Summary Report Feb 2022

SUMMARY REPORT as of February 2022 Nursing Department Dubai Parks Vaccination Center

28/02/2022 28/02/2022

1

1

SEHA Vaccination Center – Dubai Parks has been started in December 2020. Administration of vaccines (Sinopharm and Pfizer) to all residents and locals in the United Arab Emirates is part of the services of the center.

OVERVIEW

Aside from vaccination, a DPI and PCR also include in the scope of work/services of the Center.

The Health Care Facility Management is in adept on the operations and administration of the Vaccination Center that caters hundreds of thousands from the beginning of the Center.

• Patient-Centered Standards

CONTENTS

• International Patient Safety Goals (IPSG) • Access to Care and Continuity of Care (ACC) • Patient-Centered Care (PCC) • Assessment of Patients (AOP) • Medication Management and Use (MMU)

• Healthcare Organization Management Standards

CONTENTS

• Quality Improvement and Patient Safety (QPS) • Prevention and Control of Infection (PCI) • Governance, Leadership and Direction (GLD) • Facility Management and Safety (FMS) • Staff Qualifications and Education (SQE) • Management of Information (MOI)

International Patient Safety Goals (IPSG)

PATIENTCENTERED STANDARDS

IPSG 1: Identify Patients Correctly  Based on the initial Vaccination Center Audit of the Quality Team in the Dubai Parks Vaccination Center, 80% of physicians are compliant on the IPSG 1, the 20% observed is non-compliant.

Identify Patients with at least Two Identifiers Vaccination Nurse Physician Assessment Nurse 0

5

10

n=observation

15

20

International Patient Safety Goals (IPSG) Explain procedure to the patient/legal guardian (if minor) 20 15

PATIENTCENTERED STANDARDS

10 5

0 Assessment Nurse

Physician Non-Compliant

Vaccination Nurse Compliant

Post-Vaccination Nurse

Not Applicable

IPSG 2: Improve Effective Communication  The graph represents a compliance rate of explaining the procedure to the patient as part of the effective communication of which health education/teaching is essential.  Certain percent denotes that physicians and nurses are not giving a proper explanation to the patients.

International Patient Safety Goals (IPSG)

PATIENTCENTERED STANDARDS

International Patient Safety Goals (IPSG)

PATIENTCENTERED STANDARDS

IPSG 5: Reduce the Risk of Healthcareassociated Infections  100% of the healthcare workers and other support staff are compliant as to the adherence rate of hand hygiene practices within the facility.

Access to Care and Continuity of Care (ACC)

PATIENTCENTERED STANDARDS

Patients in the Vaccination Center  The Dubai Parks Vaccination Center and SEHA are in pursuit of a more comprehensive and integrated approach toward delivering health care specifically on vaccination and PCR services.  Our goal is to correctly match the candidates/patients’ health needs with the service available, to coordinate the services provided to the patient in the healthcare facility.  The triage process includes screening for vaccine history and present condition with regards to COVID-19 infection status and patients at risk of self-harm.  Patients are assessed and stabilized within Dubai Parks Vaccination Center capacity, before they are transferred (emergency cases i.e. anaphylactic and vaccination reactions, cardiovascular and respiratory problems), if required, based on the evaluation and recommendation of the physician on duty.

Access to Care and Continuity of Care (ACC)

PATIENTCENTERED STANDARDS

Observation Room

Access to Care and Continuity of Care (ACC)

PATIENTCENTERED STANDARDS

Transfer and Transportation of Patients  The facility will transfer patients as appropriate, by calling 998 (Ambulance). The endorsement is course through the physician on duty to the EMS team.  The patient is assessment prior to transport to ensure appropriate personnel, equipment and mode of transport is provided to ensure patient safety in accordance with the facility transport grid.

Patient-Centered Care (PCC)

PATIENTCENTERED STANDARDS

Goals:  To identify, protect and protect and promote patients’ rights, and inform patients with their rights;  Incorporate patient’s satisfaction and experience in the quality of care;  Educate staff about patient’s rights and inform patients;

Patient-Centered Care (PCC)

PATIENTCENTERED STANDARDS

 All staff members wear a badge that identifies them. Staff is taught to stop/question those who seek information they are not entitled to.  Computer access is limited to those who have been given access to information based on their assigned job and area.

