Quality orientation lecture (hospital orientation program)

Orientation of new hospital staff regarding Quality management System in KFH Medina

1. Dr. Nashwa Elsayed
Clinical Pathologist -CPHQ -SSMBB
Patient Safety & Risk Manager
Accreditation Manager
KFH -QPS
Quality Management
& Patient Safety
Hospital Orientation Program
For KFH Staff
January 2021

2. Welcome to KFHM
Quality Management & Patient Safety
Hospital Orientation Program
•You are Unique, Lucky.
•The Holy City Medina is relaxing and calming.
•KFHM is JCI and CBAHI accredited.
•The only Trauma Centre In Medina .

3. What is Quality ??
Quality Is Providing The Right Services In The
Right Way From The First Time & Improve It
Every Time .
Quality Management & Patient Safety
Hospital Orientation Program

4. Decrease Cost
Customer Satisfaction
Patient Safety
Quality ??
Quality Management & Patient Safety
Hospital Orientation Program

5. Why Quality Matter ??
Quality Management & Patient Safety
Hospital Orientation Program

6. For The Patient
✓Ensure Patient Safety
✓Improve Patient Satisfaction
Quality Management & Patient Safety
Hospital Orientation Program

7. For The Staff
✓Safe & Healthy Environment
✓Staff Satisfaction
Quality Management & Patient Safety
Hospital Orientation Program

8. For The Organization
✓Improve The Market Reputation & Market Share
✓Create Patient & Staff Loyalty To The Organization
✓Ensure Higher Authority Support To The Organization
Quality Management & Patient Safety
Hospital Orientation Program

9. Quality Management System
Quality Management & Patient Safety
Hospital Orientation Program
Quality
Management
Documents
Control
Performance
Monitoring
Process
Improvement
Patient Safety
Risk
Management
Accreditations

10. Quality Management & Patient Safety
Hospital Orientation Program
Quality
Management
System
Documents
Control
Performance
Monitoring
Process
Improvement
Patient Safety
Risk
Management
Accreditations

11. KFH-List of
Documents Folder
in All Hospital
desktops
Quality Management & Patient Safety
Hospital Orientation Program
Documents

12. Quality Management & Patient Safety
Hospital Orientation Program

13. Quality Management & Patient Safety
Hospital Orientation Program
Quality
Management
System
Documents
Control
Performance
Monitoring
Process
Improvement
Patient Safety
Risk
Management
Accreditations

14. Performance Monitors are Important Tool of
Quality Management System (QMS)
Quality Management & Patient Safety
Hospital Orientation Program

15. Types of Performance Indicators
Internal
Defined by the Organization to Control
their Processes,
Detailed, Specific,
Problems of Local Interest
Auxiliary
External
Defined by & Reported to External
Partners, to Enable surveillance.
General
Global Issue
Key (Strategic)
Quality Management & Patient Safety
Hospital Orientation Program

16. What The PIs Measure & Monitor ?
Structure
How the Processes
Are organized
(Resources)
Process
How the Activity
Is Performed
Outcome
Whether
Appropriate
Results have been
Achieved
Donabedian Triade
Quality Management & Patient Safety
Hospital Orientation Program

17. Quality Management & Patient Safety
Hospital Orientation Program
Quality
Management
System
Documents
Control
Performance
Monitoring
Process
Improvement
Patient Safety
Risk
Management
Accreditations

18. Performance Improvement
Methodology
•FOCUS–PDCA
•Lean
•SixSigma
Quality Management & Patient Safety
Hospital Orientation Program

19. F
•Find
process that
need
improvement
O
•Organize
the team who
understand the
process
C
•Clarify
the current
knowledge of
the process
U
•Understand
the causes of
variations
S
•Select
a solution for
improvement
AP
DC Do
•Develop Action Plan
•Implement Plan
Act
•To hold the gain
Check
•Confirm OutcomesAgainstPlan
•Identify Deviations
Plan
•For improvement
•Define & analyze problem
•Identify root cause
Quality Management & Patient Safety
Hospital Orientation Program

20. •Fishbone Diagram
•Pareto Chart
•The 5 Whys
•Scatter Diagram
•Failure Mode and Effects Analysis (FMEA)
Quality Management & Patient Safety
Hospital Orientation Program
Root Cause Analysis (RCA)

21. Quality Management & Patient Safety
Hospital Orientation Program
Root Cause Analysis (RCA)

22. Quality Management & Patient Safety
Hospital Orientation Program
Quality
Management
System
Documents
Control
Performance
Monitoring
Process
Improvement
Patient Safety
Risk
Management
Accreditations

23. Quality Management & Patient Safety
Hospital Orientation Program

24. Patient Safety
Patient safety was defined by the IOM as
“The Prevention of Harm To Patients.”
Emphasis is placed on the system of care delivery that
1)Prevents errors;
2)Learns from the errors that do occur;
3)Is built on a culture of safety that involves health
care professionals, organizations, and patients
Quality Management & Patient Safety
Hospital Orientation Program

25. Quality Management & Patient Safety
Hospital Orientation Program

26. Quality Management & Patient Safety
Hospital Orientation Program

27. Quality Management & Patient Safety
Hospital Orientation Program
Quality
Management
System
Documents
Control
Performance
Monitoring
Process
Improvement
Patient Safety
Risk
Management
Accreditations

28. Quality Management & Patient Safety
Hospital Orientation Program

29. Medical and Medication Errors
•Medical Errors the failure of a planned action to be
completed as intended or the use of a wrong plan to
achieve an aim.
•Medication error is "any preventable event that may cause
or lead to inappropriate medication use or patient harm
while the medication is in the control of the health care
professional, patient, or consumer.
Quality Management & Patient Safety
Hospital Orientation Program

30. Quality Management & Patient Safety
Hospital Orientation Program
Swiss Cheese Model

31. Types Incidents
NearMiss:Abouttohappenbutcaughtinthelastminute.
Occurrence/Incident:Doesn’tcauseinjury
AdverseEvent:Resultsininjury
SentinelEvent:Deathorpermanentlossoffunctionsnot
relatedtopatientillness.
It is the responsibility of all staffto report as soon as possible.
Quality Management & Patient Safety
Hospital Orientation Program

32. Occurrence Variance Report (O.V.R.)
Quality Management & Patient Safety
Hospital Orientation Program
It Is a Quality Improvement Tool

33. Quality Management & Patient Safety
Hospital Orientation Program
Quality
Management
System
Documents
Control
Performance
Monitoring
Process
Improvement
Patient Safety
Risk
Management
Accreditations

34. Accreditations
National
Accreditation
International
Accreditation
Quality Management & Patient Safety
Hospital Orientation Program
King Fahd Hospital is CBAHI & JCI Accredited

35. Role of the Staff
✓Report O.V.R.
✓Actively Follow The Policies And Procedures
✓Share In The Improvement Projects, Quality
Committees & Task Teams, etc
✓Adhere to Infection Control Measures & Bundles.
✓Follow The Safety Measures.
Quality Management & Patient Safety
Hospital Orientation Program

36. Thank You
January 2021