This document provides information about quality management and occurrence variance reporting (OVR) processes. It defines key terms like quality, adverse events, near misses and sentinel events. It outlines the OVR process which involves any staff member witnessing and reporting an event, investigation by relevant departments, and submission to the continuous quality improvement department for trend analysis. The purpose of OVR is to identify areas for improvement, implement corrective actions, and establish preventative measures through a non-blame approach.

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2. BASICS OF QUALIYT & OCCURANCE
VARIANCE REPORT (OVR)
PREPARED & PRESENTED BY
Ms. Alaa M. Abdeen, LSSGB, DHQM
CQI Coordinator

3. DEFINITIONS
Quality is doing the right things right
, first time and every time
What is Quality of Healthcare?
Healthcare that is accessible, effective, safe,
accountable and fair

4. Who should be interested in quality?
Patient/ satisfactory quality of received
Visitor service
Employees workplace satisfaction, career
opportunities ...
Owner maximum created value
Supplier long-lasting business relationship
Society responsible and sustainable behaviour

5. Quality Management Principles
1- Focus on Customer
2. Leadership Commitment
3- People Involvement
4- Process Approach

6. 5. System Approach to Management
6. Continuous Improvement7. Factual Approach to
Decision Making
8.Mutual Beneficial
Supplier Relation
Quality Management Principles

7. What is Quality Improvement?
It is the commitment and approach used to
continuously Improve every process & service in every
part of the hospital to meet & exceed customer needs
& expectations.
Other Labels for QI:
-Continuous Quality Improvement (CQI)
-Total Quality Management (TQM)

8. Quality is a Journey…
Not A Destination…..

9. How To Judge Quality

10. “You Can not Improve what
you cannot Measure, And
you can’t Measure what you
can’t Define”
Quality Quote

11. Strategies for Measuring Quality
 Audit
 Accreditation
 Supervision
 Self Assessment
 Peer Review
 Special Survey
 Others
Audit/
Survey
Supervision
Peer
Review

12. ACCREDITATION
&
STANDARDS

13. Accreditations & Standards
 Accreditations are acquired through neutral third
parties. Each body of which have a set of standards,
 These Standards represent the minimal
requirements for Good Quality according to the
accrediting body.
If these Standards are met by the
Hospital, It is therefore accredited.

14. Examples of Accreditation Bodies
 ISO JCI
Joint
Commission
International
CBAHI
Central Board of
Accreditation
for Healthcare
Institutions
Mandatory From

15. Why do we need standards?
 Standards puts definition of quality desired for a
specific service ( A statement of what we expect quality to
be)
=> Set a goal
 Standards provide a basis of measurement against
which performance can be compared and assessed
=> Measure Achievement of that goal
“If quality is defined by standards, then measuring
quality is assessing the level of compliance with
standards”

16. Standards are meant to help the Hospital to:
1 - Provide more, better medical services
2 - Put inspection system for everything in the work,
which in turn will lead to:
- Higher staff experience level
- Reduce Duplication of Data
- Raise Patient Satisfaction
- Save: Time, efforts and Costs of poor Quality

17.  To ensure unified processes, Standards are usually
managed through documented, approved and
implemented Policies and procedures (P&P).
These P&P’s are either :
-IPP ( Internal policies and procedures)
> concerned with the involved
department
OR,
-APP ( Administrative policies and
procedures)
> Concerns Hospital wide

18. Evidence for compliance to standards includes
Documents review
Medical record review (closed,
open)
Personnel record review
Unit Visit (observation , Interview)
Staff Interview

19. Occurrence Variance Reporting (OVR)
 Definitions
 Purpose of OVR
 Who Should Report
 What to Report
 OVR General Guidelines
 Writing Guidelines
 Responsibilities

20. DEFINITIONS
 An Occurrence is any event which happens in GNP
Hospital premises which is :
- Not consistent with patient care / routine operation of the
hospital
- Affects/threatens to affect the health or life, of patient,
visitor, employees,
- Involves loss or damage to personal or Hospital property.
- Might other wise result in any adverse situation or a claim
against the organization

21. DEFINITIONS
 Variation is the difference in results obtained in
measuring the same phenomenon more than once;
“excessive variation frequently leads to waste & loss; such
as the occurrence of undesirable patient health outcomes
and increased cost of health services”
• Occurrence Variance Report (OVR) is an
internal form used to document the details of the
occurrence and the investigation of an occurrence and the
corrective actions taken.