Patient-Centered Care (PCC)  The facility provides education that support patient and family participation in care decisions and care process.

PATIENTCENTERED STANDARDS

 Patient and family education helps patients to participate in their care and to make informed care decisions.

Patient-Centered Care (PCC) What is the patient education process?  ASSESS patient learning needs and assess educational barriers, health education history.

PATIENTCENTERED STANDARDS

Patient-Centered Care (PCC)

PATIENTCENTERED STANDARDS

 PLAN the education o Whom to be taught? o Individualize the educational plan based on learning needs assessment, patient condition, and patients’ goals and objectives. o Select appropriate method of education (demonstration, explanation, printed material, audio-visual materials, etc.)

Patient-Centered Care (PCC)

PATIENTCENTERED STANDARDS  IMPLEMENT the education: choose the appropriate education moments, create a proper learning environment, and ensure that the staff has the knowledge, time and communication skills.

Patient-Centered Care (PCC)

PATIENTCENTERED STANDARDS

 EVALUATE the effectiveness of education (return demonstration, verbalization, needs reinforcement, etc.)  DOCUMENT in the patient’s medical record.  REASSESS / refer (consultations), as necessary.

The figure shows that 57% of “identification of the education level” of the candidates are not met and 43% “failure to identity the literacy level” and “learning preference” falls as not met by the staff nurse during the patient’s interaction.

This signifies that patients are not properly received an education/teaching specifically on the post-vaccination patient’s education.

Though, majority of the nurses identified the learning needs of the patients but failed to perform the implementation of health teaching.

Patient-Centered Care (PCC)

PATIENTCENTERED STANDARDS

Barriers to learning should be identified by the staff nurse prior to health teaching or education, however, the data shows that 86% are not compliant and failed to do so that leads to confusion and unable to understand the whole process of education.

Staff nurses must undergo a re-training or enhancement training considering the conduct of education/health teaching to the candidates or patients either individually or as a group. The figures signifies a 71% of unable to identify the method of teaching to be utilized and 57% that is not met in terms of elaboration of teaching evaluation.

Assessment of Patients (AOP)

PATIENTCENTERED STANDARDS

Point of Care Testing (POCT)  POCT refers to any testing conducted outside a lab, near the site where the patient is located by a non-lab staff.  Glucose Testing (Glucometer) is the available POCT in Dubai Parks Vaccination Center.  An annual POCT competency is done; thus, the competency was done in June 2021. 64% (n=75) are not done with the competency, this indicates to schedule a training to those who did not comply with.

Glucometer Competency

43, 36%

Done Not Done

75, 64%

Assessment of Patients (AOP) AEFI Reports 25

The chart demonstrates a higher number of recorded adverse events following immunization (AEFI) is on September 2021, which comprises of 37% from the total (N=54) reports.

20

PATIENTCENTERED STANDARDS

15

10

5

0 Sep-21

Oct-21

Nov-21

Dec-21 N

Jan-22

Feb-22

It was reduce dramatically until January 2022, but it increases 200% in the following month (February 2022) as to compare from the previous month. However, the data as to associate from the highest recorded AEFI, an 89% is the difference between September 2021 and February 2022.

Medication Management and Use (MMU)

PATIENTCENTERED STANDARDS

Medication management and use is the responsibility of all healthcare practitioners under control and supervision of pharmacy department. In the Dubai Parks, Sinopharm and Pfizer vaccines are the medications to be administered apart from anaphylactic/crash cart medications needed for emergency purposes.

Medication Management and Use (MMU)

PATIENTCENTERED STANDARDS

Medication Management and Use (MMU)

PATIENTCENTERED STANDARDS

Medication Management and Use (MMU)

PATIENTCENTERED STANDARDS

Source: Survey Readiness Handbook – Based on JCI 7th Edition Standard for Hospitals; Quality and Safety Division 2021

Quality Improvement and Patient Safety (QPS)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

The goal of the Quality Improvement and Patient Safety standard is to continuously improve patient safety and clinical care outcomes. It involves measuring the functions of important process and services, and, when indicated, identifying changes that enhance performance.

