An introduction to quality and patient safety for new employees in health care with basic concepts on quality and patient safety that every new hire must know.

1. NEW HIRE ORIENTATION TO
QUALITY AND PATIENT
SAFETY
MN KIRANMAI,
BSC RN, MSC (PSY),
KSA

2. WHY VISION STATEMENTS ARE
IMPORTANT

3. ORGANIZATIONAL VISION

4. WHAT DO WE DO AS
QUALITY AND PATIENT
SAFETY PROFESSIONALS?

6. Vision
• TO REACH BEST DIMENTIONS OF EXCELLENCE BY PROVIDING DISTINGUISHED
HEALTH CARE BASED ON HIGH QUALITY MEASURES THROUGH APPLYING
INTERNATIONAL STANDARDS.
Mission
• TO PROVIDE QUALITY HEALTHCARE WITH HIGHEST LEVEL OF ETHICAL
STANDARDS, PERSONALIZED CARE TO OUR CUSTOMERS, EDUCATION AND
TRAINING AS A KEY FOR PERFORMANCE IMPROVEMENT AND ESTABLISHING
NEW MEDICAL CENTERS TO MEET COMMUNITY REQUIREMENTS AND TO
ACHIEVE SUPERIOR MEDICAL OUTCOME AND PATIENT SATISFACTION BY
IMPLIMENTING INTERNATIONAL STANDARDS.

7. QPS OBJECTIVES AND PURPOSE
• ESTABLISH CONTINUOUS QUALITY IMPROVEMENT STRATEGIES
• STABILISE THE HOSPITAL PROCESSES BY ENSURING COMPREHENSIVE
IMPLIMENTATION OF HOSPITAL STANDARDS
• COLLECT , ANALYSE AND STUDY THE KEY PROCESS INDICATORS AND
COMPARE WITH THE BENCK MARKS
• INITIATE QUALITY IMPROVEMENT PROJECTS BASED ON THE DATA
TRENDS OBSERVED
• WORK ON OCCURANCE VARIATIONS, SENTINEL EVETS, ADVERSE
EVENTS AND NEAR MISSES BY CONDUCTING ROOT CAUSE ANALYSIS
FOR PREVENTING FUTURE OCCURANCES OF THE SAME

8. WHAT DO WE DO AS QPS TEAM
• PERFORMANCE IMPROVEMENT BY ASSESSING CURRENT
SITUATION THROUGH KPIs
• ACTIVELY INVOLVE IN HOSPITAL ACCREDITATION
PROGRAMS
• ENSURE PATIENT SAFETY
• RISK MANAGEMENT, UTILIZATION MANAGEMENT AND
FACILITY MANAGEMENT
• INTEGRATE CLINICAL AUDIT PROGRAM
• DATA COLLECTION, ANALYSIS AND STUDY THROUGH
STATISTICS PROGRAM

9. WHAT SHOULD YOU KNOW
• KPIs OF YOUR DERPARTMENT LIKE FALLS
RATE, PRESSURE ULCER RATE, INFECTION
CONTROL RATES
• REPORTING UNUSUAL OCCURANCES
THROUGH OVR SYSTEM
• MEANING OF SENTINEL EVENTS, NEAR
MISS AND ROOT CAUSE ANALYSIS
• METHODS OF CONDUCTING QPS
PROJECTS
• BASICS OF DATA COLLECTION, ANALYSIS
AND REPORTING

11. OCCURANCE VARIANCE REPORTING
• An internal form used to document the details
of the occurrence/event and the investigation
of an occurrence and the corrective actions
taken.
• OVR is not a legal document, not a part of
patient medical record, it is only used for
improvement

12. WHY DO ERRORS OCCUR?

13. SWISS CHEESE MODEL

14. WHAT SHOULD BE
REPORTED QUALITY AND
PATIENT SAFETY TEAM?

15. REPORT ANY NEAR MISS
WHAT IS A NEAR MISS EVENT
A near miss is defined as any process variation which did
not affect the outcome but for which a recurrence carries a
significant chance of a serious adverse outcome

17. REPORT ALL ERRORS

18. REPORT ADVERSE REACTIONS OR
EFFECTS

19. REPORT ADVERSE EVENTS

20. REPORT ANYTHING AND
EVERY THING THAT IS NOT
IN ACCORDANCE WITH
HOSPITAL STANDARDS

21. REPORT SENTINEL EVENTS-
WHAT IS A SENTINEL EVENT
• A “SENTINEL EVENT” IS AN UNEXPECTED OCCURRENCE
INVOLVING DEATH OR SERIOUS PHYSICAL OR PSYCHOLOGICAL
INJURY, NOT RELATED TO THE NATURAL COURSE OF A PATIENT’S
ILLNESS OR UNDERLYING CONDITION.
• UNANTICIPATED DEATH UNRELATED TO THE NATURAL COURSE
OF THE PATIENT’S LIKE SUICIDE , HOMICIDE
• HEMOLYTIC BLOOD TRANSFUSIONS
• WRONG-SITE, WRONG-PROCEDURE, WRONG-PATIENT SURGERY
• INFANT ABDUCTION OR INFANT WHO WAS SENT HOME WITH
THE WRONG PARENTS

23. HOW DOES REPORTING HELP
• RIGHT REPORTING AT RIGHT TIME HELPS THE EMPLOYEE
TO STOP REPETITION OF THE ERROR
• RIGHT TRAINING AND EDUCATION OF THE EMPLOYEE
HELPS TO INCREASE THE KNOWLEDGE AND SKILL TO
HANDLE PROBLEM MORE EFFICIENTLY
• NON PUNITIVE ACTION PLAN HELPS TO ENCOURAGE
VOLUNTARY REPORTING AND UNBIASED CORRECTIVE
ACTIONS
• AND SO….WE INTEND TO FIND THE SYSTEM WEAKNESSES
AND IMPROVING THE STANDARDS OF WORKING BY RE
ENGINEERING THE SYSTEM IN A WAY IT IS IMPOSSIBLE TO
COMMIT MISTAKES (BY CLOSING THE LOOP HOLES)
INSTEAD OF FOCUSING ON PUNISHING AN INDIVIDUAL

24. WHAT IS ROOT CAUSE ANALYSIS
The purpose of the Root
Cause Analysis is to
understand how and why a
Sentinel Event occurred
and to prevent the same or
similar event from
occurring in the future by
analyzing the course and
causes behind the event
and working on our
defects.

25. IMPROVEMENT METHODOLOGY-
FOCUS PDCA
• FIND - AN OPPORTUNITY FOR IMPROVEMENT
• ORGANIZE- A TEAM
• CLARIFY- THE CURRENT PROCESS
• UNDERSTAND- THE RESOURCES OF THE PROBLEM
AND THE PROCESS VARIATION
• SELECT- THE IMPROVEMENT
• PLAN - THE IMPROVEMENT
• DO- THE IMPROVEMENT
• CHECK- THE RESULTS
• ACT- TO HOLD THE GAIN

26. INTERNATIONAL PATIENT SAFETY GOALS
• 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