1
Executive Summary This annual report provides a summary of the activities and accomplishments of the Directorate of Quality & Safety (DQS) for 2014. It represents the efforts of the eight (8) units of DQS and many hours of committed work in all aspects of quality improvement and safety as we strive to deliver the highest quality of care at King Fahd Hospital of the University (KFHU). Each unit of DQS has prepared their submission included in this report. I am grateful to all units’ staff for the time and effort put into preparing each unit’s attached reports. This annual report is an attempt to ensure that every member of staff in KFHU has awareness of what is happening across each and every unit within DQS in terms of activities for last year, but more importantly targets and goals for the coming year. 2014 marked the second year of implementation of all Joint Commission International (JCI) standards and this was also an eventful and productive year for DQS. DQS with all its units has worked extensively in collaboration with all departments of KFHU to ensure that:
process of improvement continues; completes all requirements per standard & measurable elements; conducts appropriate investigations, and, develops acceptable corrective action plans.
Our continuous collaboration with all departments of KFHU focused on the development of a culture that is free from patient and employees harm, improved communication and teamwork and leadership. DQS’ mandates are to develop and promote programs that enhance the delivery of safe patient care and to increase the overall value of patient services at KFHU. DQS continues to implement and expand innovative patient safety and quality improvement efforts. We have also identified and applied best practices that improve healthcare quality and safety. Through ongoing education and training, we plan to engage all KFHU staff and physicians in the culture of patient safety. I want to acknowledge the work done last year by all staff of DQS. I am proud that I have so many committed and skilled people who go the extra mile every day to deliver the highest possible quality of service to all departments of KFHU. The purpose of this report is to highlight our overall performance across all of the domains of quality. The report will also summarize improvements that have helped us achieve many of our goals related to quality and safety. In summary, we are proud of the accomplishments we achieved this past year as outlined in this report.
2
Activities and Significant Achievements of DQS for 2014: Structure & Manpower: Structure: Two units were added to the organizational structure of the Directorate of Quality & Safety:
To provide accurate and timely information that enables informed decision making, the Decision Support Unit was established last December 2013.
To ensure that KFHU patients receive safe high quality of care from providers with appropriate skills, training and experience, the Credentialing & Privileging Unit was established last April 2014.
Manpower: 2014 was a very demanding year for DQS. Seven (7) employees were added to the workforce totaling 18 staff at the end of the 4th quarter of 2014. The staff turnover rate of DQS remained on a stable level of 10.52%. For the year 2014, four of the employees left DQS for family reason; 2 employees went for post-graduate studies in the United Kingdom; 1 employee was transferred to another department and 1 employee left for family reason. Accreditation Preparation: The JCI standards relates to how care providers deal with patients, but also to the organizational structure around the patient. During the last quarter of 2013, it was decided to have the JCI (Joint Commission International) mock survey. The result was very encouraging and challenging for KFHU. This result was used as an indicator for the DQS to continue and pursue our aim in having the “Gold Seal of Approval” from the Joint Commission International Accreditation (JCIA). It was decided that somehow, the DQS team should be guided and assisted by experts in terms of accreditation process. An approval from the office of His Excellency, the President of the University of Dammam and Supervisor General of KFHU was sought to appoint consultants that will provide consultancy services to KFHU. A team of four (4) external consultants were contracted and came on different dates (please see below). KFHU will be surveyed as an academic hospital based on the 5th edition of the JCI standards and the whole process will be evaluated with reference to a total of 303 standards and 1,213 measurable elements. The following are the numbers and dates of visits for each consultant with their corresponding assigned chapters:
3
Dr. Ahmad Al Khateib (chapters assigned: GLD, SQE, MOI, MPE, HRP): 1st visit: January 26 – February 3, 2014 2nd visit: April 27 – May 1, 2014 3rd visit: June 15 – 18, 2014 4th visit: October 20 – 23, 2014 5th visit: December 7 – 13, 2014
Ms. Firyal Sayyed (chapters assigned: ACC, PFR, AOP, PFE, PCI): 1st visit: February 24 – 28, 2014 2nd visit: March 30 – 31, 2014 3rd visit: June 15 – 17, 2015 4th visit: October 12 – 16, 2014
Professor Seval Akgün (chapters assigned: IPSG, COP, ASC, MMU, QPS): 1st visit: March 2 – 6, 2014 2nd visit: April 13 – 17, 2014 3rd visit: June 22 – 26, 2014 4th visit: December 21 – 25, 2014
Dr. Riaz Akhtar (chapter assigned: FMS): o March 23 – 27 & 30 – 31, 2014
The team (consultants) was composed of a physician, nurse, administrator and facility management expert. Each consultant scrutinized various aspects of the hospital including facility management, infection control, patient safety, documentation of patient records, staff qualifications, disaster preparedness based on the Joint Commission International Standards 5th Edition. The external consultants meticulously and objectively check to ascertain if KFHU’ is in compliance with the stringent international patient safety quality standards, had achieved the highest level of patient care possible, improved patient outcomes, and the environment was created for continuous improvement of standards. The hospital underwent a thorough check of its medical staff, policies and procedures covering patient safety, infection control and disaster management. It was also inspected for its adherence to safety and quality standards including results-oriented processes and proper documentation of patient records and medication management. During the consultation visit, the consultants identify and highlight any opportunities for improvement using currently JCI standards as the benchmark. Chapter assignment: Once approval was obtained, the 16 chapters were allocated to each consultant according to their expertise. Chapters team with leaders and members were already formed in 2012 and composed of personnel with good people skills, timemanagement skills, and consensus-building skills. The team leader and team members of each chapter were respected champions that were tasked to overseer each chapter for its standards and carry out the process.
4
KFHU consultation journey:
Baseline Assessment Phase:
This was aim to provide KFHU an in-depth analysis of our current ability to meet the JCI standards at the early stages of our preparation process. The assessment phase cover the entire KFHU and include all the chapters related to patientfocus, organizational management and academic medical center standards. The assessment also covers the International Patient Safety Goals and identifies gaps in the organizations performance and expectations of the goals. The consultants’ baseline assessment looked at the quality data currently available in KFHU and compared that data to the JCI requirements of the quality monitoring standards. The results of the baseline assessment were used as a guide in the development of a detailed action plan. The Baseline Assessment was arranged according to the JCI standards and demonstrates KFHU status according to the standards, including findings and recommendations to achieve compliance. The consultants critically and objectively assess each area, and score as “Met,” “Partially Met,” or “Not Met” was cited with specific findings and recommendations. The consultants also collect and analyze baseline quality data as required by the quality monitoring standards (e.g., medication errors, hospital-associated infection rates, antibiotic usage, surgical complications, etc.). Part of the assessment, they establish an ongoing monitoring system for data collection (e.g., monthly, with quarterly data analysis) to identify problem areas and track progress in improvement. At the end of the assessment phase, the consultants provided KFHU a report indicating and prioritizing the standards that needed improvement. When there was an area for improvement, a subsequent action plan for each JCI standard findings was initiated. Action planning: Using the findings of the baseline assessment, DQS team developed a detailed project plan starting first with priority areas of the core standards. Responsibilities, deliverables, and time frames were assigned (e.g., revise informed consent policy, develop a new informed consent statement, educate staff in the next two-month time period.)
Implementation Phase:
The consultants performed unit visits as mock surveys, tracer activities and teaching opportunities on processes, provides guidance to overcome obstacles encountered, and provides supplemental resources such as tools and templates as required/requested. The consultants provided a comprehensive practice survey to assess KFHU’ accreditation readiness. Each consultant assessed our compliance with the JCI standards and elements of performance using the “tracer” methodology. Mock survey was tailored according to our services and size. This was exactly done exactly how the JCI survey agenda was designed. 5
A written report at the end of each visit identifying non-compliant elements or processes that needs improvement. Recommendations were made to make necessary changes to come into JCI compliance. Real time feedback and education of clinical, support and administrative staff on how to effectively showcase their compliance to JCI. Review of all related documents (i.e., policies & procedures, forms, scope of services, clinical guidelines, etc.).