Quality Improvement and Patient Safety (QPS)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

QIPS program provides a framework to be utilized that includes:  Department-level input and participation into the quality improvement and patient safety program;  Use of objective, validated data to measure how well processes work;  Effectively using data and benchmarks to focus the programs; and  Implementing and sustaining changes that results in improvement.

Quality Improvement and Patient Safety (QPS)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Programs:  Leadership driven;  Seek to change the culture of an organization;  Proactively identify and reduce variation;  Use data to focus on priority issues; and  Seek to demonstrate sustainable improvements.

Quality Improvement and Patient Safety (QPS)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

The Dubai Parks Vaccination Center uses the PDCA Cycle (Deming Cycle) as a Performance Improvement Model.

Quality Improvement and Patient Safety (QPS)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Performance Measures (Key Performance Indicators or KPI’s)  COVID-19 Vaccination Audit Tool  Nursing Assessment and Documentation Audit  Patient Family Education and Documentation Audit  IPC Daily Audit  Hand Hygiene Monitoring  Safety Resumption Audit  IPC Resumption Audit  Flu Vaccine Compliance  COVID-19 Compliance  Staff PCR Compliance

Quality Improvement and Patient Safety (QPS)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Quality Improvement and Patient Safety (QPS)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Quality Improvement and Patient Safety (QPS)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Quality Improvement and Patient Safety (QPS)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Quality Improvement and Patient Safety (QPS)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Root Cause Analysis (RCA)  A root cause analysis (RCA) is a systematic approach to understanding the causes of an adverse event and identifying system flaws that can be corrected to prevent the error from happening again.  Focusing on system causes, rather than blame, is the central feature of root cause analysis.

Quality Improvement and Patient Safety (QPS)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Quality Improvement and Patient Safety (QPS)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Prevention and Control of Infection (PCI)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

The goal of the Dubai Parks Infection Prevention and Control (IPC) program is to identify Healthcare Associated Infection (HCAI) and to reduce the risks of acquiring and transmitting infections among patients, staff, doctors, contract workers and visitors.

The facility establishes and maintains a comprehensive IPC Program within the standards of regulatory agencies of UAE, JCI, and the recommendations of CDC and guidelines of DOH and SEHA.

Prevention and Control of Infection (PCI)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

There are 32 general support staff and 1 pharmacist from Vaccination Center who are not vaccinated by FLU, consisting of 10% from the total populace of the Center.

Prevention and Control of Infection (PCI)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

In the Field Hospital, 43% out of the total staff (N=204) are not vaccinated with FLU, despite of the campaign for the Seasonal Influenza mandatory vaccination.

Prevention and Control of Infection (PCI)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Prevention and Control of Infection (PCI)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS The figure illustrates that 60% (N=194) received booster doses and considered as FULLY VACCINATED. However, 40% (N=128) are NOT FULLY VACCINATED (with a description of “no vaccine record/receive, only 1 or 2 doses received with NO booster”).

Non-Compliant are those who are working in the General Support Services. However, 8% (n=27) from the Registration Team are not fully vaccinated with the COVID-19.

Prevention and Control of Infection (PCI) 120%

100% 80% 60% 40% 20%

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

0% Compliant Compliant

Non-Compliant Non-Compliant

Majority (96%; n=345) of the Staff in the Vaccination Center and PCR are compliant with the weekly basis of PCR-Swabbing as per mandate of the DOH / SEHA within the prescribed date set by the facility. However, there are 4% staff who are not submitting with the scheduled date as to consider as non-compliant.

Prevention and Control of Infection (PCI)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

There are 3 staff who are contracted with the COVID-19 virus based on the recent Staff PCR-Swabbing.

Prevention and Control of Infection (PCI)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

The data presented illustrates that there are 17 cases reported as positive in Rapid Antigen (Ag) testing and confirmed with RT-PCR with same results.

Prevention and Control of Infection (PCI)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Prevention and Control of Infection (PCI) 40

37 34

35 30 25 21

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

20

15 10

9

9

5 1

1

2

0

The table and graph illustrate the frequency of staff in the Dubai Parks are who contracted with the COVID-19 virus. Security and Housekeeping staff garnered the high number of cases followed by the registration team.

