This document summarizes three quality improvement projects at Al-Ahsa Hospital's CQI Department: 1. The Emergency Room project aimed to reduce boarding times over 3 hours by redesigning the ER structure and adding beds. After expansion, waiting times decreased by half. 2. The Troponin I project implemented point-of-care testing in the ER to reduce turnaround times for troponin results to under 1 hour as required. Technicians were trained to prioritize troponin samples. 3. The Fall Prevention project identified issues with risk assessment tools and a lack of clear interventions. A new comprehensive program was implemented using the Johns Hopkins Fall Risk Assessment Tool along with staff education and equipment check

1. QI Projects
Tamer Gharaiybah, RN, MSN
Risk Management and Patient Safety Coordinator
Al-Ahsa Hospital
CQI Department

2. Objective
• To discuss Emergency Room (ER) Project
• To discuss Troponin I project
• To discuss Prevent Falling Down Project
CQI Department 2

3. Emergency Room (ER) Project
• The overall goal of the project was to compose health care in ER fit with
hospital mission and vision.
• FOCUS PDCA has been adapted to improve health care in ER.

4. CQI Department
4
Find
• problem in ER mostly related delaying in health care provided in ER
which is directly increases the boarding time more than 3 hours.

5. CQI Departemnt 5
Organize
• Organized team was being formed in ordered to review the process and
identify the reason of delaying

7.  Clarify
• Clarifying existed problem by comparing the expected outcome with actual
performance.
CQI Departemnt 7

8. 0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
mar apr may jun jul aug sept oct nov dec
Boarding Time indicator in ER 2015

9. Understanding
• study conducted over one month to evaluate the waiting time and summarize
the problems in ER as well validated data.
CQI Departemnt 9

10. 0
1000
2000
3000
4000
5000
6000
Figure 1: Trend of ER visit number per month
2014-2015
Series 1

11. Selecting
• To prioritize the performance improvement in ER, we matched the
problem with priority matrix of indicators.
• 1. Minimize rate of patients wait more than 3 hours
• 2. Reporting urgent and emergent lab and radiology result
• 3. Adherence to policy triage cases and physician documentation.

12. PLAN
• The overall goal of the project was to compose health care fit hospital
mission and vision.
• to reform ER structure and extend number of beds.
CQI Departemnt 12

13. DO
Supportive services director was responsible to achieve the objective.
Redesign ER structure to fit the extension number of beds.
4 beds were added to be totally 11 beds.
Also pediatric clinic is opened in ER at time off OPDs
CQI Departemnt 13

14. CHECK
• After expansion, the waiting time indicator showed decrease in percentage
to the half. For instance, in January and February the percentage of
waiting time indicator was 6.6 and 7.39, respectively.
• Regarding patient complain, it showed decrease in 1st quarter in 2016
comparing with 4th quarter 2015.
CQI Departemnt 14

15. Act
• The project has been already finished
• It is under monitoring

16. Point of Care-Troponin I
Find
• Data obtained from CAREWARE system showed that turnaround time was
more than 1 hour for patient coming to ER.
CQI Departemnt 16

17. Organize
• The team involved from head of LAB, ER, head nurse, supportive
maintenance, and CQI.
CQI Departemnt 17

18. Clarifying
• existed problem by comparing the expected outcome for TAT with actual
performance
• The expected outcome should match hospital policy to reflect hospital vision
and mission. According to hospital policy (LAB-QM-POST-7), the expected
TAT is 1 hour.
CQI Departemnt 18

19. 0
10
20
30
40
50
60
70
80
90
10-2015 11-2015 12-2015 01-2016 02-2016 03-2016
percentage of sample taken more than 1 hour

20. Understanding
• Collected specimens were sent to lab without prioritizing Troponin I. In lab,
the technician did not know which sample should be prioritize as it is
emergent.
CQI Departemnt 20

21. CQI Departemnt 21
PLAN
• The overall goal of the project was to compose health care fit hospital
mission and vision.
• Objective: to avoid delay in result and to report panic value within 1 hour for
troponin

22. DO
CQI Departemnt 22
• In the literature, the easiest method is applying Point of Care (POC) in EMS
to avoid result delaying. For instance, study showed that the result of
troponin was available on average in 15 versus 83 minutes for the laboratory
result
(A.J., J., J., & J., 2005).

23. • Supportive maintenance was responsible to provide POC kit.
• Head of laboratory revised POC policy.
• Lab technician will educate ER nursing staff how to use the kit.
CQI Departemnt 23

24. prevent Fall Down Project
CQI Departemnt 24
 To do a comprehensive assessment for all patient admitted
 To prevent patient fall during hospitalization
 Improvement done using FOCUS PDCA.
• Find
• Received OVR Monthly regarding patient fall down, and this is against
target indicator.
• should be no incidence as it is one of international patient safety goal.

25. CQI Departemnt 25

26. Organized team.
 CQI director
 Risk mngt & PT coordinator
 ICU head nurse
 ECU head nurse
 Nursing Educator
Radiology supervisor
Physiotherapy supervisor
CQI Departemnt 26

27. Clarifying
• Morse Scale was revised carefully.
• There was error in printed scale which mean the result scale for patient at
high risk for fall will be low risk and vice versa.
• Morse scale lacking assessment for change in elimination status which is
the most reason leading for fall.
CQI Departemnt 27

28. CQI Departemnt 28

29. • In pediatric scale; error in printing humpty dumpty scale.
• There is no process to check equipment may cause fall for reason such as
wheel chair, IV stand, or beds.
• Medications may cause fall integrated in the Morse scale without
sensitivity consideration.
CQI Departemnt 29

30. Understanding
• Lack proper Assessment as well no clear intervention to prevent fall is the
major cause of fall in the hospital.
CQI Departemnt 30

31. PLAN
To Implement valid fall assessment tool
To implement comprehensive fall prevention program involving
intervention
CQI Departemnt 31

32. DO
Fall prevention policy completely changed to new comprehensive program.
Assessment tool was changed from Morse scale to Johns Hopkins Fall risk
Assessment Tool (JHFRAT). (CQI Director).
Educate the staff how to implement JHFRAT (Nursing educator)
Set comprehensive intervention for scale (Head nurses).
Prepare checklist for equipment checking (OPD head nurse)
Check equipment either daily or weekly (Nurses and end users).
CQI Departemnt 32

33. CQI Departemnt 33

34. CQI Departemnt 34