UHS Medical Times October 2016

UHS Medical Times 1

Newsletter | October 2016

Quality Healthcare in University Hospital Sharjah The UHS Quality Department keeping in mind the vision, mission, values and strategic directions of University Hospital Sharjah strives to implement, monitor and evaluate systems and processes which yields in effective patient care , reducing steps or eliminating unwanted processes in the process of care delivery. Accordingly, policies are framed and implemented based on international standards and to comply regulatory requirements.

There is a continuous monitoring of the activities. It is involvement of all. All concerned individual HOD’s are responsible and drive the quality improvement initiatives within their own departments and most importantly the ground level staff who actually implement and make it as part of the day to day process so that patient safety is not compromised.

A patient is the most important visitor on our premises. He is not dependent on us.

We are dependent on him. He is not an interruption in our work. He is the purpose of it.

He is not an outsider to our workflow. He is part of it. We are not doing him a favor by serving him.

He is doing us a favor by giving us an opportunity to do so.

In this Quality edition of newsletter we have also tried to touch some basic simple subjects. It may look simple but these simple steps only matter for a patient.

Today’ s healthcare no matter whatever advanced the technologies we may use but healthcare industry is still manpower driven. So , the people involved in the care process become part of these basic steps which mostly needs to be followed each day as part of their job and these only make a huge impact patients point of view.

The difference is how we deliver it , do we deliver it with passion and commitment or we deliver just as part of our daily job.

This thinking only makes a big difference !!!

Newsletter from University Hospital Sharjah

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e-newsletter October 2016 September 2016 Newsletter ||October 2016

Message from Chairman

It gives me great pleasure to provide my introductory words to this edition of Quality in UHS Newsletter. As we all know Quality of care and Patient safety is the top most priority for University Hospital Sharjah.

Our focus is to deliver exceptional and excellent patient care across all disciplines in pursuit of patient care. This needs to be patient centric and commitments from the staff should ensure our patients feel qualitatively and medically they have been take care better than our competitors and make them believe that they are in safe hands surrounded by a caring environment.

Attaining JCI Accreditation last year by complying to the stringent standards was the result of the hardwork and efforts being put by all staff and the UHS Team achieved it by relatively better score-points. It involved all from Governance level to Senior Management Team to Medical Team, and from Quality Office to all HOD’s. The most importantly involvement of all staff with their determination and commitment was stand-point in ensuring this “Quality-Accreditation”. e-newsletter Newsletter from from University University Hospital Hospital Sharjah Sharjah

Quality is always a journey for improvements and not a destination. The systems and processes what is being implemented needs continuous and regular monitoring by the HOD’s and all relevant staff. The Accreditation was mile-stone, but the journey is on-going. We need to ensure that the certification provided to us would be ensured to sustain and consistently achieve the updated standard and we stand-out as a health-care organization that will be referred to as not mere certified organization, but in its true spirits of quality-care, quality-conscious and quality driven organization in all its manifestations and activities.

The above would be feasible only with a team work by all staff joining together as a team to deliver high-quality results for UHS. We should always be eager to grow and develop our systems which will be focused on quality improvements and patient safety in order to achieve excellence and innovation in our delivery of healthcare. We can only do this with passion from staff towards their work focused on our patient-care.

My message to you is to ensure continuous improvement by self-assessment coupled with organization in mind for such for continuous improvement.

Best Wishes for All !!!

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Newsletter | October 2016

What is Quality & Why Quality ???

What is Quality ?

Quality is conformance or adherence to Standards. It means doing the right things right. It is a common concept for various organisations, but the processes differ according to types of organisations. If one wants to cook something he should have all the requirements and most importantly he should add all the ingredients accordingly while preparing food. Only if each and every step involved in the cooking goes fine, a good, tasty and delicious food will result. Even if one step goes wrong, the food will be too salty or too spicy or tasteless. This clearly shows that every process has to be dealt with in accordance, whether its cooking food, manufacturing cars or delivering health care services in hospitals.

In UHS, a patient goes through various processes in the various departments in a hospital. He may go to the OPD, Imaging, Lab, IPD, ICU, OT, etc. It is the responsibility of each & every staff to see that everything is dealt with the patient properly so that he returns from here not only satisfied but delighted. This is what is termed as Quality of Care which emphasizes on aspects in terms for patient safety and staff safety as well, because ultimately it’s the staff who would be delivering Quality Services from their end. Most of all, it should come from within each and every staff as the internal desire to do things, not only seeing the patient as a diseased person but also keeping in mind that he or she has feelings & emotions. If this is done, most of the work is done.