Prevention and Control of Infection (PCI)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Prevention and Control of Infection (PCI)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Prevention and Control of Infection (PCI)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Prevention and Control of Infection (PCI)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Prevention and Control of Infection (PCI)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Prevention and Control of Infection (PCI)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Prevention and Control of Infection (PCI)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Other Incidents include miscommunication, missing vaccine and spilling of unknown liquid in the nurse clinic.

Facility Management and Safety (FMS)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Facility Management and Safety (FMS)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Facility Management and Safety (FMS)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Facility Management and Safety (FMS)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Facility Management and Safety (FMS)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Facility Management and Safety (FMS)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Facility Management and Safety (FMS)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Facility Management and Safety (FMS)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Facility Management and Safety (FMS)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Facility Management and Safety (FMS)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Governance, Leadership and Direction (GLD) Nurse Staffing per Location as of February 2022 70

Registered Nurses

Assistant Nurses

Total

65

8

73

89%

11%

100%

50 40 30 20

NUMBER OF STAFF

60

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Total Staff 8, 11%

10

Vaccination DPI-PCR

RN

AN

63 2

1 7

0

RN

65, 89%

AN

Governance, Leadership and Direction (GLD) • TOTAL Staff: 73 nurses; (RN = 65; PN = 8) • Vaccination Center:

(RN=63; PN=1) • DPI-PCR:

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

(RN=2; PN=7) • Duty hours: • •

10 hours (Vaccination) 12 hours (PCR)

• Timing: • •

9:00AM – 7:00PM (Vaccination) 9:00AM – 9:00PM (DPI)

• Duty Day: • •

Sunday to Friday (Vaccination) Daily (DPI-PCR)

Note: Effective 01 March 2022, duty timings for Vaccination is 12 hours (from 9:00AM to 9:00PM)

Governance, Leadership and Direction (GLD)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Governance, Leadership and Direction (GLD)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

The table illustrates the overall census of vaccines administered from the commencement day of the Center (December 2020 up to January 2022).

A total of 825,546 residents received the vaccines, which 57.8% candidates took the Pfizer and 42.2% received the Sinopharm.

Governance, Leadership and Direction (GLD) Census

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Vaccine Type

Census

Pfizer

477,419

Sinopharm

348,127

TOTAL

825,546

348127

477419

Pfizer

Sinopharm

Governance, Leadership and Direction (GLD) 120000 105082 100000

87294 81288

85950

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

80000 66967

62919

60000

52770 37642

40000 20575 20000

0

37078

50715 39092 35280 33048

29876

The vaccination starts in December 2020, a total of 20,575 candidates were vaccinated and sharply increased of 76% in the following month (January 2021).

In March 2021, a total vaccination diminished in numbers due to no stocks available and in preparation for Pfizer vaccine to be administered the succeeding month (April 2021).

Governance, Leadership and Direction (GLD) 920000

900000

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

900000

Target: 74,454 (9%)

The SEHA Vaccination Center – Dubai Parks aims to reach the target or goal into 900,000 candidates to be vaccinated until the end of first quarter of 2022.

880000

860000

840000 825546 820000

A total of 825,546 candidates received vaccines both Sinopharm and Pfizer (primary doses, booster dose), of which 74,454 (9%) residents to be vaccinated for the month of March 2022.

800000

780000 Goal/Target

Total Census

A daily census should meet at least 2,400 candidates.

Governance, Leadership and Direction (GLD) 120000

Data shows that on April 2021 was the launching of Pfizer vaccine and stocks of Sinopharm was delivered. Census shows that Sinopharm census increased to 41,669 (out of 73,911) from the previous census in March 2021 (37,642) with a percentile of 52.5%.

100000

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

80000

60000

40000

20000

0 Sinopharm

Pfizer

Comparison of Pfizer and Sinopharm Vaccines Administered

However, months of May and June respectively, Pfizer census gruffly increased to 96.7% and 42.7% correspondingly as to compare the figure in April 2021. Moreover, in July 2021, a decreased in amount of Pfizer vaccine due to non-availability of stocks and it was available on the last week of July, however, it shows that again an increase of statistics were reported and consistently fluctuating until the end of December 2021.