Ongoing Assistance:
The consultants provided advice on implementation of the JCI standards and suggestions on what the JCI surveyors would look for a survey or document review. They were also available to support KFHU and provided continuous off-site advice through emails. Significant Achievements based on the Consultants’ Findings: For every finding when there was an area for improvement, a subsequent action plan for each JCI standards was initiated. Those initiations were embedded in the JCI teams’ meetings at which the main purpose was to develop an action plan related to the deficiencies identified by the consultants, to ensure that all findings will be resolved by various involved departments and to condition KFHU’s readiness for the actual JCI accreditation survey in 2015. 1. KFHU hospital wide JCI accreditation preparation activities: a. Education With our aim to communicate the concept of “JCI readiness” throughout the hospital, the Directorate of Quality & Safety has conducted series of educational activities. It was accomplished in collaboration with different JCI team leaders and KFHU departments. These educational activities served to educate and motivate the staff. It served to raise the awareness to some policies, procedures, forms, JCI chapters and FMEA project. The documentation and forms education allowed all healthcare practitioners to enhance their documentation skills by giving them an idea of the new hospital forms, where it should be located in the patient’s medical record, how to correctly and completely fill in the forms, what the most common mistakes and how to prevent repeating the same mistakes.
6
Figure 1 – JCI Chapters Awareness Education
Figure 2 – Education on Hospital Forms
7
Figure 3 – Awareness Campaign
b. Workshop / Meetings The Accreditation Unit of DQS conducted workshop and meetings after each consultant’ visits final report. The workshop & meetings included all representatives of each chapters and departments who were involved in the action plan. The workshop and meetings covered all findings that required corrective actions.
Figure 4 – External Consultants Findings & Recommendations (Workshops/Meetings)
8
During the FMS consultation visits of Dr. Riaz Akhtar, different specialized training was conducted.
Figure 5 – FMS Specialized Training
2. Launching of KFHU Key Performance Indicators (KPI): Key performance indicators are essential tools for both monitoring and improving the quality of health services. KPI are measurable indicators that demonstrate progress toward specified targets. This will also enable decision makers to assess progress towards achievement of an outcome with in an agreed time frame. At King Fahd Hospital of the University (KFHU), Hospital-wide KPI was launched as per the approval of H.E. the President of University of Dammam & Supervisor General of KFHU, Dr. Abdullah Al Rubaish last 23rd of April 2014. The Performance Measurement (PM) & Decision Support (DS) Units of the Directorate of Quality & Safety takes the responsibility of helping all the departments in identifying their KPIs along with the formulae and inclusion / exclusion criteria.
9
Figure 6 – KFHU KPI Roadmap
Both the PM & DS units identified the hospital-wide KPIs and has developed a dashboard. These KPIs were tracked monthly and discussed among the chairpersons of the departments. The first Key Performance Measures Report covering the period of January to September 2014 was published on the 5th of January 2015. The report was constructed to demonstrate the progress of KFHU services towards meeting the targets. With the release of each quarterly report, KFHU reaffirms our commitment to provide quality of care to the patients:
18 KPIs were implemented during the 1st quarter of 2014 31 KPIs were implemented during the 2nd quarter of 2014 32 KPIs were implemented during the 3rd quarter of 2014 47 was the expected list of KPIs for the 4th of quarter 2014
Figure 7 – KPI Implemented in 2014
10
3. JCI Binders: As part of the preparation for the JCI accreditation survey, in order to show evidence, implementation and compliance, the Accreditation Unit of the Directorate of Quality & Safety had prepared 16 chapters binders on Patient Centered Standards, Organization Management Standards and Academic Hospital Standards. Each of these binders contained specific documentation that supported the requirements for the JCI standards and their measurable elements. Total standards that needed to comply are approximately 303, while the total measurable elements were 1,213. The Accreditation Unit prepared and completed the 16 chapters’ binders, as well as the policies and forms binders, according to the JCI standards (5th Edition). The Accreditation Unit ensures that the information contained in these binders were arranged systematically and organized to facilitate their review by the external consultants. 4. Hospital Forms: The Documents Control Unit (DCU) of the Directorate of Quality & Safety plays a big role in all the hospital forms used. This role starts from the creation & development of the forms to requesting for printing and finally to uploading the form to the Hospital Portal. All obsolete hospital forms were eliminated from the Stationery Store and was decided to limit the available forms to only those forms that are relevant. In 2013, a total of 111 forms were printed and processed by DCU. This year (2014) a total of 440 forms were done and out of this number 298 were approved, printed and uploaded to the hospital portal.
Figure 8 – Hospital Forms
11
5. Policies and Procedures: DQS ensures that there an established procedure for the development, review and approval of policies and procedures. In 2013, a total of 777 policies and procedures either new or revised, were done and a total of 583 policies & procedures were signed. A remarkable increase was noticed in 2014, as a total of 1536 policies and procedures were done and signed. All these P/Ps were uploaded to the hospital portal.
Figure 9 – Policies and Procedures
6. Scope of Services: With our aim to reveal the role of all KFHU departments and to demonstrate the range of activities that are consistent with the requirements for the delivery of all required information, the Documents Control Unit continuously ensures that the Scope of Service of each department is updated. An approximate number of 21 Scope of Services was done and is continuously being updated on a regular basis.
12
Figure 10 – Scope of Service
7. Strategic Plan: Each department of King Fahd Hospital of the University (KFHU) had developed a five-year strategic plan in order to meet the vision and mission of KFHU. This was initiated in 2012 and the Directorate of Quality & Safety is responsible in collaborating with these departments to implement and monitor these plans in order to ensure that the five year plan is achieved. There are 28 departments that had submitted a signed strategic plan and 10 departments were still pending for the department’ chairpersons’ signature. Compared with the 2013 strategic plan an increase of 27% was obtained in collaboration with the departments’ chairpersons.
