet body parts 0 0 Smugglers cover things in tape or nylon 0 0 Smugglers use inter body cavities 3 30 No search rooms at ward doors 0 0 3 30 No property window in gates In wards A & B no punishment for smugglers lighters 0 0 Other PT praise smugglers 0 0 Smugglers mostly smuggles lighters 0 0
    • Cause & Effect Matrix for ward lights problem Pareto Output Indicator Input/Process Indicators 10 Importance light switches are inside the rooms 0 0 light tubes are long 3 30 lights covers are easily broken 9 90 nursing rounds are not done right 9 90maintenance staff some times keep lights uncovered 9 90 patients do not fear electricity 0 0 Patients have easy access to lights 9 90 lights are not high enough 3 30 brake by hands 0 0 use hard object 0 0
    • Cause & Effect Matrix For Maintenance Problem Pareto Output Indicator Input/Process Indicators 10 Importance High work load 0 0 sometimes low quality tools are used 3 30 no policy for tool counting 3 30 maintenance staff are not safety oriented 9 90Maintenance locations are not always cleaned after job is done 9 90 no communication between maintenance and house keeping 3 30 not always use tool box 9 90 to many tools are taken to ward 3 30 problem is not always checked before taking tools 0 0 no supervision 3 30 low number of staff for the job order 3 30 Equipments used by maintenance are not will supervised 9 90
    • Cause & Effect Matrix For Frames Problem Pareto Output Indicator Input/Process Indicators 10 Importance some frames are rusty 9 90maintenance staff are not safety oriented 9 90 use of incorrect screws 9 90 use of wooden frame 3 30 some frames are easily broken 9 90 some frames are not fixed properly 9 90
    • Cause & Effect Matrix For Gardens Problem Pareto Output Indicator Input/Process Indicators 10 Importance Light stands 9 90Sport equipments are left with no supervision 9 90 Windows netting damaged 9 90 Garden components 9 90
    • 5 Why Root Cause Analysis For Smuggling ProblemValidated Root Why1 Why2 Why3 Why4 Why5 Actionable Causex-ray machine maintenance No spare parts Can not buy Manufacturer Very old Change machineis not working parts modelsearching is not Doctors are not Seeing in Only one doctor Fix number of 2always the final always present in patents in A and N shift internist /shift step in OPD clinic before admissionsecurity are not Searching is not No clear P&P No clear job Put clear job trained in included in description description and P&P searching training program for security method no property There is no There is no There is no Make a window andwindow in gates window opening property policy in policy for property made in the gates declaration at the security for declaration before gates before properties entering detectors declaration before detectors a lot of hiding the toilets, sealing They are not In purchasing Set a policy for places for and furniture are customized for toilets and consulting with restricted used for hiding an addiction furniture nursing and doctors objects in objects hospital doctors and before buyingwards and OPD nursing were not consulted
    • 5 Why Root Cause Analysis For Maintenance ProblemValidated Root Why1 Why2 Why3 Why4 Why5 Actionable Cause maintenance No training on No safety Not part of No clear P&P Educate and train staff are not PT safety education safety 1st line safety oriented program education maintenance staff program Maintenance no policy for Put clear policylocations are not location for location always cleaned cleaning cleaningafter job is donenot always use No clear policy Put clear policy tool box for using tool stating use of tool box box Equipments no policy for Put clear policy used by equipment that tools andmaintenance are supervision equipments must not will be supervised all supervised the time
    • 5 Why Root Cause Analysis For Ward Lights Problem Validated Root Why1 Why2 Why3 Why4 Why5 Actionable Cause nursing rounds Nurses are not They don’t Non Educate and trainare not done right interested understand the experienced nursing importancelights covers are Light covers are Change light easily broken made of soft covers material plasticmaintenance staff Maintenance staff Not trained nor No education No education Make policy tosome times keep do not educated in PT plan policy educatelights uncovered understand the safety maintenance dangers Patients have no barriers for Put a steal net oneasy access to lights lights lights protection