22. DEFINITIONS
 Adverse Event unwanted, undesirable and
unanticipated event, such as death of patient, an
employee, or a visitor in a health care
organization. Occurrences such as patient falls are
also considered adverse events if there is no
permanent effect on the patient
Example: patient falls, transfusion, drug or
anesthesia reaction resulting in significant
condition change in the patient. (if there is no
permanent effect on the patient).

23. DEFINITIONS
 Near Miss An event or situation that could have resulted in
an accident, injury or illness but did not, either by chance or
through timely intervention.
 Sentinel Event unexpected occurrence involving:
- death,
- serious physical or psychological injury,
- the risk thereof, includes any process variation for which a recurrence
would carry a significant chance of a serious adverse outcome.
- any event that might cause embarrassment or risk to the
hospital with potential legal ramifications and /or media
inquiries or coverage.

24. SENTINEL EVENT Includes:
 Unexpected death
 Maternal death
 Wrong patient, wrong procedure, or wrong site.
 Retained instrument or sponge
 Medication error leading to death or major morbidity
 Infant abduction or infant discharged to the wrong
family
 Unexpected loss of a limb or a function
 Hemolytic blood transfusion reaction
 Inpatient suicide
 Gas embolism

25. PURPOSE OF OVR
• OVR is used to help:
- Identify areas needing
improvement or recognition
- Plan and implement corrective
measures through
identification by root cause
analysis
- Analyze the data and develop
preventive measures
periodically.

26. WHO SHOULD REPORT
IT’s Every Staff’s
Responsibility to
report any
occurrences he/she
witnesses within the
hospital’s Premises

27. WHAT TO REPORT
 Patient Falls
Injuries/ Self Injuries
Accidental needle prick
Medication Error
Medicines not transcribed
OR:
- Delay/ Cancellation
- Shortage of Equipment/ Material
- Equipment Failure
- Missing/ Wrong Bracelet
- Wrong Site/ Side/ Patient/ procedure/
Specimen. Etc…
 Wrong patient identification
 Violation in standard
precaution
 Absconded / Against Medical
Advice (AMA)
 Blood extraction/
Transfusion/ Expired
 Pressure Sore
 Medical Records:
- File/Report/ form
- Delay/ Incomplete/ Contaminated/
Missing/ Others

28. WHAT TO REPORT
 No response to call
 Delays in reply/ notify/ ___(of any incident that might compromise safety of patient
or staff)
 Non-availability of supplies/forms
 Problem in cleanliness
 Miscommunication
 Lost/ Damaged Materials (Clothes/ money/ jewelry/ ID/Glasses..etc. )
Damage/Failure in Environment (Equipment damage/ fire/ smoke/ HazMat Spill/
water system/ utility system..etc)
 Other (Contaminated Food/ Infant to wrong Mother..etc..)

29. OVR GENERAL GUIDELINES
1. OVR is Everyone’s responsibility
2. The report will not be ever used to criticize
or blame the actions of the staff involved
“ NO BLAME” Concept
3. OVR Is confidential, it shall not be placed
in the Patient File nor in Employee File or
discussed otherwise.
4. OVR is for Improvement NOT to be ever
used solely to take any disciplinary actions.

30. WRITING GUIDELINES
• The narrative description of the occurrence by
the person involved should be a very brief
statement of fact containing no personal
judgment or opinions and no implications or
accusations of any individual or department
“presumed” to be at fault.
• If a physician was notified and actually attended
the patient, the physician is responsible for
recording a brief statement of his her findings.