Figure 11 – Strategic Plan Completed & Signed
13
8. Occurrence Variance Reporting: In May 2012, the Occurrence Variance Reporting System (OVR) was introduced and launched to be the main source of reporting occurrences. All Occurrence Variances are encouraged to be reported at KFHU and as an organization it is important there is a common understanding of what constitutes an untoward incident. The Risk Management Unit of the Directorate of Quality & Safety provides a thorough overview of the OVRs received in 2014. Data was tabulated and analyzed identifying actual and potential risk areas in addition to their variances and contributing factors. OVR Trend
Figure 12 – OVRs 2012 - 2014
The reporting system that KFHU had introduced helped increased the number of reported incidents. There was a 14.09% increase in the reported OVRs in 2014 compared to 2012. The above graph shows that reporting incidents has dramatically increased over the last three years. During the consultation visits, the KFHU Risk Management Plan was reviewed and recommendations were provided. All policies and procedures related to the Risk Management Unit such as the sentinel event were also reviewed and revised. The external consultants recommended that the administration should be involved and its role must be included in the policy and procedure. A risk assessment must also be established to better determine appropriate ways to eliminate or control all risks. 9. Medical Records Review: Starting from the first quarter of 2014, a record review team was formed to perform medical records audits. During the 1st quarter the team had review medical records files, but was stopped to evaluate the effectiveness of the team. Thereafter, the team was re-formed and at the last quarter of 2014, the team had covered 179 files of all admitted patients in each unit in the hospital. The physician documentation has improved dramatically. The team also performed a medical file audit for all OPD files which totaled for 700 files. 14
15
Executive summary: It is time once again to take keyboard in hand and put together the annual compilation of the achievements within the Directorate of Quality and Safety. The past months has been marked by significant accomplishments and many changes. As you read through this report, the growth of Directorate of Quality and Safety documented within remains impressive. The support from Dr. Ahmed Kuwaiti, Director, Directorate of Quality and Safety, Dr. Khalid Otaibi, KFHU Director General and Service Line Director continues to be unwavering. Add to this the tremendous support from the Office of the President and it is no wonder that we continue to succeed in so many endeavors. We continue to be challenged to provide the best possible training for our staff in an ever busier clinical environment. We must do so while always keeping patient safety and the hospital STEEEP principles (care that is Safe, Timely, Effective, Efficient, Equitable, and Patient-Centered) as overriding ideals. In addition, the Service line and hospital leadership has stepped up in a big way with the implementation of new hospital forms, clinical pathways and policies and procedures. Strength: KFHU JCI Accreditation percentage of achievements Standard International Patient Safety Goals Access to Care and Continuity of Care Patient Family Rights Assessment of Patient Care Of Patient Anesthesia and Surgical Care Medication Management and Use Patient and Family Education Quality and Patient Safety Prevention and Control of Infection Governance Leadership and Direction Facility Management Safety Staff Qualification and Education Management Of Information Medical Professional Education Human Research Program
Score 81.7% 75% 75% 81% 82.4% 84.8% 80.7% 81% 79.1% 87.9% 75% 80% 70% 75% 70%
Table 1: KFHU JCI Accreditation percentage of achievements
Forms, Policies and Procedures done and implemented Job descriptions signed and placed in employees file Hospital and departmental Scopes of service done 2 Clinical Pathways implemented
16
Opportunities for Improvement: 1. International Patient Safety Goals Some physicians are not aware of IPSG IPSG 3 High Alert Medication Policy and Procedures is not available 2. Access to Care and Continuity of Care Triaging area break the patients confidentiality Overstaying Performance Improvement Projects is to be completed; target date is end of February 2015. Need to alert physicians to comply with the triaging system, measure compliance Delay appointments in Radiology, Cathlab surgery but no documentation Nurses are not aware of admission and discharge criteria Clinical Dietician, Clinical Pharmacist, Physical Therapist, need to provide education Need to reinforce to complete discharge instruction Need to reinforce to the physician to write discharge summary for DAMA, Absconded, and Death Need to reinforce to the physician to update the significant data sheet every admission 3. Patient and Family Rights Need to educate the staff responsible to medical staff files about the importance of keeping files unattended. End of Life Care Patient needs not assessed 4. Assessment of Patients Interns are documenting in the patients file without counter signature Initial assessment is incomplete physician and nursing Physician discharge planning was not initiated Reassessment should be done even weekends KPI for radiology should include result discrepancy Infection Control is not observed in blood bank 5. Care of Patient Integrated care plan was not done properly AMI Clinical Pathways not fully implemented Key Performance Indicator for Code blue not available There is weakness in nutritional assessment in particular those patient at nutritional risk More training in the end-of-life care Pain assessment no reassessment after intervention 6. Anesthesia and Surgical Care Anesthesia form need to revised Implant device need to monitor 17
7. Medication Management and Use Policies and procedures are not available Key performance indicator data not share to Directorate of Quality and Safety Pharmacy Medication Management Plan not Available Pharmacy Scope of Service not Available Drug Usage Evaluation program not available Adverse Drug Event data 8. Patient and Family Education Physician, nursing, and other healthcare provider need to document to the Multidisciplinary Patient and Family Education form the education given to the patient, family or care giver. 9. Quality and Patient Safety QPS Education Plan available but not implemented Safety Risk Assessment for the contractors not done Patient Safety Culture Survey (employee survey) done but not yet analyzed Patient Falls PI project will be used as the impact of the improvements on cost and efficiency- waiting for the list of allocated budget for each patient. o Ordinary Case o Surgical Case o Obstetrics case Report of Sentinel and Adverse Event not yet finalized 10. Prevention and Control of Infection Safety Risk Assessment for Contractors not done by the Infection Control Some areas which are critical areas from infection control point of view such as laundry, CSSD, mortuary, kitchen need to be strictly monitored by Infection control practitioner. Immunization coverage of the staff should be monitored in each department by Infection control department. News stand for Prevention and Control of Infection education flyer not available Educational program for Laundry staff not available No screening for Laundry and Kitchen the staff documented 11. Governance Leadership and Direction Dr. Khalid Al-Otaibi Job description should be signed by President Dr. Abdullah Al-Rubaish Clinical Pathway not fully implemented. The physician just started the emergency case and ignore the other days Leadership rounds not yet implemented. Checklist available 12. Facility Management and Safety Please see the attached comments from the Consultant Surveyor
18
13. Staff Qualification and Education Reviews of employees file data flow for non-Saudi certificate and to have primary source verification Departmental orientation not available 14. Management of Information Printer for printed stickers (addressograph) is underway Closed and Open chart review started – poor compliance Poor compliance to the documentation policy 15. Medical Professional Education Scope of Service by the Clinical Affairs Job Description of Resident and Intern Coordinator Staff promotion policy not available 16. Human Subjects Research Program Forms, Policies and Procedures, Organizational Chart not available
19
Table 2: Action Plan and Recommendations
JCI Chapter International Patient Safety Goals
Access to Care and Continuity of Care
Identified Findings Physicians, Interns, and students are not aware of International Patient Safety Goal
IPSG 3 High Alert Medication Policy and Procedures not available
Triaging Area break the patients confidentiality
Overstaying in ER
Nurses are not aware of admission and discharge criteria.
Patient was not referred to Clinical Dietician, Clinical Pharmacist, and Physical therapist.
3 out of 17 files reviewed contain discharge instruction No discharge summary for DAMA, Absconded and Death Significant Data sheet
Action Plan / Recommendation IPSG Chapter team chairman provide lecture to all department ( clinical and non-clinical) During tracer, the team re-educate the physician, intern and students on IPSG IPSG Pocket cards provided to all staff Follow-up with Dr. Nadia Ismail, Dr. Kuwaiti informed Dr. Khalid Otaibi and Dr. Mohye were informed. Temporary screening/triaging area provided. Need to have one room for triaging Need to alert physician to comply with triaging system, and measure compliance Recommend to provide one room for screening / triaging Overstaying PI project need to be completed before the end of February 2014 Measure the outcome of PI project Admission and discharge criteria laminated and distributed to all units During tracer the team will ask the staff regarding admission and discharge criteria Instruction given to the nurses if the patient is on special diet they should inform the clinical dietician immediately Clinical Dietician was instructed to go to the inpatient unit every day to and ask the nurses for the new patient admission. Clinical Dietician initial assessment should be done for the special diet patient Clinical dietician instructed to document in the Patient and Family Education Form whenever they provide diet education to the patient Clinical Pharmacist instructed to provide education to the patient if necessary and document it in patient and family education form During tracer, the team reinforce to all physicians to complete the discharge instruction. During tracer, the team reinforce to all physicians to complete the discharge summary Need to reinforce to all physician to update the Significant Data Sheet 20
