Introduction to quality and OVR

An Introduction to Quality in Healthcare & Reporting System

1. Kindly Turn off your Mobile, or put on silent if ON-Call (And Please fill up front Lines First) Your Consideration is highly Appreciated…

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 Improvement 7. 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

19. O ccurrence V ariance R eporting ( 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: I dentify areas needing improvement or recognition Plan and implement corrective measures through identification by root cause analysis A nalyze 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 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 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 Present 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 ?!