Governance, Leadership and Direction (GLD) 60000

50000 45000

50000

40000 35000

40000

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

30000 30000

25000 20000

20000

15000 10000

10000

5000 0

0

Dose 2

Dose 1

Booster (CHO)

Booster (Reg)

Comparison of Candidates received Sinopharm Vaccines per Dose

A high volume of candidates received their 2nd dose on February 2021 and April 2021 with a frequency of 45,888 and 39,344 correspondingly. This reflects that those who received 1st dose in January 2021 (n=50,034) came after 21 days as per guidelines.

However, minimal amount of residents receiving the booster dose as shown in the graph.

GEN2 (CHO) Recombinant Vaccine started on February 2022 with a candidates vaccinated of 280.

Governance, Leadership and Direction (GLD)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

60000

60000

50000

50000

40000

40000

30000

30000

20000

20000

10000

10000

0

0

Dose 2

Dose 1

Booster

Comparison of Candidates received Pfizer Vaccines per Dose

The chart elucidates that from the start of Pfizer vaccination, a huge number of candidates received 1st dose on the months of May and June with a reference frequency of 50,825 and 50,116 correspondingly.

The 2nd dose started to increase on June 2021 (n=54,051), however, on July 2021 (n=32,202) an abrupt decrease of populace was noted due to unavailability of Pfizer stocks.

Booster dose is profoundly increasing the census from October 2021 up to January 2022.

Governance, Leadership and Direction (GLD)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Governance, Leadership and Direction (GLD) 35000

DPI & PCR started on April 2021 to accommodate residents entering Emirate of Abu Dhabi and for regular swabbing test.

32108

30000 26945

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

24671

25000

20000

18035 17970

15000

16711

13492 11881 9176

10000 6517 5000

2715 1112 1395

1300

2780

4256 1861 93

0

10

Apr-21 May-21 Jun-21 Jul-21 Aug-21 Sep-21 Oct-21 Nov-21 Dec-21 Jan-22 Feb-22 DPI

PCR

A dramatic increase in PCR testing is shown in the figure from its launching month until September 2021; however, in October 2021 an slight decrease of PCR census was recorded due to the changes of rules entering Abu Dhabi Emirate that caused gradually stopped the DPI testing.

Moreover, on the succeeding months (November and December), an increased of PCR Testing due to the demand again in entering Abu Dhabi and requirements needed in different facilities.

Governance, Leadership and Direction (GLD) 35000 32108 30000 26945

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

25000

24671

20000 18035 17970

16711

15000

13492 11881 10000

9176

PCR testing started on April 2021 as the graph shows and illustrates a dramatic increase in number until September 2021. In October 2021, there was a declined in figure due to the changes of PCR guidelines given by the UAE authority as to enter the emirate of Abu Dhabi. However, on the following month up to present, an rapid increase in quantity due to cases surge in the country.

6517

5000 2715 0

Apr-21 May-21 Jun-21 Jul-21 Aug-21 Sep-21 Oct-21 Nov-21 Dec-21 Jan-22 Feb-22

PCR

Hence, a total of 180,221 PCR testing has been recorded in Dubai Parks for a period of 10 months since it has begun.

Governance, Leadership and Direction (GLD) DPI Testing started on April 2021 and ended on October 2021 with a total candidates catered is 12,797.

5000

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

4000

4256

3000 2780

2000

1112

1000

1395

1300

1861

0 Apr-21

May-21

Jun-21

93

Jul-21

Aug-21

DPI

Sep-21

Oct-21

DPI

Moreover, in the month of August 2021 got the highest number of patients done with the DPI comprising 33.3% of the total DPI census.

Governance, Leadership and Direction (GLD)

3210

3500

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

TeleConsultation be made after 3-5 days of receiving Sinopharm vaccines ages 3-17 years. A comprehensive questions as reflected in the form thru the system be used and be recorded the pertinent data and information gathered from the parents or guardians of the minor candidate.

3000 2500

1940

2000

1252

1500

680

1000

656

922 506

500 0 Aug-21

Sep-21

Oct-21

Nov-21

Dec-21

Jan-22

Feb-22

Data shows that minimal figures have been recorded except the month of September 2021 that garnered the highest number of candidates that has been consulted via teleconference/over the phone.