JCI Chapter Patient and Family Rights
Identified Findings
Assessment of Patients
Care of Patient
Anesthesia and Surgical Care
Medication Management and
Action Plan / Recommendation
Patient Files in the hallway left unattended by the medical record staff End of Life Care Patient needs assessed Interns are documenting in the progress notes without counter signature Initial Assessment is incomplete physician and Nursing Patient reassessment should be done daily even weekend Physician’s discharge Planning was not initiated KPI for radiology should include result discrepancy
Dr. Abed consultant radiology informed Result discrepancy added to Radiology KPI
Infection Control and Fire Drill not observed in Blood Bank
Documentation in Integrated Care Plan was not properly filled More training in the end-of-life care There is a weakness in nutritional assessment in particular those patient at nutritional risk No pain re-assessment after intervention
Infection Control Officer Samia and Enas informed Infection Control and Safety Department will provide education to the staff in blood bank DQS Accreditation Unit makes a folder of completed forms (documentation) and distribute to the Unit. Accreditation Unit Staff coordinate with Clinical Nutritionist to document the initial assessment and in PFE form Continuous monitoring for compliance Reinforce to all nursing staff to do the pain reassessment Two indicators identified for code blue o Time of Arrival for code blue team should be 5 mins o % of revive
Develop an indicator for code blue Implant device need to monitor
Policies and Procedures are not available Pharmacy Key Performance Indicator data not share to Directorate of Quality and Safety Pharmacy Medication Management Plan not available Drug Usage Evaluation Program not available Drug Adverse Event Data not shared to DQS
Mr. Khalil inform to educate the medical staff to protect the patients confidentiality, don’t leave the patients file unattended The end of life care form implemented During tracer, the team re-educate the physicians, residents, interns and students regarding the non-compliance to documentation policy and JCI standards DQS thru Dr. Khalid Otaibi send a letter to the chairman with evidence regarding the non-compliance documentation
Dr. Dalal Bubshait sends a letter to all surgeons to who puts an implant to complete the Medical Device log book and complete the Implant device Adverse Event form. Follow-up with Dr. Nadia Ismail Dr. Ahmed Al-Kuwaiti informed
21
JCI Chapter
Identified Findings
Patient and Family Education
Quality and Patient Safety
Prevention and Control of Infection
Governance Leadership and Direction
Physician, nursing and other healthcare provider need to document in the Multidisciplinary Patient and Family Education. QPS Education Plan available for but not implemented Safety Risk Assessment for the contractors not done Patient Safety Culture Survey (employee survey) not yet analyzed Patient Falls PI project will be used as the impact of the improvement on cost and efficiency
Action Plan / Recommendation
Accreditation Unit staff re-enforce to the healthcare provider to document in the Multidisciplinary patient and family education
QPS Education Plan to be implemented in March 2014 Patient Safety Culture Survey report for analysis by Dr. Thena Follow-up the budget with Dr. Kuwaiti Follow-up the sentinel event and adverse event to Risk Management Unit
Ordinary Case Surgical Case
Obstetric Case Report for sentinel and adverse event not yet finalized Safety Risk Assessment for Contractors not done by the Infection Control Some areas which are critical areas from infection control point of view such as laundry, CSSD, mortuary, kitchen need to be strictly monitored by Infection Control practitioner Immunization coverage of the staff should be monitored in each Department by Infection Control Department Newsstand for PCI education flyer not available No screening for Laundry and Kitchen staff Job Description of Hospital Director not available Clinical Pathways not implemented Leadership Rounds not yet implemented. Checklist available
Hospital-wide Safety Risk Assessment related to Infection Control done by the Infection Control Department CSSD, Laundry, Mortuary and Kitchen is monitored by Infection Control Specialist thru Environmental Rounds. Infection Control Specialist in collaboration with Employee Health Clinic, and Directorate of Quality and Safety start Flu Vaccine Performance Improvement project. PCI education material available in the intranet To coordinate with Mr. Saif and Employee health Physician to do screening for Laundry and Kitchen staff Waiting for the signature of Dr. Rubaish AMI and GI Bleeding Clinical Pathways Reinforce to the Administration Dr. Jumaan and Dr. Mohye to do Leadership Rounds and provide the Report to DQS
Facility Management and Safety
22
JCI Chapter Staff qualification and Education
Identified Findings
Management of Information
Action Plan / Recommendation
Review of employees file data flow for non-Saudi certificate and to have primary source verification Departmental orientation not available
Standardized sticker and printing machine for all unit No data for chart review
Medical Professional Education
Human Subject Research program
Scope of Service by the Clinical Affairs Job description of Resident and Intern Coordinator Staff promotion policy not available Forms, Policies and Procedures, organizational Chart not available
For Saudis Human Resource Department send an email and letter to the university to validate the authenticity of Certificates of the employee. (primary source verification) The primary source verification for non-saudi through primary source verification Human Resource Department & Accreditation Unit follow-up with the department
Printer for printed stickers (addressograph) is underway Closed record review started data will be distributed to all chairman of the department Open record review will kick off next month after physician education Scope of Service done for approval of Dr. Huweish Job Description of Resident and Intern Coordinator for signature To develop staff promotion policy Mr. Muhil developed policies and procedures, forms and organizational chart.
23
JCI CHAPTER SUMMARY REPORT 2014 (Table 3) Chapter Name Team Leader No.
: INTERNATIONAL PATIENT SAFETY GOALS (IPSG) : Dr. Nasser Mohammed Amer
Date of meeting 21 January 2014 Meeting no. 11
Issues IPSG no. 1 – Identify Patients Correctly Patient Identification Policy and Procedure
ID Band Requisition
Printer for ID Band IPSG no. 2 – Improve effective Communication Reporting critical test results
Resolved
IPSG no. 4 – Ensure correct site, correct procedure, and correct patient surgery. Surgical site verification/site marking/Time-out Policy and Procedure IPSG no. 5 Reduce the risk of Health-Care Associated Infection Hand Hygiene Policy and Procedure IPSG no.6 – Reduce the Risk of Patient resulting from falls Falls – Policy and Procedure Smoking Policy and Procedure
Status
Remarks
Revised and unanimously approved by IPSG members. (17 March 2014– Meeting no. 13)
IPSG no. 3 – High alert medications High risk/high alert medication 1.
Unresolved
Pending
Revised and unanimously approved by IPSG members. (17 March 2014– Meeting no. 13)
Revised and unanimously approved by IPSG members. (17 March 2014– Meeting no. 13)
24
No.
Date of meeting
2.
3.
12 March 2014 Meeting no. 12
17 March 2014 Meeting no. 13 4.
5.
6.
31 March 2014 Meeting no. 14 26 May 2014 Meeting no. 15
03 June 2014 7. Meeting no. 16 01 September 2014 8. Meeting no. 17
Issues Security Department to be strictly involved regarding: visitors coming to the hospital inspection of personal belongings violent behavior of patient IPSG Awareness campaign
Resolved
Unresolved
Status
Closed
The IPSG Awareness Campaign was cancelled – Meeting no. 20 – 14 Dec. 2014
To be discussed after the IPSG education
2 days campaign every month
Questionnaires to be prepared regarding IPSG Standards Presentation of the 6 IPSG in the hospital lobby
Pending
Closed
Discussed the IPSG campaign
Approval of allocation of budget for IPSG campaign Education brochure from one of the Nurses was presented to the Team and it was approved and for printing Plan for the campaign – August 12,2014 Budget, Materials needed, Booths, Prizes and Giveaways and Promotional materials Taglines from each IPSG will be given by each group
Lists of materials needed for the campaign
Closed
The taglines was approved Meeting no. 19 - 15 Sept. 2014 The lists of materials needed for the campaign was finalized. a letter to be sent to the Administration regarding the budget for the campaign. – Meeting no. 9 – 15 Sept. 2014
9.
10.
8 September 2014 Meeting no. 18
Discussed the pending issues regarding the IPSG Campaign
Remarks
Closed
25
No. 11.
Date of meeting
Issues
15 September 2014 Meeting no. 19 14 December 2014 Meeting no. 20
Update for the IPSG Campaign
12.
28 December 2014 Meeting no. 21
13.
IPSG Education during Departmental Morning report
Resolved
Unresolved
Status Closed
On going
Time out was not done completely in OR
Closed
Patient ID Band color coding Patient identification P&P – Hugs and kisses to be included in the policy Tracer by the IPSG Team
Pending Pending
KPI for each IPSG IPSG 1. Identify patient correctly a. Patients identification b. Medication Administration
Remarks
Need to clarify some issues regarding the form.
Pending
Open
IPSG.2 Improve effective communication a. Critical Result – Policy and procedure b. SBAR Hand over communication Policy and Procedure
Open
IPSG.3 Compliance for storage of high alert medication Labeling of high alert medication IPSG.4 Ensure correct site, correct procedure and correct patient surgery a. Time out b. Site marking IPSG.5. Reduce the risk of Healthcare associated infections a. compliance to hand hygiene b. Healthcare associated infection IPSG.6. Reduce the risk of patient resulting from falls a. Falls rate – Pedia and adult b. % of compliance to assessment of falls Policy
Open
The Policy was made and the KPI was finalized but not yet implemented
Open
Done – Infection Control
Pending
26
Chapter Name Team Leader No.
Date of meeting
: ACCESS TO CARE AND CONTINUITY OF CARE (ACC) : Dr. Abdelhaleem Bella Issues Follow-up JCI findings: ACC.1.1 – Holding of patients in Emergency Room P&P ACC.1.1.1 – Triage Policy and Procedure ACC.1.1.3 – Treatment Delays Policy and Procedure
1.
