Introduction & Functions of Quality Department

Introduction , functions & Quality Indicators

1. Dr. Sajid Omer Chief of Quality

2. Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives .

3. EXECUTIVE DIRECTOR CEO CHIEF QUALITY INFECTION CONTROL NURSE QUALITY DEPARTMENT Organogram

4. Fire Safety Officer DHIM / MRD Committee members Clinical Pharmacologist Patient and Staff Quality Officers Infection Control Team QA TEAM

5. Functions of QAD Internal Audits and Analysis of data pertaining to the various dimensions of Quality Surveillance and Accreditation preparation Process & System evaluation Patient feedback analysis Coordinating external audits Grievance redresser Monitoring agency Adjuvant in streamlining processes “Why???” is more important than “Who???” Fact finding mission and not a fault finding mission

6. Components of Quality Assurance Strategic Level Tactical Level Operational Level Long term decision Quality policy Medium term decision Training ,facilities, operations of QA Day to day operation SOP’s worksheet

7. Quality Assurance A part of quality management focused on providing confidence that quality requirements will be fulfilled. Planned and systematic activities implemented within the quality system provide confidence that a service fulfill requirements for quality. Is a complete system to assure the quality of service Quality Control A part of quality management focused on fulfilling quality requirements. The operational technique and activities used to fulfill requirement of quality. Quality control just measures and determines the quality level of services. Quality Assurance vs Quality Control

8. It has been said that there will be two kinds of organizations in the future - one which have implemented Total Quality and other which are out of business

9. CUSTOMER EXPECTATIONS ENVIRONMENT CONCERN LEGISLATIONS ECONOMICS COST MANAGEMENT TECHNICAL INNOVATION STAFF EXPECTATION COMPETITION SHARE HOLDERS INTERESTS BUSINESS CHALLENGES FOR THE BUSINESS

10. Internal audits Feedback Implementing the Pillars of Quality Incidents

11. Accreditation Duties of QAD

12. NABH – National Accreditation Board for Hospitals & Healthcare Providers Established in the year 2006 by QCI – Quality Council of India, which is under guidance of Ministry of Commerce. Currently using NABH 4 th Edition standards. 10 Chapters 110 Standards 683 Objective Elements 70 Quality Indicators. Equivalent to JCI – Joint Commission International. NABH

13. Chapters of NABH Access, Assessment and continuity of care (AAC) Patient rights and education (PRE) Care of patient (COP) Management of medication (MOM) Hospital infection control (HIC) Continuous Quality Improvement (CQI) Responsibility of Management (ROM) Facility management &Safety (FMS) Human Resource Management (HRM) Information Management System (IMS)

14. Patient Centered Chapters: Access, Assessment & Continuity of Care (AAC) Care of Patients (COP) Management of Medications (MOM) Patient Rights & Education (PRE) Hospital Infection Control (HIC ) NABH - Chapters Organization Centered Chapters Continuous Quality Improvement (CQI) Responsibilities of Management (ROM) Facility Management & Safety (FMS) Human Resource Management (HRM) Information Management System (IMS)

15. QUALITY INDICATORS

16. PATIENT ASSESMENT Patient Assessment (CQI 3 a) Average time for initial assessment of ER patient Minutes Total time for initial assesment in randomly selected cases in a given month Total number of randomly selected cases in that month Average time for initial assessment of In-patient Minutes Total time for initial assesment in randomly selected cases in a given month Total number of randomly selected cases in that month Compliance of care plan documented % Number of cases in which care plan is documented and continued by clinician in given month Total number of randomly selected cases in that month Compliance of nutritional assessment % Number of cases in which screening is done for nutritional needs in given month Total number of randomly selected cases in that month Compliance of nursing Care Plan % Number of cases in which care plan is documented Total number of randomly selected cases in that month unit Numerator Denominator

17. LAB- FUNCTIONS LAB Microbiology UNIT     NUMERATOR   DENOMINATOR Diagnostics Services ( CQI 3 b) Number of reporting error per 1000 investigations Numbers Number of reporting error Total number of tests done in that month % of re-dos % Number of tests which are repeated in given month Total number of tests done in that month % of reports co - relating with clinical diagnosis % Number of reports correlating with clinical diagnosis Total number of randomly selected investigations in that month % of adherence to safety precautions by employee working in diagnostics (All lab) % Number of employees found to be adherent to safety precautions on random checking Total number of employees randomly checked