Governance, Leadership and Direction (GLD) TeleConsultation Pruritus

Symptoms

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

5

Swelling

9

Induration

1

Rash

1

Pain

500

Swelling Rash

Induration

Total Cases

Redness

Pruritus

Redness

In the Classification of Symptoms at Inoculation Site (Local), pain is the most common symptoms reported by the candidates after receiving the Sinopharm vaccines.

TeleConsultation is done on the 5th day after vaccination and to identify the problems associated with the vaccination site.

A total of 500 out of 517 candidates reported of pain manifestation at the site of injection with a percentage of 96.7%.

1 Pain

Swelling and redness of the injection site have been conveyed as the succeeding manifestations or symptoms with a percentage of 1.7% and 0.96% respectively.

Governance, Leadership and Direction (GLD) 152

160 140 120

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

100 80

68

58

60

35

40 20

12

18

13 1

0

0

4

8

0

7

4

0

8

Governance, Leadership and Direction (GLD)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

The figure shows the classification of symptoms at non-vaccination site (systemic) as where the candidate experienced or encountered after receiving the Sinopharm vaccines.

The report illustrates that fever, fatigue & asthenia, and headache are the common manifestations testified by the candidates.

Medical and nursing interventions were discussed to the candidate’s parents or guardians to reduce and eradicate the symptoms occurred.

Governance, Leadership and Direction (GLD)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

A nursing audit is the process of evaluating the quality of nursing care through the review of clinical records made by healthcare professionals. In SEHA Vaccination Centre- Dubai Parks, we have a designated audit team to safeguard the quality of documentations and adherence to vaccination processes.

It was formally started on February 2021 with 2 auditors with the main purpose of reviewing the documentations of the nurses to ensure its accuracy. But before that, the nurse manager ran the report and assigned some nurses to review and fix the errors. We are doing internal audit on a daily basis following concurrent and retrospective evaluation to make sure the compliance in the nursing process is being followed.

Monthly audit review also helps us to identify the areas that needs improvement and action plan for the betterment of the nursing services.

Governance, Leadership and Direction (GLD) Nursing Documentation Errors – Vaccine Not Signed 25

From the start of the Nursing Audit, it has been noted that in April 2021 and May 2021 respectively have the highest number of Vaccines not Signed by the Nurse.

22

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

20 17 15

10

5

0 Apr-21 May-21

0

0

0

0

0

0

0

0

Jun-21

Jul-21

Aug-21

Sep-21

Oct-21

Nov-21

Dec-21

Jan-22

Vaccine Not Signed

As the succeeding months, this error to mistake has been eradicated due to the diligent monitoring and guidance of the Audit team and nursing office.

Governance, Leadership and Direction (GLD) Nursing Documentation Errors – Registration Concerns Registration concerns or issues i.e. wrong appointment is one of the common nursing documentation errors made by the registration team and in the part of the nurse, not able to recheck the appointment as being registered that cause a wrong FIN number in the documentation.

300 266 250

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

200 141

150

100

87

76

66

52 50

35

23

18

25

0

Apr-21 May-21 Jun-21

Jul-21

Aug-21 Sep-21 Oct-21 Nov-21 Dec-21 Jan-22

Registration Concerns

In June 2021, this is the month that registration concern error reached to 266 which an improvement counseling and documentation re-training were done for the staff nurses.

Governance, Leadership and Direction (GLD) Nursing Documentation Errors – Incomplete / No Documentation 200

154

150 100

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

50

49

25

0 Apr-21

May-21

Jun-21

0

2

3

1

3

0

0

Jul-21

Aug-21

Sep-21

Oct-21

Nov-21

Dec-21

Jan-22

Incomplete Documentation 15

12

10

5 1

1

May-21

Jun-21

0 Apr-21

0

0

Jul-21

Aug-21

1 Sep-21

No Documentation

0

0

0

0

Oct-21

Nov-21

Dec-21

Jan-22

Incomplete Documentation is one of the errors encountered by the nurses in the documentation process.

Missing this item leads to unverified data of patient’s details.

In May 2021, 154 errors reported as incomplete documentation due to about 2-3 candidates assisted at a time. To this matter, one patient at a time must be observed to avoid any errors aside from incomplete documentation.