14 January 2014 Meeting no. 18
ACC.2.1 – Transfer and Transport of Patients Between Services Policy and Procedure. Inter-services transfer of patient form Hospital Transfer Form ACC.3 – Admission, Discharge, Transfer and Criteria Policy and Procedure Out on Pass Policy and Procedure ACC.3.2.1 – Discharge Instruction Form ACC.3.3 – Significant Data sheet Form ACC.3.5 – Patient Refusal to Treatment & Discontinuing of Treatment DAMA form Discharge Summary form ACC.4.3 – Inter Hospital Transfer Form ACC.5 – Transfer & Transport of patient P&P Referral of request for Consultation Form Physician’s shift to shift Hand-off Communications Form Continuity of care within KFHU Policy and Procedure
Resolved
Unresolved
Status
Done –meeting no 22 – 10 June 2014 Done –meeting no 22 – 10 June 2014 Done –meeting no 22 – 10 June 2014 Done -01 April 2014 – Meeting no.21
Remarks
Closed
Done- 21 January 2014 – meeting no. 20
For implementation – Meeting no.21 – 01 April 2014
27
No.
Date of meeting
Issues Outpatient Clinic Treatment Record Form ER Crash Area Policy and Procedure Process of Inpatient Admission Policy and Procedure
2.
3. 4.
5.
21 January 2014 Meeting no. 19 18 Feb. 2014 Meeting no. 20
01 April 2014 Meeting no. 21
Elective admission of patients Policy and Procedure Follow up meeting for JCI standards Referral from OPD to Physiotherapy Preparation for the upcoming visit of the external Consultant. ACC.1 Policy that includes acceptance care in OPD, admission criteria, list of screening tests required before admission, transfer or referral. ACC.1.2 – delay Policy include only minor delays like Physician is 30 minutes late ACC.2 Revise the Policy on holding patients in ER to include all the requirements and educate staff on the 3 process ACC.2.2.1 – no policy or process in providing information for the patient upon admission Flowchart – Patients flowchart starting admission Policy and Procedure in holding the patients within 4 to 6 hours ACC.3.2 – Develop a Policy in transferring care responsibilities and Physician ACC.4.1 – PFE policy and Procedure to be revised Forms need revision
6.
10 June 2014 Meeting no. 22
Education/ lecture to be conducted after revising the forms and policy for the inpatient admission
Resolved
Unresolved
Status
Remarks
closed
closed
28
Chapter Name Team Leader No.
: ASSESSMENT OF PATIENT (AOP) : Dr. Abid Hussain Gullenpet
Date of meeting
Issues Radiology safety program Service contract and warranty of all biomedical equipment in Radiology Department Lists of chemicals to be provided by the Medical Store Director Nursing forms
13 January 2014 1. Meeting no. 17
Physiotherapy recommendations from the JCI findings PPM stickers
Staff competency checklists departmental meeting regarding the infection control/ Fire and Safety Program Temperature gauge and checklist for hydro collator hot packs and tank false fire alarm bell activated in the dept.
Assessment and Reassessment of patient Policy Nutritional screening Policy and Procedure 2.
21 January 2014 Meeting no. 18
Physiotherapy Policy and Procedure Pain assessment and Management P&P End of life care P&P
3.
17 February 2014 Meeting no. 19
4.
25 March 2014 Meeting no.20
13 May 2014 5. Meeting no. 21
Resolved
Unresolved
Status
Remarks
On going Open
To be checked the FMS Chapter
On going Open
In process – SQE Chapter
Done
Follow up meeting AOP.1 to AOP.4 – Policy and Forms Radiology Policy and procedures Radiology Policy and Procedure presentation
29
Chapter Name Team Leader No.
: CARE OF PATIENT (COP) : Dr. Haya Mojil
Date of meeting
Issues COP.1 – Plan of Care implementation - finalizing the nursing care plan Education to be done by the NQI Coordinator COP.3.1 – Care of Patient in ER Policy and Procedure COP.3.2 – Code Cardio Pulmonary Resuscitation (CPR) Policy and Procedure for adult and Pedia Education on crash cart COP.3.3 – Blood and blood product transfusion P&P COP.3.4 – Care of patient in life support system P&P
1.
COP.3.5 – Care of Patient with communicable disease P&P COP.3.7 – Use of restraints for adult & children P&P COP.3.8 – Care of vulnerable patients P&P 01 January 14 Meeting no. 15
COP.3.9 – Care of Patient receiving Chemotherapy P&P COP.4.1 - initial nutritional assessment form – education COP.6. – Pain assessment and management P&P COP.7 end of life care policy and procedure
15 January 2015 Meeting no. 16 19 February 3. 2014 Meeting no. 17 2.
25 March 2014 Meeting no. 18
Unresolved
Status
Remarks
Done – Meeting no. 18- 25 March 2014
Closed
Meeting no. 16 – 15 January 2015
Follow up meeting Follow up meeting
Physician stamp
DNR Form must have a place to sign the family
COP.5.2 High risk population policy 4.
Resolved
Closed
Most Physicians have stamp The DNR form will sign by Two Physicians only, the family will not sign.
30
No. 5.
Date of meeting 08 April 2014 Meeting no. 19
06 May 2014 Meeting no. 20 20 May 2014 7. Meeting no. 21 13 August 2014 8. Meeting no. 22 17 Sept. 2014 9. Meeting no. 23 6.
Issues
Resolved
Unresolved
Status
Educational plan – The Policy that involves the COP Chapter was distributed to all members to prepare slides for education
Closed
Follow up meeting for the task given to the COP members.
Closed
Follow up meeting – education on Policy
Closed
Follow up meeting – education on Policy
Closed
Follow up meeting – education on Policy
Closed
Remarks
31
Chapter Name Team Leader Co-Team Leader No.
: ANESTHESIA AND SURGICAL CARE (ASC) : Dr. Dalal Bubshait : Dr. Alaa Mohammad Khidr
Date of meeting
Issues Surgical wound classification Policy and Procedure Sending patients to operating room P&P Asc.7.1 stamp template Policy and Procedure
1.
14 January 2014 Meeting Minutes no. 13
ASC.2 lack of uniformity of implementing and monitoring during the post procedure recovery ASC.3 P&P on Procedural sedation/analgesia ASC.5.1 – P&P Anesthesia Consent ASC.7 – Surgical Care Assessment information Patient Management in RR P&P
2.
11 February 2014 Meeting no. 14
3.
22 April 2014 Meeting no. 15
4.
13 May 2014 Meeting no. 16
ASC.7.4 – a policy and procedure to be developed regarding the special consideration needed in planning surgical care that involves the implanting of medical devices. ASC.7.4 – Implanting medical device policy and procedure: Medical device logbook Adverse event form Surgical site verification Anesthesia Pre-Operative Clinic (APEC) Policy and Procedure Sedation course Follow up meeting
Resolved
Unresolved
Status
Remarks
Available but not yet implemented
--
--
--
32
Chapter Name Team Leader No.
: QUALITY IMPROVEMENT AND PATIENT SAFETY (QPS) : Dr. Ahmed Al Kuwaiti
Date of meeting
Issues
Resolved
QPS Plan
KPI – measurement of selection and data collection
1.
Data validation Policy and Procedure
Analysis and validation of measurement data
Sentinel events, RCA Policy and Procedure Near Miss Monitoring of pre-op and post op diagnosis – DQS staff will be a member of Tissue Review Committee.
2.
20 January 2014 Meeting no. 6
Status
Remarks For signature
To be updated by Ms. Susan Al Yami Policy and Procedure is available but not yet implemented.
Performance Measures Policy and procedure
7 January 2014 Meeting no. 5
Unresolved
Dietary department survey form
On going
Customer satisfaction questionnaire form
On going
Discrepancies in the pre-op and Post-op Diagnosis Gaining and sustaining Improvement – Nursing Department PI Project
Open
To be monitored On going
33
Chapter Name : GOVERNANCE LEADERSHIP AND DIRECTION (GLD) Team Leader : Dr. Mohammed Al Jumaan Co-Team Leader: Dr. Ahmed Al Kuwaiti No.
