لخّصلي

PURPOSE

The purpose of the Hayat National Hospital- Jazan (HNH) Quality Improvement and Patient Safety Program is to describe the details associated with the Hospital-wide Quality Improvement and Patient Safety Program.2.2 QPS VISION:

To be Pioneer Hospital Providing Excellency in Healthcare Quality

2.3 OUR PRINCIPLES:

We will focus on:

2.3.1 HNH mission, vision, values, goals and objectives
2.3.2 Continuous improvement
2.3.3 Customer orientation
2.3.4 Leadership commitment
2.3.5 Empowerment
2.3.6 Focus on processes
2.3.7 Collaboration / cross-functional
2.3.8 Focus on data, scientific and statistical thinking
2.3.9 Total employee involvement, which is critical
2.3.10 Emphasizing on teamwork
2.3.11 Prevention rather than inspection

2.1 "A hospital-wide management concept and leadership commitment to provide "value" to all customers through creating an environment of continuous improvement of people skills and creating an environment of continuous improvement of processes and building excellence into every aspect of the hospital work. 2.2 Hayat National Hospital will consider that quality and patient safety will mean TWO things to us:
2.2.1 Effectiveness:- Doing the RIGHT THING (Providing right care / services truly important to the customer). 2.2.2 Efficiency:- Doing THINGS RIGHT (Providing care / services right the first time and all the time). 3.1 Freedom from accidental injury; ensuring patient safety involves the establishment of operational systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them when they occur. Hayat National Hospital will implement the International Patient Safety Goals, which are:

Goal 1 - Identify Patients Correctly
Goal 2 - Improve Effective Communication
Goal 3 - Improve the Safety of High-Alert Medications
Goal 4 - Ensure Correct-site, Correct-Procedure, Correct Patient Surgery
Goal 5 - Reduce the Risk of Healthcare Associated Infections
Goal 6 - Reduce the Risk of Patient Harm Resulting from Falls

3.2 Hayat National Hospital will establish an effective process to implement Patient Safety and create the quality and patient safety culture and to consistently monitor the activities. Patient Safety activities will involve the following:


3.3.1 To establish a mechanism on how to implement the International Patient Safety Goals. 3.3.2 To develop, review and revise policies related to International Patient Safety Goals:

3.3.2.1 Define Strategies:

3.3.2.1.1 Assign a leader for each goal. 3.3.2.1.2 Assign patient safety coordinator for each department / section. 3.3.2.1.3 Policy and Procedure for each goal, measure for each goal. 3.3.2.1.4 Improvement of Patient Safety culture in hospital. 3.3.2.1.5 Patient safety rounds. 3.3.2.1.6 Training and Education to staff. 3.3.3 To develop and oversee a framework for managing risks. 3.3.4 To identify key measures for each of the International Patient Safety Goals and measurement data is used to evaluate the effectiveness of improvement. 3.3.5 The protocols and monitoring details of each goal is explained in the attachment. Hayat National Hospital QPS Program evolves from the following organizational strategic initiatives:
4.1 Hayat National Hospital as a provider of advanced and unique health care services to the Jizan, and encourages the continuity of developing and staff training. 4.2 HNH Vision to be recognized as a referral and educational hospital applying international quality standards. 4.3 HOSPITAL BOARD STRATEGIC OBJECTIVES. Goal 1: Enhance Patient Safety Culture and Practices. Objectives:

1.1 Develop comprehensive, integrated safety Programs. 1.2 Provide orientation and training that emphasizes patient safety. Goal 2: Establish Quality Culture

Objectives:

2.1 Encourage fearless (Non-Punitive) reporting
2.2 On- going efforts to address patient safety recommendations of the Joint Commission International (JCI) and CBAHI the National Accreditation. 2.3 Conduct Root Cause Analysis for sentinel and serious adverse events. 2.4 Orientation and Training of staff in principles of quality improvement and patient safety. 2.5 Improve performance on JCI core measures

Goal 3: Improve quality of care by reducing variations in clinical Practice

Objectives:

3.1 Clinical practice guidelines. Goal 4: Improve Patient Satisfaction. Objectives:

4.1 Improve patient satisfaction scores as assessed by surveys


5.1 Criteria for Prioritization:
5.1.1 Quality Improvement Committee, through QPS manager, shall be providing appropriate resources to address the quality improvement and patient safety needs of the hospital and support the selection of measures throughout the hospital at the hospital wide level and at the department service level. 5.1.2 Selection criteria for quality improvement projects. ( See: Policy-Performance Monitoring and Data Analysis- HNH-Jz-APP-089) are as follows:
5.1.2.1 High Volume - The process occurs frequently or affects large numbers of patients. 5.1.2.2 High risk - Patient at risk for serious consequences if the process is not provided correctly in a timely manner, or based upon proper indications. 5.1.2.3 Problem Prone - The process has a history of producing problems for staff and / or patients. 5.1.2.4 High cost - The process (es) that are highly costly. 5.2 The Methodology of Improvement in Hayat National Hospital (HNH):
5.2.1 Among the many tools, the familiar approaches / models and Quality tools that will be used upon training are the FOCUS PDCA. The Performance Improvement Methodology. STEPS TO IDENTIFY AND DEFINE IMPROVEMENT OPPORTUNITIES - FOCUS
F Find - an opportunity for improvement
O Organize - a team
C Clarify - The current process
U Understand - the sources of the problem and the process variation
S Select - The improvement
STEPS FOR IMPLEMENTATION OF IMPROVEMENT OPPORTUNITIES - PDCA
P Program - the improvement
D Do - the improvement
C Check - the results
A Act - To hold the gain

5.3 Each monitoring and evaluation will evolve the dimensions of quality :

5.3.1 Appropriateness
5.3.2 Availability
5.3.3 Competency
5.3.4 Continuity
5.3.5 Effectiveness
5.3.6 Efficacy
5.3.7 Efficiency
5.3.8 Prevention and early detection
5.3.9 Respect and caring
5.3.10 Safety
5.3.11 Timeliness


6.1 The QPS program provides coordination and integration of measurement activities throughout the hospital. 6.2 The QPS Program shall focus on achieving the following:

6.2.1 Quality Healthcare. 6.2.1.1 Compliance to Patient Safety (JCI) standards. 6.2.1.2 Customer satisfaction. 6.2.1.3 Benchmark system and standard for the healthcare industry. 6.2.2 Safety