Why Quality ?

Life style changes including the living pattern and changing dietary habits are making people more prone to diseases at an early stage than expected. There is a need for health care focusing on early diagnosis to the curative aspects of diseases. The health insurance companies have also played a major role taking medical care to extreme heights due to its cover for masses, ultimately leading to the benefits for the patients.

Healthcare establishments are flourishing. Latest technology is in great demand. Most hospitals have the latest equipments. These indicate that patients have more choices.

This being the case, in terms of a patients perspective, they are definitely going to choose a hospital that is focused on taking excellent care of their needs & comforts in a way no other hospital takes.

Many healthcare organizations target is to have satisfied patients , but in the current scenario we need to develop loyal patients and create relations and a sense of bonding between them and UHS. This is the key in retaining patients to cater to any of their healthcare needs arising in future.

Thus, rendering Quality Services is the need of the hour.

Every Patient is a BABY !!!

When a child cries the mother feeds the baby. The mother not only feeds the baby with the intention that the child's stomach is filled but also sees that the baby is highly satisfied. The hospital should also treat the patient as its baby and see that the patients are not only satisfied with the services being delivered to them at various service points but also see that they trust us and are loyal to us and develop a bonding towards us. As said earlier , if this is achieved most of the work is done.

- Mr. Sohan S Poojari , Quality Manager Newsletter from University Hospital Sharjah

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Newsletter | October 2016

UHS QUALITY POLICY We at the University Hospital Sharjah (UHS) are committed to delivering care that is compassionate and caring, meeting the needs of the community, prioritizing on patient and staff safety which will be achieved through the effective implementation of our Quality Management System.

UHS QUALITY DEPARTMENT VISION & MISSION

Vision: To ensure that the highest quality is delivered at all levels such that UHS is the trusted provider of comprehensive healthcare in Sharjah and in the region.

Mission: Monitoring of processes with an objective of identifying opportunities for Continuous Quality Improvement.

Implementing Strategies to deliver patient-centric care focusing on overall safety.

Maintaining effectiveness and efficiency of resources by introducing initiatives that will lead to optimal utilization of resources.

Providing a conducive, specific and continuous learning atmosphere for all staffs, thus enhancing and updating their knowledge levels at regular intervals.

What are Patient Expectations……?

In simple terms it’s the same what we as an individual expect from healthcare person when we fall sick.

Some expectations could be : 1. Prompt attention and concerned provider, timely services 2. Excellent Clinical capabilities and safe care 3. Affordability of Services 4. Amenities like clean waiting area, clean toilets, privacy, drinking water, etc 5. Latest Technology.

6. Excellent Operations Management processes

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Newsletter | October 2016

Key factors in Delivering Healthcare services Reliability Delivering consistent and timely services.

Knowledge Having complete knowledge of services being offered in UHS Empathy Offering individual care and listening to patients requirements and problems.

Responsiveness Demonstrating willingness and readiness to solve problems.

Implementation of PDCA (PLAN, DO, CHECK, ACT) Cycle in UHS as one of the Basic Quality Improvement tool in UHS for delivering consistent Quality Services

Plan is the process of identifying changes or developing hypotheses in response to the desire to improve. This includes planning process for improvement, developing objectives and rationale and also developing action plan.

Do is the process of carrying out the changes identiďŹ ed in the "plan phase" or the process of developing relevant databases. This includes description of measurement process, performance measures and developing systems to access and utilize data.

Check is the process of observing and evaluating the effect of the change through measurement. This includes description of analysis process and its rationale, individual (Units/Sections) performance process and evaluation of comparison levels.

Act is the process of reacting to the ďŹ ndings from the "check phase" including formulating new goals, setting objectives, re-prioritizing activities, and communicating to leadership and governing bodies.

Newsletter from University Hospital Sharjah

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Newsletter | October 2016

A Patient is Highest Priority…….

People may go for pizza’s at shelling out few currency of Dirhams for a circular dough with some toppings having enjoyed that with lots of fun. But the hospital scenario is entirely different because here a patient walks in with lot a physical pain and mental agony. They come here for the treatment and it has to be perfect at all stages. We in this industry are not only dealing with their disease but also with ones emotions, hopes, etc. A sole bread winner for the family if falls ill then along with the disease he has something else in his mind i.e. .thinking about his family.