    • 5 Why Root Cause Analysis For Frames Problem Validated Root Why1 Why2 Why3 Why4 Why5 Actionable Causesome frames are Old frames Do regular rounds rusty and change rusty frames maintenance No training on No safety Not part of No clear P&P Make policy to staff are not PT safety education safety for educate and train safety oriented program education maintenance 1st line program staff on PT maintenance staff safety traininguse of incorrect Some screws Use screws that screws that are used are not easily easily removed removed by patentssome frames are Maintenance maintenance Chick after fixatingnot fixed properlystaff do not chick staff are not and educate will after fixating safety oriented maintenance staffsome frames are Some frames Cheap material Chick material 1st easily broken are made of bad material
    • 5 Why Root Cause Analysis For Gardens ProblemValidated Root Cause Why1 Why2 Why3 Why4 Why5 Actionable light stands PT climbs them up To brake top glass To use glass or wires Remove light stands and use high sealing lightssport equipments are Sport therapist do Sport therapy Make clear policy for left with no not remove them department have no sport therapist to be supervision clear P&P for that responsible for equipment windows netting Easy to cut netting Netting is rusty No regular Do regular damaged maintenance maintenanceGarden components Patents use garden Cover all gardens with components for harm floor tiles
    • Generate Solutions Conduct Screen DOEGenerate alternative Use DOE andsolutions to root response surfacecauses of problems optimization to quantify relationships Improve Piloting Process Change ManagementRank and Select SolutionsTo rank and select Pilot the solution Develop andsolutions by considering on a small scale deployexpected impact, ROI and evaluate the a plan for how toand timeline result respond to process changes
    • Possible solutions for smuggling problem Root Cause Possible Solutions x-ray machine is a very old model buy new x-ray machine search for spear parts in other hospitals buy portable x-ray machine only one internist in A and N shift 2 internists / shift In patients to be examined in OPD clinic higher more internists No clear job description for security Put clear job description for security put clear search P&P for security train security personnel on P.T searchThere is no policy in security for properties Make a window before the metal detectors declaration before detectors Make a policy for property declaration before entering Set the metal detectors on the highest sensitivity In purchasing toilets and furniture Set a policy for consulting with nursing and doctors and nursing were not consulted doctors before buying Bring samples Consult with nursing manager and head of psychiatric department before purchasing
    • Possible solutions for maintenance problem Root Cause Possible Solutions No clear P&P for maintenance education in PT Set policy for maintenance education in PT safety safety Set training program for 1st line maintenance staff Monitor maintenance safety issuesno policy for location cleaning after maintenance Set clear policy for location cleaning Corporation between maintenance and housekeeping Monitor maintenance activity no policy for equipment supervision Set clear policy that tools and equipments must be supervised all the time Count tools before and after maintenance order Maintenance supervisor must chick every maintenance sight No clear policy for using tool box Set clear policy stating use of tool box Prevent any tool movement from warehouse with out tool box Ask maintenance company to provide tool boxes
    • Possible solutions for ward lights problem Root Cause Possible Solutions Non experienced nursing Educate and train nursing Monitor nursing staff performance Security rounds in wards Light covers are made of soft plastic Change light covers material Chick material strength before purchasing Consult with nursing before purchasingNo education policy for maintenance on PT Set policy to educate maintenance PT safety safety Set policy to follow safety measures in maintenance order Set education program for maintenance no barriers for lights protection Put a steal net on lights Change type of wards lights