6.2.2.1 Reduced incident occurrence. 6.2.2.2 Minimized side effects and complications of treatment made to patients. 6.2.2.3 Prevention and control of infection. 6.2.2.4 Prevention and control of process hazards such as Laboratory and Radiology Safety programs. 6.2.2.5 Maximize Protection and security. 6.2.2.6 Achieve International Patient Safety Goals. 6.2.3 Process Efficiency and Effectiveness:

6.2.3.1 Implement Policies and Procedures. 6.2.3.2 Practice effective Resource Management (material, equipment, people, infrastructure, and environment). 6.2.3.3 Maintain Continuous Performance Monitoring and Improvement. 6.2.3.4 Maintain Cost efficiency
6.2.3.5 Redesign processes to improve performance (corrective and preventive measures, etc.):

6.2.3.5.1 Quality improvement principles and tools are applied to the design of new or modified processes. 6.2.3.5.2 Indicators are selected to measure how well the newly designed or redesigned process operates. 6.2.3.5.3 Indicator data are used to evaluate the ongoing operation of the process. 6.2.3.6 Good process design is:

6.2.3.6.1 Is consistent with the organization's mission and programs. 6.2.3.6.2 Meets the needs of patients, families, staff, and others. 6.2.3.6.3 Uses current practice guidelines, clinical standards, scientific literature, and other relevant evidence-based information on clinical practice and patient care. 6.2.3.6.4 Is consistent with sound business practices. 6.2.3.6.5 Considers relevant risk management information. 6.2.3.6.6 Builds on available knowledge and skills in the organization. 6.2.3.6.7 Builds on the best/better/good practices of other organizations. 6.2.3.6.8 Uses information from related improvement activities. 6.2.3.6.9 Integrates and connects processes and systems. 6.2.4 Quality Culture

6.2.4.1 Shape the Quality Culture of the organization. 6.2.4.2 Celebrate completed and effective Quality Improvement and Patient Safety projects. 6.3 OBJECTIVE OF THE PROGRAM:

The objective of Quality Improvement and Patient Safety at Hayat National Hospital is twofold:

6.3.1 The ongoing quality improvement monitoring of key indicators that represent safety, patient outcomes, and the quality of patient care, including those indicators required by regulatory and accrediting bodies - MOH, CBAHI and JCI. 6.3.2 The performance improvement activities that focus on:

6.3.2.1 High risk
6.3.2.2 High volume
6.3.2.3 High cost or
6.3.2.4 Problem-prone areas and result in measurable and sustainable improvements. The authority of the Quality Improvement and Patient Safety system is granted by the Chief Executive officer of Hayat National Hospital. The Quality Improvement and Patient Safety Program provide supports and coordination to departments/service leaders for like measures across the hospital and for the hospital's priorities for improvement. The Quality Improvement and Patient Safety Program implements a training program for all staff that is consistent with staff's roles in the quality improvement and patient safety program. The Quality Improvement and Patient Safety Program is responsible for the regular communication of quality issues to all staff. 8.1 Quality Improvement and Patient Safety Program at Hayat National Hospital involves all hospital departments and services; and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. 8.2 Each year, the Hospital Leadership and clinical Leadership in collaboration with other departments like Human Resources, Information Technology and Finance will select and develop quality improvement and patient safety indicators and areas of quality performance improvement focus for the fiscal year. 8.3 The QPS program focuses on these areas:

8.3.1 Monitoring quality indicators:

8.3.1.1 Oversight of JCI & CBAHI quality monitors as identified by hospital leadership and other indicators. 8.3.1.2 Oversight of adverse event reports. 8.3.2 Teaching staff the quality improvement techniques. 8.3.3 Serving as a consultant to departments and teams engaging in quality improvement:
8.3.4 Coordination and support of quality teams or circles. 8.3.5 Oversight of special quality improvement activities. 8.3.6 Providing statistical support. 8.3.7 Continuous improvement. 8.3.8 Patient and employee satisfaction
8.3.9 Special quality improvement activities like in medication management and use. 8.3.10 Professional / provider credentialing. 9.1 Documentation: where programming and gap analysis occurs and the required documents (P& P, Programs ...etc.) to guide the implementation of the desired improvement are developed and approved. 9.2 Communication: orientation and training of staff. 9.3 Implementation of the required improvement and reporting compliance. 9.4 Monitoring, analysis and evaluation through performance measures. 9.5 Continuous improvement and sustenance of achievements. 10.1 QPS Committee:

10.1.1 The QPS Committee is chaired by the Chief Executive Officer CEO and is composed of the following:

10.1.1.1 QPS Manager,
10.1.1.2 Chief Medical Officer,
10.1.1.3 Chief Nursing Officer
10.1.1.4 Chief of Pharmacy
10.1.1.5 PCI Manager
10.1.1.6 Manager of Facility Management and Safety,
10.1.1.7 Head of Surgery
10.1.1.8 Head of Internal Medicine, Anesthesiology, Radiology, and Laboratory,
10.1.1.9 The Assistant for Administrative and Financial Affairs
10.1.1.10 Head of Human Resources. 10.1.2 The QPS Committee has ultimate authority and responsibility for the quality of care and service delivered by Hayat National Hospital. The QPS Committee is responsible for the direction and oversight of the QPS Program and delegate's authority to the QPS Department. 10.1.3 The QPS Committee is responsible for the generation, implementation and ongoing monitoring of the QPS Program. Through the QPS Department, the QPS Committee recommends policy decisions, analyzes and evaluates the progress, results and outcomes of all quality improvement activities, institutes needed actions and ensures follow-up. 10.1.4 QPS committee is the strategic and operational think tank for the QPS Department. The QPS Committee select, prioritize, and recommend hospital-wide monitors, review data on adverse events and make recommendations for improvement, review update tables and graphs on all monitors and discuss performance status, recommends the formation of quality circles for improving performance on a given monitor, recommend the processes for a Failure Mode and Effect Analysis (FMEA), develop strategies to ensure monitoring is being done at the department level, etc. 10.1.5 The QPS Committee sets the strategic direction for all quality activities at HNH. The QPS Committee receives reports from the QPS Department, advises and directs the QPS Department on the focus and implementation of the QPS Program. The QPS Committee reviews data from QPS activities to ensure that performance meets standards and makes recommendations for improvements to be carried out by the QPS Department and designated groups. 10.1.6 The Hospital Director is responsible to program, design, implement and coordinate QPS activities. His responsibilities include but are not limited to:

10.1.6.1 Demonstration and promotion of the QPS Program through communication, practice, and resource allocation. 10.1.6.2 Achievement of organizational goals. 10.1.6.3 Direct involvement in QPS activities to include:

10.1.6.3.1 Analysis of QPS data. 10.1.6.3.2 Serve as chair for QPS Committee. 10.1.6.3.3 Ensure effectiveness of QPS activities and allocate resources. 10.1.6.3.4 Ensure participation of all HNH staff. 10.1.6.3.5 Reports QPS activities to governance. 10.2 Quality Improvement and Patient Safety Department (Program Core Team)

10.2.1 The QPS Department is headed by the QPS Director and is comprised of appropriately credentialed registered nurses and health professionals. 10.2.2 Responsibilities of QPS Department include, but are not limited to:
10.2.2.1 Coordination of clinical and service quality measurement and periodic reporting to the QPS Committee. 10.2.2.2 Management of QPS projects, studies and interventions, preparation and submission of QPS documents and reports, and recommendations to the QPS Committee. 10.2.2.3 Formation and management of special Quality Improvement Teams (QIT). 10.2.2.4 Identification of opportunities for improvement by providing assistance in monitoring and data analysis of clinical and satisfaction data. Assist in designing data collection forms. 10.2.2.5 Ensuring compliance with HNH and regulatory standards. 10.2.2.6 Monitoring QPS preparations for future accreditation. 10.2.2.7 Development, adoption, and implementation of relevant health education programs. 10.2.2.8 Development, maintenance and implementation of QPS procedures. 10.2.2.9 Maintenance of necessary QPS resources. 10.2.2.10 Responds to the medical staff when requesting technical assistance in collecting physician specific data for annual performance evaluations. 10.3 QPS Manager Responsibilities :

10.3.1. Basic Function

10.3.1.1. Develops a standardized Quality Improvement and Patient Safety program to ensure compliance of the hospital processes to meet it mission and strategic priorities. 10.3.1.2. Oversight and guide the implementation of hospital quality improvement and patient safety program, selects and supports qualified staff for the program and supports those staff with quality and patient safety responsibilities throughout the hospital. 10.3.1.3. Liaises with the external assessment body on all matters related to the external accreditation process. 10.3.1.4. Establishes and maintains tracking and monitoring system for health quality improvement activities according to accreditation standards, policies and procedures; and contractual agreements. 10.3.1.5. Report to top management whether clinical and managerial regarding hospital performance and unusual events for any improvement regarding high risk, high volume, high cost, and problem prone events. 10.3.1.6. Researches and develops performance measurement including process and outcome studies to assess and improve the quality level. Plans, organizes and manages the design, development and analysis of many aspects to the care services. 10.3.1.7. Develops and implements performance improvement activities concerning with the utilization management and risk management. 10.3.1.8. Prepares, compiles, reviews and submits monthly and quarterly reports for quality and patient safety committee meetings. 10.3.1.9. Participates in the development, review and updating of policies and procedures. 10.3.1.10. Develops and analyzes reports to monitor and evaluate quality performance in meeting established goals related to quality improvement plan and accreditation requirements. 10.3.2. Organizational Responsibilities:

10.3.2.1. Guides the implementation of the Quality Improvement and Patient Safety program. 10.3.2.2. Manages the activities needed to carry out an effective program on continuous quality improvement and patient safety within the hospital. 10.3.2.3. Ensure that the performance activity of the quality program is reviewed at planned intervals to ensure its continuing suitability, adequacy and effectiveness, thus assessing opportunities for improvement and the need for changes to the quality program. 10.3.2.4. Ensure that Quality Objectives are set by top management for measuring the performance program and these are regularly reviewed. 10.3.2.5. Analyzes data on the effectiveness of the quality program and evaluate where continual improvement of the program can be made. This shall include data generated as a result of monitoring and measurement and from other relevant sources. 10.3.2.6. Provides guidance and training to all hospital leaders and staff. 10.3.2.7. Selects a multi-disciplinary, qualified and capable staff to coordinate with the implementation of the program. 10.3.2.8. Support these staff with information and assistance needed to sustain implementation. 10.3.2.9. Promotes quality achievement and performance improvement throughout the organization. 10.3.2.10. Advocates compliance of the hospital with national and international standards and legislation. 10.3.2.11. Monitors performance by gathering relevant data and producing statistical reports. 10.3.2.12. Collates and analyzes performance data and charts against defined parameters. 10.4 Department Specific QPS Designee:

10.4.1 Identified person to be responsible in coordinating the QPS activities and teams of the department. The Department Specific QPS Designee is chosen based on the following:

10.4.1.1 Has willingness and determination to become the QPS Designee of the department. He/she has inherent leadership in the department. 10.4.1.2 Has attention to details and data collection, tabulation and presentation. 10.4.1.3 Computer literate. 10.4.1.4 Able to communicate and coordinate to his/her department the QPS program of the entire hospital. 10.4.1.5 The Department specific Quality Designee shall report to the QPS Manager regarding implementation of QPS activities in his/her department. 10.4.1.6 The Quality Improvement Team/s of the department report to the QPS Coordinator of the QPS department. 10.4.1.7 The QPS Designee per department shall oversee and monitor the progress of the Quality Improvement activities and teams and shall report the progress to the QPS Core team. 10.4.1.8 Coordinates and communicates to the QPS Core team the needed trainings of the department regarding QPS. 10.4.1.9 May train his/her department's Quality Improvement Team members if needed. 10.4.1.10 Directs and performs the data collection in his/her department. 10.5 Quality Improvement Teams (QIT):

10.5.1 Quality Improvement Teams (QIT) are special working teams identified by the QPS Committee, to address specific areas, in conjunction with the QPS Program and performance to the identified QPS indicators. Based on the topic or the issue, certain specialties shall be appointed, and the QPS Committee as needed shall designate the members of the Quality Improvement Team. These QIT shall only exist for their specified assignment, after which the team is disassembled. 10.5.2 To be managed by the QPS Department, the QIT shall assume the following responsibilities:

10.5.2.1 Collect data that will be used to report the level, trend and comparative performance of the concerned department's Productivity Targets. 10.5.2.2 Report such level, trend and comparative performance to the QPS Department on a periodic basis. 10.5.2.3 Investigate the issue and make necessary recommendations to improve the department performance based on the level, trend and comparative performance of:

10.5.2.3.1 Central Board for Accreditation fo Health Institutions( CBAHI) and Joint Commission International (JCI) Indicators -Quality Parameters and Reporting System of this Program and;
10.5.2.3.2 Productivity Targets of the work unit. 10.5.2.3.3 Utilize systematic problem solving and decision-making tools to investigate the issue, and define and implement appropriate corrective and preventive measures. 10.5.2.4 Designated General Committees will be ensured to effectively and collaboratively function according to the formation order and the Terms of Reference for each. These committees are:
10.5.2.4.1 Administrative Executive Committee. 10.5.2.4.2 Quality Improvement & Patient Safety Committee
10.5.2.4.3 Medical Record s Review Committee. 10.5.2.4.4 Infection Prevention and Control
10.5.2.4.5 Utilization Review Committee. 10.5.2.4.6 General Safety Committee. 10.5.2.4.7 Patient's Rights & Complaint. 10.5.2.4.8 Cardiology Pulmonary Resuscitation (CPR) Committee. 10.5.2.4.9 Pharmacy & Therapeutic. 10.5.2.4.10 Morbidity & Mortality Committee. 10.5.2.4.11 Intensive Care Unit (ICU). 10.5.2.4.12 Operating Room Committee. 10.5.2.4.13 Medical Executive Committee
10.5.2.4.14 Blood Utilization Review & Tissue Review Committee
10.5.2.4.15 Credentialing Privileging & Peer Review Committee
10.5.2.4.16 Ethics Committee. 10.6 HNH QPS Workforce:

10.6.1 All HNH personnel have a key role in quality improvement and the execution of the QPS Program, thus they are considered the HNH QPS Workforce. 10.6.2 The HNH QPS Workforce shall participate in interdepartmental activities but also focus on intradepartmental opportunities to improve effectiveness or efficiency. 10.6.3 The HNH QPS Workforce shall take part in identified QPS projects. 10.6.4 It is the responsibility of the HNH QPS Workforce to get familiarized with the latest hospital standards being implemented in Hayat National Hospital. This can be made possible by attending required orientation/training sessions, reading and internalizing the most updated department quality manual, participating in QIT
activities, reading bulletin boards and posters, and providing improvement suggestion through their departmental meetings which is reported through department Quality Designees to QPS Department. 10.6.5 The HNH QPS Workforce is composed of the following:

10.6.5.1 Medical Staff - composed of residents, specialists and consultants. 10.6.5.2 Nursing Staff - composed of all registered nurses
10.6.5.3 Allied healthcare Professional Staff - composed of all allied professionals including nursing aides. 10.6.5.4 Employees of Outsourced Service Providers - composed of all employees of outsourced service providers, including On-the-Job, Kitchen Staff, Construction Workers, Biomedical Equipment Engineers, security guards and janitors. 10.7 Quality Measurement and Improvement Activities:

To meet the purpose, goals, and scope of the QPS Program, the activities shall be focused in the following areas:

10.8 Monitoring the outcomes of care against national and international practice standards:

10.8.1 The quality indicators are the measures used to determine over time HNH performance of structures, processes and outcomes. 10.8.2 The organization's leaders will identify targeted areas for measurement and improvement. The measurement is part of the quality improvement and patient safety program. The results of measurement are communicated to the oversight mechanism and periodically to the organizational leaders and the governance structure of the organization. 10.8.3 Consideration must be given to the following prioritization and selection criteria when developing indicators;

10.8.3.1 High Volume
10.8.3.2 High risk
10.8.3.3 Problem Prone
10.8.3.4 High cost

10.8.4 The HNH Leadership identifies key measures or indicators to monitor HNH clinical and managerial structures, processes, and outcomes and the International Patient Safety Goals. 10.8.5 Due to inherent limitation in resources, the QPS Committee shall choose which clinical and managerial areas and outcomes are most important to monitor based on HNH goals and objectives. 10.8.6 For each of these areas, the QPS Committee shall decide:

10.8.6.1 The process, procedure, or outcome to be measured;


10.8.6.2 The availability of "science" or "evidence" supporting the measure;
10.8.6.3 How measurement shall be accomplished;
10.8.6.4 How the measures fit into HNH QPS Program; and
10.8.6.5 The frequency of measurement.10.9.2.3 Sentinel Event: A "Sentinel Event" is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof, not related to the natural course of a patient's illness or underlying condition. (HNH-JZ-APP-003: Sentinel Events and Root Cause Analysis.)

10.9.2.4 Unanticipated death unrelated to the natural course of the patient illness or underlying condition. 10.9.2.5 Major or permanent loss of function unrelated to the natural course of the patient's illness or underlying condition. 10.9.2.6 Wrong site, wrong procedure and wrong patient surgery. 10.9.2.7 There is a defined process to document, analyze and report the adverse event, near miss and sentinel events. 10.9.2.8 Patient education regarding their role in receiving safe and error-free healthcare services. 10.9.2.9 Education of providers regarding improved safety processes in their practice. 10.9.2.10 Dissemination of information regarding important safety activities. 10.9.2.11 Evaluation for safe clinic environments. 10.9.2.12 Patient education regarding safe practices at home. 10.9.2.13 Intervention for identified safety issues. 10.9.2.14 Collection of data regarding hospital activities relating to patient safety. 10.10 Evaluation of the continuity and coordination of care through analysis of data. 10.10.1 Improvement of transition of care processes. 10.10.2 Medical record review. 10.10.3 Tracking quality of care issues progress on the planned collections of measures data for the priorities selected, including adverse outcomes and sentinel events. 10.10.4 Focused health management programs. 10.10.5 Patient and practitioner complaint and appeal review. 10.10.6 Evaluation of all satisfaction measures for availability and access to care. 11.1 Step 1 - Performance Review Measures:

11.1.1 Key Measure or Indicator shall be selected and assessed through the following:

11.1.1 Describe the Indicator
11.1.2 Describe the importance/rational of the Indicator
11.1.3 Determine availability of data to effectively define the Indicator
11.1.4 Describe the numerator for the Indicator
11.1.5 Describe the denominator for the Indicator

11.1.2 Data for the Key Measure shall be collected through the following:

11.1.2.1 Describe the source of data
11.1.2.2 Describe the collection method
11.1.2.3 Describe the frequency of data collection
11.1.2.4 Tabulate the data
11.1.2.5 Establish the targets

11.1.3 Clinical and Managerial Key Measures Monitoring, as part of the QPS program:

11.1.3.1 Shall include the areas identified in the JCI standards. 11.1.3.2 Shall be used to study areas targeted for improvement. 11.1.3.3 Data shall be used to monitor and evaluate the effectiveness of improvements. 11.1.3.4 Clinical Key Measures Monitoring shall include the following:

11.1.3.4.1 Aspects of patient assessment
11.1.3.4.2 Aspects of laboratory services
11.1.3.4.3 Aspects of radiology services
11.1.3.4.4 Aspects of surgical procedures
11.1.3.4.5 Aspects of antibiotic and other medication use
11.1.3.4.6 Monitoring of medication errors and near misses
11.1.3.4.7 Aspects of anesthesia and sedation use
11.1.3.4.8 Aspects of the use of blood and blood products
11.1.3.4.9 Aspects of availability, content, and use of patient records
11.1.3.4.10 Aspects of infection control, surveillance, and reporting. 11.1.4 Managerial Key Measures Monitoring shall include the following:

11.1.4.1 Procurement of routinely required supplies and medications essential to meet patient needs. 11.1.4.2 Reporting of activities as required by law and regulation

11.1.4.2.1 Risk management
11.1.4.2.2 Utilization management
11.1.4.2.3 Patient and family expectations and satisfaction
11.1.4.2.4 Staff expectations and satisfaction
11.1.4.2.5 Patient demographics and clinical diagnoses
11.1.4.2.6 Financial management
11.1.4.2.7 Prevention and control of events that jeopardize the safety of patients, families, and staff,
11.1.4.2.8 International Patient Safety Goals (IPSG). 11.1.4.2.9 Departmental performance measures as needed. 11.1.4.3 The results of the Quality Indicator or Key Measures Monitoring shall be communicated by the QPS Department to the QPS Committee and periodically to the Leaders and Governance of the hospital. 11.2 Step 2 - Performance Analysis:

11.2.1 Data shall be aggregated, analyzed, and transformed into useful information. 11.2.2 Individuals with appropriate clinical or managerial experience, knowledge, and skills shall participate in the analysis process. 11.2.3 Statistical tools and techniques shall be used in the analysis process when appropriate. 11.2.3.1 Graph the data using trend lines. 11.2.3.2 Determine the variance of the data. 11.2.3.3 Determine the reason for the variance. 11.2.3.4 Describe the analysis of graph. 11.2.4 The frequency of data analysis shall be defined as appropriate to the process under study, shall meet the requirements of the organization. This shall be accomplished according to the timetable defined by the QPS Committee. 11.2.5 Benchmarking activities of known Best Practices shall be done, and with other similar organizations when possible. 11.2.6 Intense analysis will be performed to determine where best to focus improvement in particular, when levels, patterns, or trends vary significantly and undesirably from;

11.2.6.1 What was expected;
11.2.6.2 that of other organizations; or
11.2.6.3 Recognized standards. 11.2.7 An analysis is conducted for the following:

11.2.7.1 All confirmed transfusion reactions, if applicable to the organization. 11.2.7.2 All serious adverse drug events, if applicable and as defined by the organization. 11.2.7.3 All significant medication errors, if applicable and as defined by the organization. 11.2.7.4 All major discrepancies between preoperative and postoperative diagnoses. 11.2.7.5 Adverse events or patterns of adverse events during moderate or deep sedation and anesthesia use. 11.2.7.6 Other events, such as infectious disease outbreaks. 11.2.8 Data Validation:

11.2.8.1 Data validation is an important tool for understanding the quality of the quality data and for establishing the level of confidence decision makers can have in the data. Data validation becomes one of the steps in the process of setting priorities for measurement, selecting what is to be measured, selecting and testing the measure, collecting the data, validating the data, and using the data for improvement. 11.2.8.2 The essential elements of a credible data validation process include the following:

11.2.8.2.1 Re-collecting the data by a second person not involved in the original data collection. 11.2.8.2.2 Using a statistically valid sample of records, cases, and other data. A 100% sample would only be needed when the number of records, cases, or other data is very small. 11.2.8.2.3 Comparing the original data with the re-collected data. 11.2.8.2.4 Calculating the accuracy by dividing the number of data elements found to be the same by the total number of data elements and multiplying that total by 100. A 90% accuracy level is a good benchmark. 11.2.8.2.5 When data elements are found not to be the same, noting the reasons (for example, unclear data definitions) and taking corrective actions. 11.2.8.2.6 Collecting a new sample after all corrective actions have been implemented to ensure the actions resulted in the desired accuracy level. 11.2.8.3 Data validation is most important when:

11.2.8.3.1 A new measure is implemented (in particular, those clinical measures that are intended to help an organization evaluate and improve an important clinical process or outcome). 11.2.8.3.2 Data will be made public on the organization's Web site or in other ways. 11.2.8.3.3 A change has been made to an existing measure, such as the data collection tools have changed or the data abstraction process or abstractor has changed;
11.2.8.3.4 The data resulting from an existing measure have changed in an unexplainable way
11.2.8.3.5 The data source has changed, such as when part of the patient record has been turned into an electronic format and thus the data source is now both electronic and paper; or
11.2.8.3.6 The subject of the data collection has changed, such as changes in average age of patients, co-morbidities, research protocol alterations, new practice guidelines implemented, or new technologies and treatment methodologies introduced. 11.3 Step 3 - Performance Improvement Options:

11.3.1 The organization shall program and implement improvements using a consistent process selected by the leaders. 11.3.2 The organization shall document the improvements achieved and sustained. 11.3.3 The priority areas identified by the leaders shall be included in the improvement activities. 11.3.4 Human and other resources shall be assigned or allocated. 11.3.5 Changes shall be programmed and tested. 11.3.6 Changes shall be implemented. 11.3.7 Data shall be available to demonstrate that improvements are effective and sustained. 11.3.8 Policy changes necessary shall be made. 11.3.9 Successful improvements shall be documented. 11.3.10 Root Cause Analysis Tools shall be used to identify cause of the problem or sentinel event. Root cause analysis focuses on processes that have failed and addresses the question: What went wrong? 11.3.11 Root Cause Analysis (RCA) is a process for identifying the basic or causal factor(s) that underlie variation in performance including the occurrence or possible occurrence of sentinel event. 11.3.12 Root causes are classified as:

11.3.12.1 Common cause is the way the process is designed. Common cause is a cause that is the baseline, inherent in the system or process, explains what is going on and no need for intense analysis. 11.3.12.2 Special cause is unusual circumstances that occur in the process. It is attributed as a human error/ mechanical malfunction and needs an intensive analysis. 11.3.12.3 Criteria for acceptable Root Cause Analysis are;
11.3.12.4 Focus on systems and processes. 11.3.12.5 Identify both special and common causes in processes. 11.3.12.6 Repeatedly dig deeper by asking "why"
11.3.12.7 Identify changes that can be made in systems and processes to reduce risk of reoccurrence.They shall create an Annual Calendar of Activities where all quality improvements and patient safety activities per year will be listed and budgeted accordingly, subject to the approval of the Executive Committee.The Quality Improvement and Patient Safety Manager, in partnership with the Department head, shall create an Annual Calendar of Quality Improvement and Patient Safety Activities with proposed budget for each activity.11.5.3.4 Evaluation of the effectiveness of QPS activities in generating measurable improvements in the care and service provided to patients through:

11.5.3.4.1 Organizations of multi-disciplinary teams to analyze service and process improvement opportunities, determine actions for improvement, and evaluate results.14.1 Reporting Mechanism for Events or Incidences:

14.1.1 HNH provides for the integration of event reporting system safety culture measures; facilitate integrated solutions, improvements and takes action to eliminate the cause of non compliance to its patient safety standards or non conformities in order to prevent recurrence.10.9.2 Adverse event reporting and analysis including sentinel events and near misses:

10.9.2.1 Adverse Events: Are unexpected incidents, therapeutic misadventures, iatrogenic injuries or other adverse occurrences directly associated with care or services provided.11.7 Proactive Risk Reduction:- is a method for evaluating a high risk process to identify where and how it might fail and to assess the relative impact of different failures, in order to identify the parts of the process that are most in need of change;

11.8 Proactive risk-reduction focuses on processes that are at risk of failing, resulting serious consequences, and addresses the question: What could go wrong?12.2 Design of Clinical Practice Guidelines (CPGs):

12.1 Hayat National Hospital ensures that workforce with responsibility to design clinical practice guidelines competent to achieve design requirements and are skilled in applicable tools and techniques.12.2 Hayat National Hospital establishes and maintains documented procedures for identifying training needs and achieving competence for all workforce performing QPS activities.11.3.12.8 Categories of Root Causes
11.3.12.9 Leadership
11.3.12.10 Environment
11.3.12.11 People/Staff
11.3.12.12 Processes
11.3.12.13 Equipment and supplies
11.3.12.14 Information management and communication
11.3.12.15 Sentinel event requires intensive analysis and requires formation of Quality Improvement Team (QIT).11.9.1 Failure Mode and Effect Analysis (FMEA) is a method to evaluate processes for possible failures and to prevent them by correcting the processes proactively rather than reacting to adverse events after failures have occurred.These details include the scope, structure, process, roles and responsibilities, and guiding principles used by Hayat National Hospital-Jazan for quality and patient safety and performance improvement activities that support safety, patient outcomes and the quality of patient care.10.8.6.6 The QPS Committee/Department shall aggregate and analyze data in the organization using identified benchmarking methodologies, statistical tools and techniques, at a defined frequency.10.9.2.2.1 Medication near miss
10.9.2.2.2 Non medication near miss
10.9.2.2.3 All Near-miss events are to be reported to QPS department through OVR and Medication near-misses are
10.9.2.2.4 Reported to pharmacy (HNH-JZ-APP-004: Occurrence Variance Reporting System).11.5 Utilization of multi-disciplinary (Quality Improvement Teams) to address process improvements that can enhance care and service:

11.5.1 Review of practitioner surveys and proposed activities for improvement.11.5.4.1 Hospital and clinical leaders use clinical guidelines and pathways to guide patient care processes and to standardize care processes, reduce risk within care processes, especially those associated with critical decision steps, and to provide clinical care in a timely, effective manner using available resources efficiently.13.4 Monitoring and Measurement Tools / Evaluation Tools:

13.4.1 Patient Satisfaction:- As one of the measurement of the performance of the Quality Improvement and Patient Safety, HNH monitors information relating to patient perception and experience as to whether the hospital meets patient safety standards.13.4.3 Results of tracer methodologies and surveys shall be communicated to all hospital staff or clinical departments and these shall be the basis in selecting indicators they want to propose to the QPS Department.14.1.20 The results of the Performance Key Measures / indicators / Measures are reported quarterly to the Governance body by the CEO and at least once every three month, the quality report to governance includes:

14.1.20.1 The number and type of sentinel events and associated root causes.14.22 HNH shall ensure that appropriate communication processes and tools are established within the organization, and that communication takes place regarding the implementation, monitoring and effectiveness of the QPS program.The objectives of this initiative are to:

15.1 Recognize and appreciate those who participated in the Quality Improvement and Patient Safety activities by providing them the opportunity to make presentations;

15.2 Convince the employees that Quality Improvement and Patient Safety Activities can assist the hospital in solving work related problems.2.1 QPS MISSION:

In consistence with HNH Mission the Quality Improvement and patient safety department is committed to raise and maintain the quality culture at all hospital departments by implementing nationally and internationally recognized.11.9.6.8 Step 8 - Pilot Testing the improvement


12.1 Hayat National Hospital shall:

12.1.1 Determines the necessary competence for workforce performing QPS activities.12.1.4 Ensures that its workforce is aware of the relevance and importance of their activities and how they contribute to the achievement of the quality objectives.12.3 Employee Motivation and Empowerment:

12.3.1 Hayat National Hospital has a process to motivate employees to achieve quality objectives, and create an environment to continuous improvement.14.1.3 HNH documents, records or reports any incidences or events like adverse events, near misses and sentinel events through the Occurrence Variance Report (OVR) form.14.1.4 The Occurrence Variance Report Form contains the criteria for Sentinel Events, Adverse events and Near Misses, problem description or complaint and the containment action done if necessary.14.22.14 Leadership has ensured that appropriate communication processes are established within the whole hospital and that communication takes place regarding the effectiveness of the Quality Improvement and Patient Safety cycle.16.5 Budget:-Funds necessary for improvement activities identified will be discussed, prioritized by the QPS committee and forwarded to the Administrative Executive Committee for approval and then to the hospital director for final approval.In the succeeding years, when the program is fully functioning, budgets will be requested on an annual basis, based on the results of quality improvement and patient safety monitoring, each department shall determine its required resources for quality improvement and patient safety.11.5.3 Ensure that medical records comply with standards of structural integrity and contain evidence of appropriate medical practices for quality care by:

11.5.3.1 Review of medical record audit results and corrective actions.11.5.4.3.2 Reducing risk within care processes, especially those associated with critical decision steps
11.5.4.3.3 Providing clinical care in a timely, effective manner using available resources efficiently.11.9.6.6.1 Calculate the RPN for each failure mode:
11.9.6.6.2 Multiply the scores for each of the three factors:
e.g 3X5X5 = 75 RPN
Highest possible score is 1000

11.9.6.6.3 Add RPN for each failure mode to derive the total score for the process.All important announcements, memos, process changes or revisions, policies & procedures are posted at the bulletin boards per department.15.3 Obtain feedback on the problems faced in the implementation of Quality Improvement and Patient Safety Activities in the hospital with the view to improve the effectiveness of the program.15.5 Internally during the Quality day Celebration, awards are granted for the following activities:

15.5.1 Individual award:- To a member who generates the largest number of Quality Improvement and Patient Safety Activities within the year.Other hospital staff participating in quality improvement projects and members of hospital wide committees and quality coordinators in the department, will be granted time to participate in the different activities and to attend the training activities in quality and patient safety.10.8.6.7 Security and Confidentiality of all Data are maintained
When are used for external data base
10.8.6.8 List of Quality Indicators (Key Measures), see Attachment.10.9.1 Evaluation of pharmacy data for provider alerts about drug interactions, recall, and pharmacy over and under-utilization.10.9.2.2 Near-miss - Any process variation that did not affect an outcome but for which a recurrence carries a significant chance of a serious adverse outcome.11.5.3.3 Oversight of patient satisfaction measurement and improvement activities:

11.5.3.3.1 Review of all sources of patient satisfaction information.11.5.4.2 Clinical Practice Guidelines - are a systematically developed statement designed to assist practitioner and patient to make decisions about appropriate healthcare for specific clinical circumstances.11.5.4.3 The goals of the hospital in developing Clinical Practice Guidelines and are:

11.5.4.3.1 To standardize clinical care processes.11.6 Clinical Practice Guidelines (CPGs) are:

11.6.1 Selected from among those applicable to the scope of service of the hospital.This emphasis on prevention may reduce risk of harm to both patients and staff (from the Institute of Healthcare Improvement).11.9.6 The steps in conducting Failure Mode and Effect Analysis (FMEA) are:

11.9.6.1 Step 1 - Select a Process for improvement.12.4 The HNH QPS Workforce shall be required to undergo the following modules:

12.4.1 Quality Improvement and Patient Safety.14.1.9 Root cause identification for sentinel events or adverse events and improvement action program is done within 15 calendar days & finalize it within 30 days.14.1.18 If the event/incident is a Sentinel event then intensive analysis is required and the QPS Manager shall immediately inform the Hospital Director or the Director on duty to decide to form a task force to perform root cause analysis.The following are the major communication strategies:

14.22.1 Communication Channels for Leadership
14.22.2 Policies and procedures.This procedure is applicable in managing all changes or revisions in the hospital policies, procedures, processes, forms, check list and work instructions.14.22.12 Managers with responsibility and authority for corrective actions are promptly informed of processes or procedures that do not conform to patient safety standards.14.22.13 All processes and procedures across all shifts are staffed with personnel in charge of, or delegated responsibility for ensuring uniform and safe care processes.Necessary equipment and resources (computers, software, data analysis programs, office equipment and stationary will be provided to QPS office as needed.10.9.2.1.5 Adverse events or patterns of adverse events during moderate or deep sedation and anesthesia use.11.4.2.4 There shall be a process using a proactive risk reduction tool at least annually on one of the priority risk processes and it is documented.11.9.6.5 Step 5 - Assign Risk Priority Numbers:

11.9.6.5.1 Assign a risk priority number (1-10) for each failure mode


11.9.6.5.2 RPN is based on an analysis of the following 3 factors.11.9.6.5.2.2 Likelihood of detection: If this failure mode occurs, how likely is it that the failure will be detected?Workforce performing specific tasks are qualified and certified, as required;


12.2.1 Staff members participate in quality and patient safety training as part of their regular work assignment.The process includes the promotion of Quality Improvement and Patient Safety awareness throughout the whole organization.12.4.5 The HNH Problem Solving Tools

12.4.6 HNH QPS Workforce Training Program (see attachment).13.4.2 Medical Records Review:- Is a data collection method to identify clinical documentation problems that do not meet the patient safety standards, policies and procedures.All hospital leaders are given an electronic email by the hospital for faster and more efficient communication channel.(Hospital Policy - Information Privacy, Confidentiality, Security and Data Integrity - HNH-JZ-IDPP-MRD-250).The governing body quarterly receives, and acts on reports of the quality and patient safety program, including reports of adverse and sentinel events.In addition the Quality Management and Patient Safety Program describe specific quality objectives for HNH-Jazan for the fiscal year.Analysis is conducted on the following:

10.9.2.1.1 All confirmed transfusion reactions.10.9.2.1.4 All major discrepancies between preoperative and post operative diagnoses.This is any situation (where medical error including medications but not exclusive to medications) that an error is about to be committed but does not actually occur, because the mistake was understood or detected before it happened.11.4 Step 4 - Action Program Development:

11.4.1 The leaders shall;

11.4.2.1 Adopt a process by which high-risk areas in terms of patient and staff safety are identified.11.5.3.3.2 Design and evaluation of initiatives to improve satisfaction.11.5.3.4.2 Track the progress of QPS activities through appropriate QPS Committee minutes, and periodic review / update of the QPS Program.11.5.4 Development of clinical practice guidelines to guide and standardize patient care processes.Following is the definition of clinical guideline and pathway.11.6.6 Implemented and monitored for consistent use and effectiveness.11.6.9 Clinical Practice Guidelines are updated on annual basis.11.8.1 The steps in conducting a Proactive Risk Reduction Project are:

11.8.1.1 Select and describe a high-risk process.11.9 HNH shall use the Failure Mode and Effect Tool (FMEA) as its Proactive process tool.11.9.6.4.3 Team brainstorm on failure modes and Risk Priority Number (RPN) scoring.11.9.6.5.2.1 Likelihood of occurrence: How likely is it that this failure mode will occur?11.9.6.5.2.3 Severity: If this failure mode occurs, how likely is it that harm will occur?11.9.6.5.2.4 The score assigned to each of the 3 factors is 1-10 wherein 1 is the lowest and 10 is highest.Among the many, the following are the tools that HNH is using:
13.1 Data Gathering & Presentation Tools:

13.1.1 Check lists.13.3 Improvement Tools / Corrective / Preventive Actions Tools:

13.3.1 Root Cause Analysis.14.1.2 Corrective actions are appropriate to the outcome or effects of the non compliance encountered.14.1.12 The Department head shall affix his/her signature at the OVR form to ensure appropriate communication was done.14.1.13 The Supervisor shall submit the OVR to the QPS Manager in the QPS Department.14.1.19 It is mandatory that the Chief Executive officer (CEO) and the Chief Medical Officer (CMO) shall be informed immediately of any sentinel event that occurred in the hospital.14.1.20.3 Actions taken to improve safety in response to evens and
14.1.20.4 If the improvements were sustained.14.22.4 QPS and other hospital committee meetings

14.22.5 Communication Channels for Staff

14.22.6 Endorsement Meeting.15.4 Encourage all Quality Improvement Teams to document their improvement actions and present to the management using Storyboard.15.5.3.2 Gift