1.
Date of meeting
Issues
05 January 2015 Meeting no. 18
GLD.1 Hospital Bylaws – to include the role and responsibility of the University Council Performance self-assessment form for Governance (HEC) Yearly assessment on monitoring of function/responsibility GLD.2 – Chief executive – Hospital Organization Structure to be included the job description and responsibilities of each hospital leaders. GLD.3 – Hospital Leadership Accountabilities; Scope of Service policy and procedure for revision Hospital website to be updated
Patient information handbook GLD.3.2 Effective communication throughout the hospital GLD 4 & 5 Key Performance Indicators must be aligned with the Hospital’s strategic Plan GLD.6 Description of nature and scope of service for the clinical and non-clinical contract. 18 November 2. 2014 Meeting no. 19
GLD education Sample questionnaires were given to members
Resolved
Unresolved
Status
Remarks
through UD email
34
Chapter Name Team Leader No. 1.
: FACILITY MANAGEMENT AND SAFETY (FMS) : Dr. Ahmed Al Kuwaiti
Date of meeting 19 January 2014 Meeting no. 16
Issues Detailed report on JCI mock survey was distributed to the following department. Staff education program ROOFTOP: Door leading to rooftop sign board “Restricted area, Authorized Person Only” Penetration near entrance door
Wall of Terrace is too low need to raise the wall to 1.5 meter Scrap items Elevator Room- need one telephone in case of emergency Chairs and trash to be removed in the rooftop and to maintain area clean Flood lights are normally fixed at every 3meters April 2014 Meeting no. 17 2.
Safety side rails Expansion joints Hazmat (diesel) stored inappropriately in plastic bottles Duct cleaning Exhaust outlet from the isolation rooms Exit sign on the door of rooftop KITCHEN: Access not restricted Use of PPE – instruction board
Resolved
Status
Remarks
24 April 2014- Meeting no. 18
24 April 2014- Meeting no. 18
Closed
To be discontinued Done -17 July 2014 –Meeting #24
Dishwasher temperature was not being monitored. Food trolley
Unresolved
35
No.
Date of meeting
Issues HOSPITAL WIDE: Fire hose cabinet Inspection for fire extinguisher
3.
Resolved
Unresolved
Open
ID Cards of staff First aid box expired at medical supply store and not available in CSSD and Laundry
Eye wash instruction Fire training Housekeeper is not aware of dilution and contact time of disinfection and cleaning supplies Batteries are being thrown in general waste
Meeting no. 17- 030414
Arrived but not yet distributed
24 April 2014 Meeting no. 18
Policy and Procedure for Laundry Dept.
Training done
Clear instructions in the stairway at ground floor Planned Preventive Maintenance sticker LAUNDRY: Proper signage – to be fixed in the door for some restricted area
On going
Use of mobile phones
5.
17 July 2014 – meeting #24
Pocket mask
4.
To be discontinued
Emergency stop button Log sheet
Remarks
Directive sign for assembly point in Emergency exit stairway Floor levels at emergency exit stairway
Status
A policy to be made For discussion
On going
Done – 03 July 2014 Meeting #23
36
No.
Date of meeting
Issues
Resolved
Signboard is required to identify clean and dirty area
Ceiling tiles to be replaced Segregation of chemicals inside the cabinet First aid kit, eye wash and chemical spill kit 6.
Fire hose cabinet inspection log not filled WASTE COLLECTION ROOM: Waste collection room in trolley without biohazard symbol RADIOLOGY DEPARTMENT: Non-magnetic fire extinguisher needed for MRI Cleaning schedule for all mechanical shafts Lockers inside dressing room
Curtains in ultrasound Fire extinguisher block by trolley
Done - 16 Oct. 2014 – Meeting no.25
Emergency stop button to be identified and labelled. Radiation leak surveillance
Remarks
240314 – Meeting no.18
Washing sink between clan and dirty area
CSSD: PPM Stickers to be available in all equipment with date of maintenance and due date
Status
Store room: No smoke detector Low pressure fire extinguisher
Unresolved
05 June 2015 – Meeting no. 21
16 Oct. 2014 – Meeting no.25
No call system inside bathroom
Door louvers to be taken out from office
37
No.
Date of meeting
Issues Wall corner – to be clean X-ray control area fix extinguisher placed at wrong height
08 May 2014 Meeting no. 19
Many boxes blocked fire hose cabinet Ladder Fire extinguisher was placed in the floor
CHEMICAL STORE: Eye wash instruction to be posted both in Arabic and English Fire extinguisher, first aid box and chemical spill to be placed outside the chemical store NFPA diamond and label in laboratory and main store ENDOSCOPY: Sterilization room: negative air pressure required
Remarks
03 July 2014 – Meeting #23
Pest control MSDS master inventory along with all MSDS’s
Status
MEDICAL SUPPLY STORE: Sprinkler system Temperature recording - freezer
Unresolved
No smoke detectors in IVR
7.
8.
Resolved
19 June 2015 –Meeting #22
done
Trolley blocked fire blanket
ICU: Biohazard specimen bag is being used for storing items
done
Medication refrigerator without sticker.
LABORATORY: Portable or privacy shower curtain around emergency shower Exit door blocked by machine
done
Not required
38
No.
Date of meeting
Issues
Resolved
Unresolved
Daily log temperature Female patient inside the room, put signage outside the room MSDS inventory along with all MSDS’s to be available Op-sire spray to be included in MSDS
9.
Formalin bottle was leaking
Remarks A follow up letter was sent to the admin. 22 May 2014 – Meeting #20
Fabric chairs DENTAL: Biohazard waste overflowing and mixing of general waste – Ms. Enas will give training. CARDIAC LAB.: Patient medical records easily accessible through the computer since computer was not log off OPERATING ROOM: Clock to be repaired
Status
17 July 2014 –Meeting #24
A letter was sent to Cardiac Lab. done done done
Ongoing
done
done
done
Eye washer should be away from electrical power Dusty ventilation in male changing room Additional fire extinguisher
10.
22 May 2014 Meeting no. 20
Damaged flooring OTHER BUSINESS: Delivery Room needs Head shower PSYCHIATRIC DEPT.: Exit sign at the entrance All electric panels in the building should be kept locked at all times. key shall not be left inside the panel door Fire hose material to be changed
To be checked
03 July 2014 – Meeting #23
Done
39
No.
Date of meeting
Issues All exposed cables inside clinics to be channeled to floor level indication to be written to avoid misuse by the patient Cleaning gas cylinder Fungal in the ceiling tile to be replaced All elevator and mechanical rooms to be identified and labeled and no smoking signs to be fixed Full body harness to be fixed at entrance to rooftop.
11.
All emergency exit light is not working Staff locker rooms to be labeled All elevators to have instruction board All fire extinguisher to be hanged outside the room Janitor room without sign and cabinet to store cleaning supplies Housekeeping trolley to be changed Training for Mr. Strong CATH LAB.: Ladder to be stored upright and chained or to be placed horizontally on the floor Changing room – specified for female and for male Accumulated dust on the arm of radiation machineequipment need to be cleaned regularly Crash cart should not be obstructed Distal water without opening date – write the date of opening of the bottle Fire extinguisher was blocked Exit sign
Resolved
Unresolved
Status
Remarks
Done
17 July 2014 – Meeting #24 done Done
16 October 2014 – Meeting #25
16 October 2014 – Meeting #25 Ongoing - 16 October 2014 – Meeting #25
03 July 2014 – Meeting #23
40
No.