    • Possible solutions for frames problem Root Cause Possible Solutions Old frames Do regular rounds and change rusty frames Change all wards frames regularly Change frames when they are brokenNo clear P&P for maintenance staff on PT safety Make policy to educate maintenance staff on PT training safety Train maintenance staff on PT safety Monitor all maintenance activities all the time Some screws that are used are easily removed Use screws that not easily removed by patents Prohibit the use of any other type some frames are easily broken Use strong materials Ask nursing opinion before purchasing
    • Possible solutions for gardens problem Root Cause Possible Solutions Patients brake lamps to use glass or wires Remove light stands Use high sealing lights Use wall lampsSport therapy department have no clear P&P for Make clear policy for sport therapist to be removal of equipments after use responsible for equipment Educate sport therapist on PT safety Remove movable sport equipments from garden No regular maintenance for windows netting Do regular maintenance Nursing chick netting daily Maintenance supervisor chick netting daily Patents use garden components for harm Cover all gardens with floor tiles Use artificial plants Keep a nursing staff in gardens at all times
    • Solution matrix Sigma Level Time to Implement Cost/Benefit Other <<<< Criteria 10 8 5 0 <<<<<<<<Importance ----- Possible Solutions ----- --------- Ratings --------- --------- Total --------- Remove light stands from gardens 10 8 9 209 Use high sealing lights in gardens 9 8 8 209Use wall lamps in gardens 5 6 5 123 Make clear policy for sport therapist to be responsible for equipment 9 7 9 191 Educate sport therapist on PT safety 9 9 9 207 Remove movable sport equipments from garden 8 8 8 184 Do regular maintenance for windows neting 8 8 7 179 Nursing chick windows netting daily 5 7 7 141Maintenance supervisor chick windows nettingdaily 8 7 9 181Do regular rounds and change rusty frames 9 8 9 199Change all wards frames regularly 8 3 1 109Change frames when they are broken 5 5 9 135Make policy to educate maintenance staff on PTsafety 8 7 9 181Train maintenance staff on PT safety 8 7 5 161Monitor all maintenance activities all the time 5 4 7 117Use screws that not easily removed by patents 7 7 8 166Use strong materials for frames 8 6 6 158Ask nursing opinion before purchasing materialsfor frames 7 4 9 147Educate and train nursing on PT safety 9 4 7 157Monitor nursing staff performance on PT safety 9 7 9 191Security rounds in wards 5 3 8 114
    • Sigma Level Time to Implement Cost/Benefit Other <<<< Criteria 10 8 5 0 <<<<<<<<Importance ----- Possible Solutions ----- --------- Ratings --------- --------- Total --------- Change light covers material 9 6 6 168 Chick light covers material strength before purchasing 8 8 9 189 Consult with nursing before purchasing 7 4 9 147Set policy to follow safety measures in maintenance order 9 9 9 207 Put a steal net on lights 9 6 7 173 Change type of wards lights 7 4 5 127 buy new x-ray machine 10 3 2 134 search for spear parts in other hospitals 9 5 9 175 buy portable x-ray machine 10 4 4 152 2 internists / shift 9 7 5 171 in patients to be examined in OPD clinic 3 6 9 123 Put clear job description for security 8 8 8 184 put clear search P&P for security 9 8 8 194 train security personnel on P.T search 9 7 8 186 Make a window before the metal detectors 7 5 5 135 Make a policy for property declaration before entering 9 8 9 199 Set the metal detectors on the highest sensitivity 8 8 9 189Set a policy for consulting with nursing and doctors before buying furniture 9 8 9 199 provide samples of furniture before purchasing 9 7 9 191 Corporation between maintenance and housekeeping 9 8 9 199set clear policy for maintenance sight cleaning after order complited 9 8 9 199 Set clear policy that tools and equipments must be supervised all the time 9 8 9 199 Count tools before and after maintenance order 9 8 9 199 Maintenance supervisor must chick every maintenance sight 8 7 6 166 Set clear policy stating use of tool box 9 8 9 199 Ask maintenance company to provide tool boxes 9 7 9 191Prevent any tool movement from warehouse with out tool box 9 8 10 204 Monitor maintenance activity 6 5 7 135 Cover all gardens with floor tiles 10 7 5 181 Use artificial plants 0 9 4 92 Keep a nursing staff in gardens at all times 5 5 5 115
    • Filtering Solutions• After ranking the solutions it was found that the highest ranking was at 209 and the lowest was at 92 and the total number was 52 solutions and after the 1st filtering the team chose the solutions that ranked above 150 and it was found to be 35 solutions.