18.   Biochemistry UNIT     NUMERATOR   DENOMINATOR Diagnostics Services (CQI 3 b) Number of reporting error per 1000 investigations Numbers Number of reporting error Total number of tests done in that month % of re-dos % Number of tests which are repeated in given month Total number of tests done in that month % of reports co - relating with clinical diagnosis % Number of reports correlating with clinical diagnosis Total number of randomly selected investigations in that month   Haematology       Diagnostics Services (CQI 2 b) Number of reporting error per 1000 investigations Numbers Number of reporting error Total number of tests done in that month % of re-dos % Number of tests which are repeated in given month Total number of tests done in that month % of reports co - relating with clinical diagnosis % Number of reports correlating with clinical diagnosis Total number of randomly selected investigations in that month   Immunology       Diagnostics Services (CQI 3 b) Number of reporting error per 1000 investigations Numbers Number of reporting error Total number of tests done in that month % of re-dos % Number of tests which are repeated in given month Total number of tests done in that month % of reports co - relating with clinical diagnosis % Number of reports correlating with clinical diagnosis Total number of randomly selected investigations in that month

19.   Molecular medicine and biology UNIT     NUMERATOR   DENOMINATOR Diagnostics Services (CQI 3 b) Number of reporting error per 1000 investigations Numbers Number of reporting error Total number of tests done in that month % of re-dos % Number of tests which are repeated in given month Total number of tests done in that month % of reports co - relating with clinical diagnosis % Number of reports correlating with clinical diagnosis Total number of randomly selected investigations in that month

20. RADIOLOGY FUNCTIONS Radiology MRI       Diagnostics Services (CQI 3b) Number of reporting error per 1000 investigations Numbers Number of reporting error Total number of tests done in that month % of re-dos % Number of tests which are repeated in given month Total number of tests done in that month % of reports co - relating with clinical diagnosis % Number of reports correlating with clinical diagnosis Total number of randomly selected investigations in that month % of adherence to safety precautions by employee working in diagnostics % Compliance with safety precaution criteria Total no. of random sample   CT       Diagnostics Services (CQI 3 b) Number of reporting error per 1000 investigations Numbers Number of reporting error Total number of tests done in that month % of re-dos % Number of tests which are repeated in given month Total number of tests done in that month % of reports co - relating with clinical diagnosis % Number of reports correlating with clinical diagnosis Total number of randomly selected investigations in that month   DSA       Diagnostics Services (CQI 3 b) Number of reporting error per 1000 investigations Numbers Number of reporting error Total number of tests done in that month % of re-dos % Number of tests which are repeated in given month Total number of tests done in that month % of reports co - relating with clinical diagnosis % Number of reports correlating with clinical diagnosis Total number of randomly selected investigations in that month

21.   X-ray       Diagnostics Services (CQI 3 b) Number of reporting error per 1000 investigations Numbers Number of reporting error Total number of tests done in that month % of re-dos % Number of tests which are repeated in given month Total number of tests done in that month % of reports co - relating with clinical diagnosis % Number of reports correlating with clinical diagnosis Total number of randomly selected investigations in that month

22. MANAGEMENT OF MEDICATION Medication Management(CQI 3 c) Incedence of medication error % Total no. of medication error in a month Total no. patients days in that month % of admission with adverse drug reaction % No. of adverse drug reaction Number of discharge and death in that month % of medication Chart with error prone abbreviations % No. medication Chart with error pron abbreviations Total No. medication Chart reviewd % Patient receiving high risk medication developing adverse drug event % No. of Patient receiving high risk medication developing adverse drug event No. of Patient receiving high risk medication Medication Procurement ( CQI 4 a) ( PURCHASE AND STORE ) % of drug procured by local purchase % No. of item purchased by local purchase No. of drug listed in formulary % of stock outs excluding ER drugs % No. of stock outs No. of drug listed in formulary and hospital consumable list % of stock outs of ER drugs % No. of stock outs No. of ER drugs listed % of Drug rejected before preparation of GRN % Total quantity rejected Total quantity received before GRN % of consumables procured by local purchase % No. of item purchased by local purchase No. of consumable listed % of Consumables rejected before preparation of GRN % Total quantity rejected Total quantity received before GRN % of variations from procurement process % Total no of variations from the usual procurement process Total no of item procured

23. BLOOD BANK Use of Blood & Blood Products (CQI 3 f) % of transfusion reaction % Total no of transfusion reactions in given month Total no of transfusion given in that month % of wastage of blood and blood products % No of blood and blood products used No. of blood and blood product issued from blood bank % of blood component usage % No. of component used No of blood and blood products used TAT for issue of blood and blood product Minutes Sum of time taken No. of blood and blood product issued from blood bank unit Numerator Denominator

24. HUMAN RESOURCES Employee Satisfaction (CQI 4 e) Employee satisfaction index % Score achieved Max. possible score Employee attrition rate % No of employees left organization in a given month Total no of employees available in that month Employee Absenteeism rate (permanent) % No of employees who are absent from the duties in a given month Total no of employees available in that month Employee Absenteeism rate (badly) % No of employees who are absent from the duties in a given month Total no of employees available in that month % of employee who are aware of employee rights, responsibilities and welfare % No. of employee who are aware of employee rights, responsibilities and welfare Total no of employees interviewed in that month unit Numerator Denominator