Date of meeting
Issues
Resolved
Emergency stop button – identify and label Cables channeled to avoid misuse by the patients HEMODIALYSIS: Monitoring of Hemodialysis store Corridor need to have one exit sign Sharp container Emergency stair way indication levels needed Emergency exit light to be fixed Isolation room: a contact precaution need to be displayed in the door
Emergency Stairway level EMERGENCY DEPT.: Noticed that biohazard specimen bag used for storing
Wheelchair to be inventoried and labeled. Cleaning schedule for wheelchairs to be maintained Temperature medication to be monitored in ambulance kit Oxygen cylinder in ambulance to be monitored and checked regularly
Fire extinguisher in ambulance without PPM sticker Electric shaver QC should be performed for the tire and engine regularly and it should be documented Temperature monitoring and hand sanitizer in ER Morgue Isolation room – call bell More racks for supplies
Status
Remarks To be checked
Curtain hanger very dusty
Unresolved
17 July 2014 –Meeting #24 To be checked To be checked 17 July 2014 –Meeting #24
17 July 2014 –Meeting #24
03 July 2014 – Meeting #23 16 Oct. 2014 – Meeting no.25
Done -17 July 2014 –Meeting #24 Done 16 Oct. 2014 – Meeting no.25 To be checked
Done -17 July 2014 –Meeting #24 Done -17 July 2014 –Meeting #24
41
No.
Date of meeting
12.
13.
05 June 2014 Meeting no. 22
Issues ER Store room in the basement needed emergency exit light in the exit door and a key and the key box should be available FSM implementation Plan Disaster Management Plan for handling epidemics Security: Review of Translated policies New Policies and forms
14.
03 July 2014 Meeting no. 23
Fire and Safety Fire risk Assessment Program 6 old policies + ILSP + Fire Safety Equipment impairment Disaster Management Procedure for handling influx patient Procedure for assigning nurses staff Disaster Preparedness training and drill program P&P for handling routine emergencies Written protocol for identifying location for keeping infected patients during an emergency Responsibilities and mode of action – KFHU fire Brigade Hazmat P&P on handling Hazmat and annual inventory form as per GHS in process. Safety Guidelines
Resolved
Status
Remarks
Done – 03 July 2014 – Meeting #23
Done
Done – 16 Oct. 2014 – Meeting no.25
Done In progress –16 Oct. 2014 – Meeting #25 Done -16 Oct. 2014 – Meeting no.25 Done - 16 Oct. 2014 – Meeting no.25
done
Pending-16 Oct. 2014 – Meeting no.25
Utility Systems – P&P Biomed – P&P 15 KPI Definition forms discussed
Unresolved
Done 2 KPI form Laboratory was not Approved by Dr. Hissa- 17 July 2014 Meeting #24
42
No.
15.
Date of meeting 17 July 2014 Meeting #24
Issues Fire extinguisher inventory
Resolved
ďƒź
Unresolved
Status
Remarks In progress, mostly completed
Follow up meeting
43
Chapter Name Team Leader Co-Team Leader No.
: STAFF QUALIFICATIONS & EDUCATION (SQE) : Ms. Nadia Al Nassri : Ms. Basma Al Khudairy
Date of meeting
Issues Unannounced tracer in Human Resource Department General orientation manual Proposal of 3days orientation program for all staff and the contractor to be included. BLS requirement and specialization to be included in job description Credentialing/ Verification of license Primary source verification (data flow)
1.
Recruitment policy and procedure 75% completed files in HR Hospital organization Chart 2.
22 January 2014 Meeting no. 9
5.
18 September 2014 Meeting no. 12
Unresolved
Status
Remarks Meeting no.9 – 22 January 2014
On going
Hospital Telephone directory – to be updated Lists of sub-contractual employees
Open
On going
Random review of Allied health job description
Open
not yet completed
Employee’s handbook
Done
For approval – meeting no. 12 – 18 Sept. 2014
Auditing report
Open
On going
Open
On going
Open Open
For approval For approval
Job description of all staff must be available 02 April 2014 3. Meeting no. 10 16 April 2014 4. Meeting no. 11
Resolved
Lists of staff competency Updated lists of staff for the new hired employees need to be submitted to the Team Leader. Lists of KFHU staffing plan for 2014-2015for all department was presented to the members Continuous Professional Development Policy and Procedure Training and staff development Policy and procedure CME Activities for 2014-2015
44
Chapter Name Team Leader Co-Team Leader No.
: MANAGEMENT OF INFORMAION (MOI) : Dr. Abdullah Hosni Al Reddy : Dr. Hanan Al Ghamdi
Date of meeting
Issues
Resolved
Unresolved
Status
Remarks
Policy and Procedures – for review Maintaining information Security and data integrity Policy and Procedure Maintaining patient information Privacy & confidentiality Policy and Procedure
09 February 2014 - Meeting no. 14
16 March 2014- Meeting no. 16
16 March 2014- Meeting no. 16 16 March 2014- Meeting no. 16 18 February 2014 - Meeting no. 15 Letter was sent-18 February 2014 - Meeting no. 15 The system had been in used for more than 10 years 18 February 2014 - Meeting no. 15 18 February 2014 - Meeting no. 15
Retention of medical records
1.
02 January 2014 Meeting no. 13
Hospital data and information retention, time, storage and destruction Approved abbreviations Administrative policy and procedure Preparation of Policies and procedures and document control Review and revision schedule of policies and Procedures Confidentiality of patient information Documentation standard – emphasizing the use of stamp Survey form Closed cabinets/bags/sign in sheets needed for transport in and out of MR files
2.
09 February 2014 Meeting no. 14
Open
Health information system Maintaining Information Security and Data Integrity Policy and procedure Education and training in principles of information use and management – to be included in hospital Orientation program
Closed
45
No.
Date of meeting
Issues
Resolved
Unresolved
Status
Remarks
Critical areas to have closed cabinet to store MR files 3.
4.
18 February 2014 Meeting no. 15
Record Review Team must be a composed members who are authorized to make entries in the patient’s record Psychiatry Department/ Dialysis Unit has a separate filing system for patient’s records
MR files accessible only to Psychiatrist and Nurses
Needed a process for completion of patient’s medical records
Closed
Process on requesting file form in and out patient department 5.
16 March 2014 Meeting no. 16
Meeting room for file review
18 February 2014 - Meeting no. 15
Follow up issues in the Medical records Department: Fire extinguisher inside MR Emergency exit signage 6.
29 October 2014 Meeting no. 17
Ramp was very high Roof was open
AC in the filing room is in the floor MOI questionnaires Shadow files in dialysis unit
Closed
Door lock - electronic 7.
05 November 2014 Meeting no. 18
IT department to be involved in the Hospital Orientation Program MOI Plan
21 January 2015 – Meeting no. 19
46
Chapter Name Team Leader No.
Date of meeting
: MEDICAL PROFESSIONAL EDUCATION (MPE) : Prof. Maha Abdelhadi Issues Obtain details of the training program Obtain details of facilities used in the training program
1.
05 January 2014 Meeting no. 5
Ensure adequate space for equipment Ensure safety of patient and staff Design standard continuous evaluation forms to ensure trainee supervision Design monitoring forms to ensure compliance of teaching staff
Resolved
Unresolved
Status
Remarks
47
Chapter Name Team Leader No.
Date of meeting
1.
12 October 2014
: HUMAN SUBJECT REASEARCH PROGRAM (HRP) : Dr. Fahad Al Khamis Issues
Clinical research committee to be involved in this chapter SCRELC Manual
2.
Resolved
19 October 2014 Policies and procedure
Unresolved
Status
Remarks
Open
Done but to be formatted as per Hospital Policy and Procedures format.
48
Chapter Name Team Leader Co-Team Leader No.
: PFE and PFR JOINT CHAPTER MEETINGS : Mrs. Nada Al Amri : Dr. Amani Al Nimer
Date of meeting
Issues Consent for surgical and invasive procedure P&P
Resolved
Patient’s and Family rights & Responsibility P&P Provision of Privacy during care of treatment P&P Admission instruction booklet DAMA form The process to be added in the Policy and Procedure showing the common barriers that might be encountered during patient care Process on how to respond to religious support 1.
Process to guide staff on privacy and confidentiality Protection of patient’s personal belongings P&P DNR Policy and Procedures Withdrawal of critical care support Care of vulnerable patient policy and Procedure End of life care Policy and Procedure Pain assessment and Management Policy and Procedure
2.