    • Final Choice Of Solutions• Set policies• Gardens renovations• Repair frames and widows netting• Training programs• Training of employees• Monitoring number of incidences• Provide X-Ray machine
    • Plan and Implement Key Learning Process IntegrationSolution &Closure •Integrate permanent •Document results solution into appropriateTo develop a plan to make •Identify potential futureimprovements permanent Quality System projects •Identify replication •Hand off to process owner and/or standardization •Reward the team opportunities to expend ROI ControlProcess Control Systems Monitoring Evaluating Results Monitor the process Recalculate process•Control KPIV and KPOV using control charts to capability, and•To prevent mistakes or ensure process stays financial results basederrors in stable on improvements
    • Implementation Schedule Reducing the number of reports of potentially harmful Process: objects found with patients in ward Location: Al-amal Hospital in Jeddah Responsibil Complete Tasks Activities ity Start Date Date Prepare needed policies for maintenance, sport therapy, security, nursing Quality Set policies departments department 5/4/2011 5/5/2011 Support Cover gardens with floor services tiles, remove light stands,Gardens renovations install sealing lights Eng, Turki 10/4/2011 30/4/2011 Do round and chick all wards frames and window WardsRepair frames and netting and ask maintenance safety widows netting to repair damaged ones officers 7/4/2011 10/4/2011
    • Reducing the number of reports of potentially harmful objects Process: found with patients in ward Location: Al-amal Hospital in Jeddah Quality department Hatim banjar Nursing Prepare training program education for maintenance, nursing and security departments in naïf Training programs patient safety alomari 15/4/2011 10/5/2011 Education department Training of Implement training Majed employees programs sahafi 30/5/2011 30/7/2011 Quality departmentMonitoring number of Keep track of incident hatim incidences reports on daily bases banjar 1/4/2011
    • Reducing the number of reports of potentially harmful objects Process: found with patients in ward Location: Al-amal Hospital in Jeddah Support services department eng. fawaz Finance departmentProvide x-ray Get a portable x-ray Ibrahim machine machine asiry 1/4/2011 1/10/2011 Quality department Compare number of incidents/month with the HatimVerify Results expected goal banjar 1/4/2011
    • Verification of ImplementationThe implementation of the quick wins started in the2nd quarter of 1342 and the final implementation ofthe program started in the 3rd quarter of 1432 andthe result was that after implementing the quick winsthe numbers of reports dropped from 9 / month inthe 1st quarter to 7/month in the 2nd quarter and afterthe full implementation of the program the number ofreports dropped to 4/month and the goal of theproject was not fully met and that is because not allchosen solutions were implemented due to financialand legal issues.
    • Verification of ImplementationYear Month No of Harmful Objects2010 Oct 102010 Nov 72010 Dec 82011 Jan 122011 Feb 92011 Mar 62011 Apr 92011 May 82011 Jun 42011 Jul 62011 Aug 42011 Sep 2
    • Control Verification of Implementation Before ( Oct 2010- After ( June—Aug Mar 2011) 2011 No of 9 4 Harmful Objects /mth
    • Verification of Implementation Trend Chart ( No of Harmful Objects)No of Harmful Objects Per 10 9 7 8 No of Harmful 6 Objects per mth Mth 4 4 Target 3 3 3 2 0 Before ( Quick After ( Oct 2010- Wins ( July- Aug) Mar 2011) Mar-June 2011) Phases
    • Control Process Control SystemsHold the GainsProcess Description: CAF activation Process Customer: Ext Cust Critical Customer Requirements: Outcome Indicator(s): Process Flow Chart Checking Position Input-Process- Control Checking Item Frequ Responsi Contingency Plan Outcome Indicators Limits ency bility Charts and Graph Specs/Tar What to Check When Who Action Req’d for Type gets to Checks ExceptionStep/or Time Critical Process Step Check harmfull objects harmfull objects 1 no of incedents week hatim Corrective ACTION
    • CORRECTIVE ACTION REQUESTTO: Eng. Turki Al-GhamdiDEPARTMENT: Support servicesFROM: Hatim BanjarDEPARTMENT: Quality ManagementPROBLEM DESCRIPTION:What: Dangerous object ( wire cuter )Where: Ward BWhen:20 July 2011Who: in patientHow: 1ROOT CAUSE: Took from maintenance location in ward – maintenance staff didn’t havetool boxCORRECTIVE ACTION:ACTION WHO COMPLETION DATEEnforce caring tools in tool box Eng. fawaz 23July 2011VERIFIED:ACTION: DONE/ NOT DONERECEIVER SIGN: Eng. Turki Al-GhamdiORIGINATOR SIGN: Hatim Banjar