25. MEDICAL RECORDS Medical Records (CQI 4 g) % of medical records not having discharge summary % No of medical records not having discharge summary No of medical records randomly selected for audit Percentage of medical records not having codification as per international classification of diseases (ICD) % Medical records not having codification as per international classification of diseases (ICD) No. of discharge and death % of medical records having incomplete / improper consent % No of medical records having incomplete or improper consent No of medical records randomly serlected for audit % of missing records % No of medical records found missing No of medical records randomly selected for audit % of medical records not having initial assessment and plan of care % No of medical records not having initial assessment and plan of care in a given month No of medical records randomly selected for audit unit Numerator Denominator

26. MORTALITY AND MORBIDITY Mortality and Morbidity (CQI 3 h) Mortality rate % No. of deaths Total no. of discharge and death Return to ICU within 48 hour % Return to ICU within 48 hour Total no. of discharge/transfer and death in the ICU Return to the emergency department within 72 hours with similar presenting complaints. % No. of return to the emergency department within 72 hours with similar presenting complaints Total no. of patient who have come to emergency re-intubation rate.(with in 48 hr ) % No. of re-intubation with in 48 hour of extubation No. of extubation unit Numerator Denominator

27. OPERATIONAL INDICATORS Utilization (CQI 4 c) Bed occupancy rate % No of in-patient days in a given month No of available bed days in that month ALOS Days Total length of stay of all patients discharged in a given month Total no of discharges and death in that month OT utilization rate % No of minutes OTs utilized in a given month Total no of minutes available for use in that month ICU utilization rate % Total no of in-patient days in all ICUs in a given month No of available bed days in that month Critical equipment down time Hour Sum down time for all critical equipments   Nurse patient ratio Ratio Number of staff nurses in ICUs Number of Beds Available Number of staff nurses in wards Number of Beds Available unit Numerator Denominator

28. PATIENT SATISFACTION Patient Satisfaction (CQI 4 d) Patient Satisfaction Score Score Average score of IP Max score Average score of OP Max score Waiting time for diagnostics test Minutes Total waiting time in minutes for patient in diagnostic services in a given month Total no of randomly selected patients for study in a given month Waiting time for OPD Minutes Total waiting time in minutes for patient in outpatient department in a given month Total no of randomly selected patients for study in a given month Average time taken for discharge Cash Hour Total waiting time for discharge of in-patients in a given month(Random ) Total no of discharged patients in a given month(random ) Average time taken for discharge Crdt Hour Total waiting time for discharge of in-patients in a given month(Random ) Total no of discharged patients in a given month(random ) unit numerator Denominator

29. RISK MANAGEMENT unit Numerator Denominator Risk Management (CQI 4 b) Number of variations observed in mock drill Numbers --   Incidence of fall Numbers --   Incidence of bed sores after admission Numbers --   Percentage of employees provided pre-exposure prophylaxis % No of employees given the pre-exposure prophylaxis Total no of employees in high risk areas and clinical field areas

30. OT- INDICATORS Use of Anesthesia (CQI 3 d) % of modification of anesthesia plan % No of patients in which anaesthesia plan modified Total no of patients in whom anesthesia given in that month % of unplanned ventilation following anesthesia % No of cases in which unplanned ventilation done in given month Total no of patients in whom anasthesia given in that month % of Adverse anaesthesia events % No of patients who develop adverse reaction to anaesthesia Total no of patients in whom anasthesia given in that month Anaesthesia related mortality rate % No of patients who died due to anesthesia in a given month Total no of patients in whom anesthesia given in that month unit numerator Denominator

31. SURGICAL SERVICES Surgical Services (CQI 3 e) % of unplanned return to OT % No. of unplanned return to OT No. of patient operated % Rescheduling of surgeries % No. of cases rescheduled No. of surgeries performed Percentage of cases where the organization’s procedure to prevent adverse events like wrong site, wrong patient and wrong surgery have been adhered to % Number of cases where the procedure was follwed No. of surgeries performed % of cases who receive appropriate prophylactic antibiotic within the specified time frame % No. of patient who did receive prophylactic antibiotic No. of surgeries performed unit Numerator Denominator

32. INFECTION CONTROL Infection Control (CQI 3 g) Pneumonia rate VAP/1000 ventilator days No of ventilator assosciated pneumonia in a month No of ventilator days in that month Surgical site infection % No of surgical site infection in a given month No of surgeries performed in that month Blood stream infection BSI/1000 catheter days No of central line assosciated blood stream infection in given month No of central line days in that month Urinary tract infection UTI/1000 catheter days No of urinary catheter associated UTI in a given month No of urinary catheter days in that month unit numerator Denominator

33. Thank you…