31. RESPONSIBILITIES
1. The employee who witnesses or discovers an
occurrence he/she has the professional
obligation and the responsibilities for:
1.1 Immediately notifying:
- The physician on call if the occurrence involves any
questions of patient or employee injury or harm.
- The head / supervisor / head nurse.
1.2 Initiating the Occurrence Variance Report
form before the end of the current shift.
1.3 Submitting the original of the Occurrence
Variance Report form to the head / supervisor
/ head nurse on duty for completion.

32. RESPONSIBILITIES
2.The head / supervisor / head nurse (originator) is
responsible for:
2.1 Ensuring that all employees are aware of Occurrence
Variance Reporting System and how to report process
Occurrence Variance Report Form.
2.2 Conducting immediate follow-up of the occurrence by
initiating and documenting on the Occurrence Report the
actions taken at the time of the Occurrence and/or any
corrective measures taken to prevent a recurrence of the
event.
2.3 Ensuring thorough and accurate completion of the
Occurrence Variance Report form , by forwarding it to
responding department , The boxes assigned to the
"responsible department notification" and "list of staff &
department involved" should be checked in by the
Department Head / Supervisor / Head Nurse.

33. RESPONSIBILITIES
2. Cont.: The head / supervisor / head nurse
(originator) is responsible for:
2.4 Signs the Occurrence Report with his/her
position title and ID no.
2.5 Evaluates incident if meets sentinel event
criteria.
2.6 Forwarding the completed Occurrence
Variance Report form to the CQI Department
within 24 hours of the occurrence.
2.7 Conducting any further investigation and
documenting investigative findings of the
reported occurrence upon request of the Hospital
Administration, the CQI Department/Committee
or the safety Committee.

34. RESPONSIBILITIES
3.The head / supervisor / head nurse of the
responding department is responsible for:
3.1 Conducting immediate investigation of the
occurrence and Record the action plans and any
systems recommendations in their assigned places.
3.2 Forwarding the OVR Form back to the
originating department.
The Department Head / Supervisor / Head Nurse,
where the occurrence happened, will forward the
completed form to the CQI Department for trending
and analysis.

35. RESPONSIBILITIES
4.The CQI Department is
responsible for:
4.1 Monitoring all Occurrence Variance Reports
for follow up to the proper authorities so that
necessary steps may be taken by those in charge
to resolve the situation if necessary.
4.2 Trending and preparing a monthly summary
of all reported occurrences.
4.3 Submitting a quarterly report to the CQI
Committee for discussion and further action, if
deemed necessary by this committee.
6.4 Maintaining a file of all Occurrence Variance
Reports submitted to the CQI Department for
three years.

36. RESPONSIBILITIES
5.The Safety Officer is responsible for:
5.1 Investigating all safety related occurrences referred
for investigation by initiating department and/or Head
and CQI Department.
5.2 Activating a review team of selected Safety
Committee members to investigate critical safety
related occurrences.
5.3 Documenting the results of investigation and
corrective action taken to the Occurrence Report
Form.
5.4 Returning the completed form to the CQI
Department.
5.5 Reviewing monthly summary data to determine if
safety hazard issues exist and reports to the Safety
committee.

37. SUMMARY
Employee
Witness an event Do OVR
Deliver report to
direct supervisor
where incident
has occurred
Doctor
Presen
t
Immediate /
corrective
actions taken
Deliver to head/
HN/ S.visor of the
responsible Dept.
Action Plans/
Recommendation
NO
YES 4
Brief
statement of
his/ her
finding
OVR
PROCESS
DELIVER
TO CQI
Department
5
1
2
3
Sentinel
Event
NO
YES
Regular trending
& analysis

38. REFERENCES
Slideshare.com
Janet Brown
OVR Policy & Procedure
AUC Educational Materials
CBAHI Manual

39. QUESTIONS ?!