So, the professionals like the Doctors , the Paramedics, and the Non Medical Staff who form a part of this system are equally responsible for handling these sensitive touch points which act a step to step process within the system and sub systems leading to the care for the patients.

On the other hand if the patient is extremely delighted he will never forget us because we have not given him pizza or food which can fill stomach only for a definite period but we have given him a new Life of Health. The patient should not be treated only as a diagnosis or a disease point of view but a human touch is required.

This touch from health care professionals is needed to make the patients feel not only satisfied but to make them delighted. The touch should not be superficial but it should be from within the desire to help the needy.

SPECIAL ANALYSIS UNIT

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Newsletter | October 2016

Patient Safety & Medical Errors The simplest definition of patient safety is the prevention of errors and adverse effects to patients associated with health care (World Health Organization).

A medical error is a preventable adverse effect of care, whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment.

As per the report by Institute of Medicine (IOM) there are a minimum of 98,000 deaths occurring each year by medical errors in US. As a healthcare institution it becomes our responsibility to have safe processes and systems such that medical errors are prevented and patient safety is not compromised.

It has been noted and found out across hospitals that major errors take place only due to the following factors and nothing else The factors are linked to :

Leadership and Communication Processes: This includes communication barriers to potential risk factors.

Information Management Process: This includes computer programs, Medical Records Data, policies and procedures, documentation.

Environment Management Process: This includes physical environment, policy and procedures regarding the environment, equipment and emergency planning and responses.

Human Resources Processes: This includes staff qualification and competence orientation training and education and staffing levels.

These are considered major factors in any healthcare establishment within which if any of the processes has any issues of gaps errors may happen and may lead to minor, intermediate or major catastrophic outcomes.

The trend in healthcare revolves around providing services in an environment wherein communication forms an important factor as its all about communicating right information to right people at the right time as this could save life of somebody.

The staff in UHS are aware of all the policies being implemented towards the compliance for International Patient Safety Goals which addresses patient flow issues on Patient Identification, Patients Falls Precaution, Assurance of Correct Patient, Correct Site, Correct procedure, Improve Effective Communication, Having effective handover communication, Improving safety of high alert medications and Reducing the risk of healthcare associated infections.

Newsletter from University Hospital Sharjah

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Newsletter | October 2016

University Hospital Sharjah Commitment to Quality “Quality is not an act. It is a habit.”

~Aristotle

True to its Quality vision to ensure that the highest quality is delivered at all levels of care, we would like to state that we strive to work as a team that is committed to the Quality Improvement and Patient Safety (QIPS) goals of the hospital.

In Quality everyone is involved, right from the Governance to all staff working in UHS , its only then quality can be achieved in any healthcare organization. One of the biggest testimony is achieving Joint Commission International Accreditation ( JCIA) wherein all staff gave their best to achieve it and UHS passed the rigorous JCI survey complying to all of their standards by excellent score of more than 98% which only a few hospitals have achieved in UAE and in the GCC region.

The JCI golden seal of approval means we have more work to do. Checklists, assessments, competencies, orientations, meetings, KPI monitoring, trainings, risk asessments, culture of safety, projects and departmental monitoring by the department heads, Infection Control team, Supervisors, Patient Relations Officer, Quality Department rounds and among other things are part of the QI activities of the hospital to ensure that our patients are receiving the highest quality of care and sustain the quality improvements that we worked hard for.

Quality is not the responsibility of the Quality department alone but all of us are responsible in improving and maintaining quality.

Again, the question is, how can I contribute to the Quality improvement activities of the hospital?

The things we do to our patient, it is part of Quality Improvement. There are so many day to day activities that we do which contribute to delivering Quality care such as: performing correct and timely assessments, making care plan, follow-up of treatment, patient education, complete and accurate documentations, reporting incidents and involve in putting up corrective and preventive actions, helping your supervisor collect data for your departmental KPIs, reporting medication errors and near miss, maintaining numerous checklists such as medication checklist, consumables, attending departmental meeting or committee meetings, participation in drills, it may be the simple act of greeting our patients and their relatives and sometimes going out of our way just to help and support them will improve our patient’s satisfaction to a great extent.

Quality is everyone’s responsibility.

Newsletter from University Hospital Sharjah

For appointment call +971 6 505 8555 or visit www.uhs.ae

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Newsletter | October 2016

Key Components Quality Improvement & Patient Safety Program Implementation, On-Going Monitoring and Evaluation Quality Improvement & Patient Safety Program intends to bring a culture of Quality throughout UHS as everyone being involved in Quality.