Governance, Leadership and Direction (GLD) Nursing Documentation Errors – Incorrect Documentation 250 204

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

200

150 112 100

Incorrect documentation data illustrates that nurses need to be very careful in entering details and information in each file of the candidate. The highest percentage rate of incorrect documentation reported on June 2021 and August 2021 with a tally of 204 and 112 correspondingly.

83 59

50

51 27

24 0

0 Apr-21 May-21 Jun-21

Jul-21

44 8

Aug-21 Sep-21 Oct-21 Nov-21 Dec-21 Jan-22

Incorrect Documentation

However, in September 2021, there was no error in relation to documentation reported due to re-enhancement training done by the Audit team and cautiously monitoring the progress and development of each nurse.

Governance, Leadership and Direction (GLD) Nursing Documentation Errors – Incorrect Lot and Expiry Date Entry of Lot number and Expiry date were carefully entered in the system (file) per candidate. Nurses are cautiously enough and rechecked many times before to sign the form.

600

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

500 400

497 441 372

300 200 107 100

100

57

56

Sep-21

Oct-21

40

19

50

0

Apr-21 May-21 Jun-21

Jul-21

Aug-21

Incorrect LOT and Expiry Date

Nov-21 Dec-21

Jan-22

The graph describes how nurses are efficient in improving themselves in terms of other fields in nursing documentation.

Governance, Leadership and Direction (GLD)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Based on the report, the most common nursing documentation error was the incorrect entry of vaccine LOT number and expiration date. It was highest on the month of May 2021 with 497 counts, it also displayed a dramatic drop on the number of errors recorded on December 2021 with 19 entries.

Registration related concerns was second on the list with seemingly improved numbers as well. Incorrect documentation was the next in line with an up and down trend. The next in the row is the wrong appointment documentation followed by incomplete documentation.

Vaccine not signed was only recorded on April and May 2021 while no documentation is highest only on the first month.

Medication error was only marked on May 2021.

Governance, Leadership and Direction (GLD)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

As part of ensuring the quality of the nursing documentations, we are also identifying the common documentation errors and the contributing factors to have an action plan to minimize or to totally avoid the same inaccuracies if possible.

In line with that, we pilot the PIP program (Performance Improvement Plan) on August 2021 with aim to identify the reasons and the challenges faced by the nurses and to address the same issues to improve their documentations.

We conducted a one-on-one coaching to the responsible nurses and made a tailored-fit goal-oriented approach to help them improve their performances.

Staff Qualification and Education (SQE)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Staff Qualification and Education (SQE)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Staff Nurses who garnered high number of candidates vaccinated with NO ERRORS for the month of January 2022.

A benchmark of 1000 candidates per month as measurement on the declaration of accuracy rate against number of errors.

Staff Qualification and Education (SQE)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

The table represents the top performers with 1 ERROR recorded as the benchmark is not less than 1000 total candidates vaccinated per nurse in a month.

Data is extracted from the January 2022 report.

Staff Qualification and Education (SQE)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

List of Trainings and its status

Staff Qualification and Education (SQE)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

List of Trainings and its status

Staff Qualification and Education (SQE)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

List of Trainings and its status

Staff Qualification and Education (SQE)

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

Management of Information (MOI) Communication shall be done through:

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

 Email  WhatsApp  Telephone / Mobile

ADDENDUM

ADDENDUM

ADDENDUM

Addendum

HEALTHCARE ORGANIZATION MANAGEMENT STANDARDS

ADDENDUM

ADDENDUM

ADDENDUM

ADDENDUM

ADDENDUM

ADDENDUM

ADDENDUM

ADDENDUM

Nurse Manager

Medical Supplies

Asst. Nurse Manager

ADDENDUM

Nursing Audit Team Leader

Nurse Supervisor

Over-all Team Leader

Med-Prep Team Leader

Clinical Team Leaders

Nurses

Clinic Nurses

PCR Team Leaders

PCR Nurses

Nurse Auditors

IPC, Safety & TeleCon TL

IPC Link Nurse

Safety Nurse Officer

TeleCon Nurses

Research & Education Coordinator Clinical Nurse Educators

Prepared and Presented by:

Ronald Soriano Gamiao, MSN, RN Asst. Nurse Manager

Reviewed and Approved by:

Bassam Hussein Abu Haifa, MBA, RN Nurse Manager

28/02/2022 28/02/2022

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