16.1 HNH ensures the confidentiality of data and records related to patients, projects under development and related service or health care information.The said calendar shall be forwarded to The Quality Improvement and Patient Safety Committee in coordination with the Quality Improvement and Patient Safety Department.The QPS program shall be reviewed annually, by the Governing Body, QPS office and the QPS Committee.10.9.2.1.3 All significant medication errors, as defined by the hospital.Intense Analysis requires Root Cause Analysis (RCA).11.4.2.3 Take action to redesign high-risk processes based on the analysis.11.5.2 Review of credentialing / re-credentialing policies and procedures.11.5.3.2 Practitioner education and corrective actions where indicated.11.6.2 Mandatory national guidelines, if any, are implemented.11.6.7 Supported by staff trained to apply the guidelines or pathways.11.6.10 Revise interventions as required based on analysis.11.8.1.4 Prioritize potential breakdowns based on severity.11.9.2 The FMEA shall be used by the Chief Medical Officer, Managing Director and the QPS Committee members.11.9.4 Process Mapping is used to define the specific activities or points per process step.11.9.6.1.2 Select a process that has high potential for failure and high likelihood of drastic consequences on patient or staff safety.11.9.6.3.2 Use value stream and process mapping to demonstrate the process.11.9.6.3.3 Develop team consensus of the process steps and sequence.11.9.6.7.1 Focus redesign efforts on the failure modes with the highest priority.13.3.2 Failure Mode and Effect Analysis (FMEA).14.1.6 HNH has a system to track the incident, event or patient problem analysis completion time.14.1.10 The witness of the incident or event shall submit the OVR to his/her supervisor.14.1.14 The QPS Manager shall screen the problem description written in the OVR as well as the containment actions written.14.1.15 The QPS Manager shall communicate with other concerned department or person for further verification.14.1.16 QPS Manager prepares all the needed information for data analysis for the QPS committee.14.1.17 The QPS committee shall identify if intensive analysis is necessary or a quick fix is appropriate.The Department head shall inform immediately the Medical and Managing Directors of the hospital.All minutes are recorded in the Minutes of the Meeting templates and shall be distributed to all concerned hospital staff.14.22.11 Clinical Practice Guidelines (CPG).These are tools to communicate all standardized care processes.The best Quality Improvement and Patient Safety Activity of the year shall be the highlight of the annual Quality Celebration held at least once a year.16.3 QPS staff has access on confidential information used for data collection and analysis.16.4 Staffing:- The QPS office will be staffed (as per the organization structure) with full time staff.10.9 Identification of Appropriate Safety and Error Avoidance.10.9.2.1.2 All serious adverse drug events, as defined by the hospital.10.9.2.2.5 Data on near misses are analyzed and actions are taken to reduce near miss events.11.4.2.2 Prioritize patient and staff safety risks at least once annually.11.6.3 Evaluated for their applicability and science.11.6.4 Adapted when needed to the technology, drugs and other resources of the organization or to accepted national professional norms.11.6.5 Formally approved or adopted by the hospital.11.6.8 Periodically updated.11.8.1.5 Identify why breakdowns could occur.11.8.1.6 Redesign process or system to minimize risk.11.8.1.7 Test, implement and monitor redesigned process/system.11.9.3 Patient Safety Committee shall identify on a yearly basis one high risk process for an FMEA.11.9.6.1.1 Always select a small focused process without a lot of sub-processes.11.9.6.2 Step 2 - Select a Team

11.9.6.2.1 Identify a team leader and facilitator.11.9.6.2.2 Engage staff who are directly or indirectly involved in the process.11.9.6.2.3 Use the same recommended approach for root cause analysis.12.1.2 Provides training or take other actions to satisfy these needs.12.1.3 Evaluates the effectiveness of the actions taken.12.4.2 The Quality Improvement Methodology.12.4.4 The Quality Improvement and Patient Safety Activity Cycle.13.1.2 Run charts/Trend charts.13.1.3 Sampling techniques.13.1.4 Pareto Analysis.13.1.6 Scatter Diagram.13.2 Data Analysis Tools:

13.2.1 Risk Stratification.13.2.2 Control chart analysis.13.2.3 Variance analysis.13.3.4 Statistical Process Control including Pre-Control Charts.13.3.5 Tracer Methodology.That is done by monthly patient surveys.14.1.11 The supervisor after taking action shall give the OVR to his/her Department head.The supervisor shall immediately inform his/her department head.14.21 Recommendations and project cost shall be approved by the board.This is a meeting done first hour per shift to communicate updates or special instructions that will be done in the next shift or for the day.This is an activity that requires all staff to attend for information dissemination.14.22.8 Bulletin board postings.14.22.10 HNH outlook facility.15.5.3 Prizes:

15.5.3.1 Certificate for each member.Final approval of the program is the responsibility of the Governing Body, QPS Committee and the Chief Executive Officer.10.9.2.1.6 Other events defined by the hospital.11.9.5 FMEA shall identify which point/s in the process might fail.11.9.6.3 Step 3 - Identify all steps in the process

11.9.6.3.1 Have team members identify all steps in the process by doing a tracer from beginning to the end.11.9.6.4 Step 4 - Identify Failure Modes and Causes.11.9.6.4.1 Identify all possible failure modes for each step in the process.11.9.6.4.2 Identify for each failure mode the likely causes for that failure.11.9.6.6 Step 6 - Evaluate the Results.11.9.6.7 Step 7 - Redesign the Process.11.9.6.7.2 Use a root cause analysis process to identify the reasons for the high priority risk points.12.1.5 Maintains appropriate records of education, training, skills, and experience.12.4.3 Policy and Procedure on Sentinel Events.13.1.5 Histogram.13.1.7 Stratification.13.3.3 Risk Assessment.13.3.6 Comparisons.13.3.7 Benchmarking.13.3.8 Peer Review.14.1.5 The witness of the incident or event shall document immediately what had happened using the OVR Form.14.1.7 Problem verification is done within hours.14.1.8 Containment action or temporary fix is done within 24 hours.14.1.20.5 Minutes of the meeting shall be published.14.22.3 Process Change Notification.14.22.7 Committee meetings, special meetings & departmental meetings.Attendance record is used to monitor the presence of all hospital staff.14.22.9 QPS Meeting Minutes.15.5.2 Team award:- which is to be given to a Quality Improvement and Patient Safety Circle who is able to:

15.5.2.1 Give the greatest impact on Quality& patient safety, Cost and Delivery.16.2 No patient identifier, specific data or information shall be given out.However, a Confidentiality Agreement Statement shall be signed by the team.11.8.1.2 Identify potential breaking/failure points.