A Total of 14 JCI Standards comprising 8 Patient Centered Standards & 6 Organization Management Standards which covers 1,022 of their measurable elements is being implemented successfully.

A Total of 553 policies , 18 Hospital Programs and 711 forms is being implemented and being followed across all departments in UHS. Policies are revised every 2 years and as required.

Programs are reviewed yearly and as required. In additional to it we have a number of guidelines, competencies, privileges, etc.

Incident reports Analysis & Feedback monitoring Medical Records Documentation Monitoring.

Key Performance Indicators (KPI's) monitoring and evaluation, we have around 72 quality

related KPI’s across all UHS departments.

Patient Feedback monitoring Sentinel Event analysis and Root Cause Analysis (if required) Quality Department Rounds ( Weekly Announced , Un-announced & Daily rounds).

Infection Control Team rounds Facility Management Team hospital wide rounds Departmental Heads rounds within their own departments.

Quality Facilitators monthly meeting for KPI/Projects Monitoring of Hospital Quality Improvement Projects PDCA Project Cost Effectiveness & Efficiency Risk Assessment Failure Mode & Effect Analysis ( FMEA) Culture of Safety Others as deemed relevant for any improvement opportunities Preparation on going for achieving ISO 10001 & 10002 Certification for Aviation Medicine Clinic

Newsletter from University Hospital Sharjah

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Newsletter | October 2016

Trainings

Mandatory trainings on General Policies, Infection control, Fire & Safety.

Training to relevant staff on the new or revised policies/program/projects/new initiatives organized by Quality Department.

On-going Trainings for existing staff and new hire orientation by Department Heads

New staff hire orientation (organized by HR Dept.)

Hospital wide weekly trainings organized by Quality Department

Infection Control Trainings co-ordinated by Chair and Co-ordinator, Infection Control committee

Hospital Committees They play a very important role in the monitoring and evaluation activities. The following are the committees in UHS.

Hospital Executive Committee

Quality Improvement & Patient Safety Committee

Credentialing & Privileging Committee

Clinical Audit Committee

Mortality & Morbidity Committee

Prevention and Control of Infection Committee

Pharmacy and Therapeutics Committee

Resuscitation Committee

Facility Management and Safety Committee

CME Committee

Radiation Protection Committee

Medical Records Committee

Newsletter from University Hospital Sharjah

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Newsletter | October 2016

ISO 10001 & 10002 for UHS Aviation Medicine Clinic One of our next goal is to achieve the certification for ISO 10001 & 10002 for our Aviation Medicine Clinic. As mandated by the General Civil Aviation Authority , any clinic providing aviation medicine services needs to be certified by ISO 10001 & 10002 by this year end.

We have already started preparation for the same with the concerned team in Aviation Medicine Clinic. There will be two stages of Audit. Stage 1 will be document review and Stage 2 would be implementation audit.

We intend to finish the final survey/audit by end of November 2016.

Newsletter from University Hospital Sharjah

For appointment call +971 6 505 8555 or visit www.uhs.ae

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Newsletter | October 2016

Culture of Safety The safety culture of a hospital is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proďŹ ciency of, a hospital’s health and safety management.

In University Hospital Sharjah each year we undertake the Culture of Safety Survey. The tool used for the survey is by AHRQ (Agency for Healthcare Research in Quality), USA. The comparison results on below parameters highlights the UHS commitment to Quality and depicts how safe UHS is for the patients and the staff as a healthcare provider delivering quality and reliable services.

Results of Culture of Safety Survey conducted in University Hospital Sharjah.

The survey results comparison 2016 v/s 2015 is also highlighted below

Newsletter from University Hospital Sharjah

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Newsletter | October 2016

Patient Satisfaction The best way to know on patients experience in UHS is by knowing from them. Patient satisfaction is key priority for us to monitor throughout UHS. The below graph highlights the ŮŞ segregation of the patients perception towards us for this year (January to August 2016).

This demonstrates that our team comprising Doctors, Nurses, Pharmacists, Technicians, Physiotherapist, Dietician as well as Non-licensed staff are doing their best in providing excellent care. Also for the suggestions and complaints we have a mechanism wherein it is reviewed by Patient Relations OfďŹ cer and appropriate investigations carried out with concerned team in a process to ensure effective patient feedbacks management.

Newsletter from University Hospital Sharjah

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Newsletter | October 2016

Good Catch for Medication Error and Near Miss Award Awarding the “Good Catch Award” certificates started around July this year to recognize a staff member’s professional diligence to “Speak up” that helped prevent medication errors and Near Misses.

The following staffs are the first batch of recipients of the Good Catch Award: 1.

Ms. Marichu Flores (Medical Surgical Ward)

2.

Mr. Leopoldo Cunanan Jr. (Medical Surgical Ward)

3.

Mr. Mark Chester C. de Vera (Medical Surgical Ward)

4.

Dr. Fahim Mehmood (Pharmacy)

5.

Mr. Mohammed Zaher (Pharmacy)

6.

Jooly Kottukara Chandy (ICU)

7.

Ms. Sweety Prakash (Pediatric Ward)

8.

Gladys Amor (Pharmacy)

Way Forward If we even take our own hospital as an example then many options the patients have in Sharjah and in UAE for getting treatment relating to Care. The patient may walk fully satisfied from our place but is he loyal to us? If he needs care services again, will he return to us or choose another hospital ?

If he is loyal surely he will return to us. Best Clinical outcomes , patient experience including wherever they visit in our hospital and excellent behavior of healthcare personnel can only make them loyal towards us.

Commitment to Quality and change plays a vital role in the Quality improvement activities of the hospital. Our senior leaders steer change through the organization’s structure and processes to set a constant direction, reinforce expectations, and provide resources and accountability to support change.

The HOD’s need to continually maintain standards compliance with effective monitoring and evaluation for the achievement of the common goal for achieving patient safety.

“Commitment is what transforms a promise into reality.”- Abraham Lincoln

Newsletter from University Hospital Sharjah

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Newsletter | October 2016

Laughter Zone

Medical Record Documentation Blunders Discharge status: Alive but without my permission.

On the second day the knee was better, and on the third day it disappeared.

Patient has chest pain if he lies on his left side for over a year.

The patient has been depressed since she began seeing me in 1993.

The patient refused autopsy.

Newsletter from University Hospital Sharjah

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Newsletter | October 2016

SCOPE OF SERVICES AT UHS MEDICAL SERVICES

SURGICAL SERVICES

CARDIOLOGY

NEUROPHYSIOLOGY

Anesthesiology

Bariatric Surgery

24-Hour BP Monitoring

Electroencephalogram (EEG)

Aviation Medicine

Ears, Nose and Throat Surgery

24-Hour Holter Monitoring

Electromyography (EMG)

Cardiology

General Surgery

2D/3D Echo

Evoked Potential Test

Critical Care

Neurological Surgery

3D Transesophageal Echo

Brain Auditory Evoked Potential

Dermatology

Obstetrics and Gynecologic Surgery

CT coronary Angiography

(BAEP)

Emergency Medicine

Ophthalmic Surgery

Somato Sensory Evoked Potential

Endocrinology

Orthopedic Surgery

Dobutamine Stress Echo for Ischemia and Viability Studies

Family Medicine

Pediatric Surgery

Gastroenterology

Plastic and Reconstructive Surgery

Internal Medicine

Urologic Surgery

Medical Oncology

Vascular Surgery

Neonatology Nephrology Neurology Pediatrics Psychiatry Pulmonology Rheumatology MEDICAL DIAGNOSTICS IMAGING (MDI) 128 Channel CT Scan with Coronary and Cardiac Facility

PATHOLOGY & LABORATORY MEDICINE

Interventional Cardiology Stress Test

(SSEP) Visual Evoked Potential ( VEP) Nerve Conduction Studies (NCS)

Treadmill Stress Test

AUDIOLOGY

OTHER SPECIALTY SERVICES

Biochemistry

Acoustic Reflex Threshold

24/7 Emergency Services

Blood Transfusion Medicine

Auditory Brainstem Response

Ambulance

Cytology

Auditory Steady State Response

Hemodialysis

Hematology

Cochlear Implant Mapping

Physiotherapy

Histology

Electrocochleography

Pharmacy

Immunology

Free Field Audiometry

Sharjah Breast Centre

Microbiology

Hearing Aid Fitting and Programming

Phlebotomy

Newborn Hearing Screening

Bone Densitometry

Otoacoustic Emission

Digital X-Ray and Fluoroscopy

Pure Tone Audiometry (PTA)

Mammography and Guided Breast Intervention

Speech Audiometry

MRI 1.5 TESLA

Tinnitus Evaluation

Ultrasound

Tympanometry

Vascular Interventional Lab

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Newsletter from University Hospital Sharjah

For appointment call +971 6 505 8555 or visit www.uhs.ae