11 Sept. 2014 – Meeting no. 6
Pain assessment forms Patient and Family complaints form/ Policy and Procedure – Legal department to be added Education on hospital Policy and procedure relating PFE and PFR chapter General and informed policy Hospital forms patients and families about how to choose to donate organs and other tissues
Status
Remarks
Hospital Information handbook Patient’s and Family rights & Responsibility booklet
Unresolved
Open
11 Sept. 2014 – Meeting no. 6
Flyers only
11 Sept. 2014 – Meeting no. 6
11 Sept. 2014 – Meeting no. 6 11 Sept. 2014 – Meeting no. 6 11 Sept. 2014 – Meeting no. 6 11 Sept. 2014 – Meeting no. 6
11 Sept. 2014 – Meeting no. 6
12 January 2015 – Meeting no. 7
49
Executive Summary It was established in April 2014 to define the desired education, skills, knowledge and frequency of ongoing evaluation for all KFHU staff to meet patients need. The unit established mechanisms for gathering, verification and reevaluating the credentials of those clinical hospital staff to provide patient care and build a quality professional staff. Also, it made soft copy and hard copy of clinical privileges for clinicians (specialists and consultants) available to those locations in KFHU hospital in which the medical staff member will provide services. It ensures continuous monitoring of competencies for physician and allied health providers to increase patient safety and quality of care. To maintain and improve JCI-SQE standards, we have to measure elements. This report reflects the enormous effort that goes into measurement and provides patient care in compliance with medical staff bylaws, credentialing and privileging policies & procedures, regulation and clinical department requirements. I. 1. 2. 3.
4.
5. 6.
7. 8.
SQE required measurement standard Recruitment process – There is Recruitment Plan. Job description for employee –74.4% of the total Departments in KFHU which compliance comparing with 25.6% are not. Process of staff evaluation (probationary and annual period) – All medical staff members (Physicians, Nursing & Allied medical services) and non- medical staff members are evaluated on periodic basis (probationary and annual period) to ensure continuing competences in their positions. There are 40% of Allied Clinical Departments in KFHU which are using competency evaluation to monitor their staffs. The clinical and nonclinical Departments used MCS appraisal template for their staff. Staff orientation : New clinical staff, new non-clinical staff, contractor workers , medical Interns, medical student, volunteers – there are 95.1% of new clinical staff members, 71.2% of medical students, 85.2% of medical Interns and 84 volunteers are oriented to hospital. Non-clinical staffs and contract workers are not orient to hospital. There are no documents or statistical data of departments orientation for new non-clinical staff, contractor workers, medical Interns, medical student, volunteers. BLS/ ACLS/ATLS – percentage certification are 20% of the new staff (January 2014December 2014) compliance and 80% did not respond. OPPE – Ongoing Professional Practice Evaluation is an evidence-based privilege process that continually monitors physician’s competency and is part of a decisionmaking process. Primary source verification (Medical – Nursing – Allied) - started by HR and waiting for data. Staffing Plan – Making an inventory of present manpower resources, assessing the extent to which these resources are employed optimally and forecasting future manpower
51
requirements in different Hospital Departments initiated on November, 2014. There are 37% of the total Departments in KFHU which compliance. 9. Personal file content for new staff as following: Not Applicable
CURRICULUM VITAE SECTION
1. 2. 3. 4.
Curriculum vitae Degree/ professional certificate Letter Of Appointment (for leadership positions) Job Description (signed)
1. 2. 3. 4. 5. 6.
Country of Origin Credential Process Documentation Saudi Commission Registration Document Verification CPR/BLS Privileging
PERFORMANCE EVALUATION
1. 2. 3.
Probationary Period Evaluation Annual/ Yearly Evaluation Competency assessment (Nursing)
ORINTATIONS AND CONTIUING EDUCATION
1. 2. 3. 4. 5. 6.
Available 67 % 98%
74%
26%
100%
Not Applicable 27%
LICENSE IN LINE WITH JOB
Not Available 33% 2%
Not Available 9% 66% 49%
Available 64% 34% 51%
63%
80% 13%
20% 24%
Not Applicable 4% 97% 52%
Not Available 85% 1% 43%
Available 11% 2% 5%
Not Applicable
Not Available 75% 93% 93% 86% 89% 79%
Available 25% 7% 7% 14% 11% 21%
Hospital Wide Orientation Department Orientation Job Specific Orientation Continuing Education Training in Specialty Confidentiality statement ( signed)
Table 4: Personnel File Content
10. Continues education-14% of new staffs that provided continues education to HR while 86% did not respond.
11. Occupational health safety of staff (employee health clinic & safety handling ) 12. Privileging / Re-Privileging – The granted clinical privileges started in May 2014 for consultants and specialists in KFHU. There are 69% of the privileges granted to physicians in 2014. II. Status of each required evidence
Graphs: -
Graph for personal file content of the Physicians Staff
52
Figure 13 – Graph for Personnel File Content for Physicians
Curriculum Vitae Section 40 35 30 25 20 15 10 5 0
Available Not Available Not Applicable
- CV: Curriculum Vitae - Professional Certificate: Degree/Professional certificate - Letter of Appointment: Letter of Appointment (for leadership positions)
Performance Evaluation 40 35 30 25 20 15 10 5 0
- Competency assessment (Nursing)
Available Not Available Not Applicable
License in Line with Job 40 35 30 25 20 15 10 5 0
Available Not Available Not Applicable
- License: Country of Origin - C.P.D: Credential Process Documentation - S.C.R: Saudi Commission Registration
Orientations & Continuing Education 35 30 25 20 15 10 5 0
- Hospital Wide Orientation - Department Orientation - Job Specific Orientation - Continuing Education - Training in Specialty - Confidentiality Statement
Available Not Available Not Applicable
-
Graph for personal file content of the Nursing Staff
Figure 14 – Personnel File Content for Nursing Staff
Curriculum Vitae Section 80 70 60 50 40 30 20 10 0
Available Not Available
License in Line with Job 80 70 60 50 40 30 20 10 0
Available Not Available
Not Applicable
- CV: Curriculum Vitae - Professional Certificate: Degree/Professional certificate - Letter of Appointment: Letter of Appointment (for leadership positions)
Not Applicable
- License: Country of Origin - C.P.D: Credential Process Documentation - S.C.R: Saudi Commission Registration
Performance Evaluation 80 70 60 50 40 30 20 10 0
Available Not Available Not Applicable
Orientations & Continuing Education 80 60 40 20 0
Available Not Available Not Applicable
- Competency assessment (Nursing)
- Hospital Wide Orientation - Department Orientation - Job Specific Orientation - Continuing Education - Training in Specialty - Confidentiality Statement
54
-
Graph for personal file content of the Technician Staff
Figure 15 – Personnel File Content for the Technician Staff
Curriculum Vitae Section 40 30 Available 20
Not Available
10 0
License in Line with Job 40 30 20 10 0
Available Not Available
Not Applicable CV
Not Applicable
Professional Letter of Job Certificate Appointment Description
- CV: Curriculum Vitae
- License: Country of Origin
- Professional Certificate: Degree/Professional certificate - Letter of Appointment: Letter of Appointment (for leadership positions)
- C.P.D: Credential Process Documentation - S.C.R: Saudi Commission Registration
Performance Evaluation 40 30 20 10 0
Available
Availavble Not Available Not Applicable
- Competency assessment (Nursing)
Orientations & Continuing Education 40 30 20 10 0
Not Available Not Applicable
- Hospital Wide Orientation - Department Orientation - Job Specific Orientation - Continuing Education - Training in Specialty - Confidentiality Statement
55
-
Graph for personal file content of the Dietitian/ Bid-med. Technician.
Figure 16 – Personnel File Content for Dietitian / Bio-Med Technicians
Curriculum Vitae Section 5 4 3 2 1 0
License in Line with Job 5 4 3 2 1 0
Available Not Available Not Applicable
Available Not Available Not Applicable
- License: Country of Origin
- CV: Curriculum Vitae - Professional Certificate: Degree/Professional certificate - Letter of Appointment: Letter of Appointment (for leadership positions)
- C.P.D: Credential Process Documentation - S.C.R: Saudi Commission Registration
Performance Evaluation 5 4 3 2 1 0
- Competency assessment (Nursing)
Available Not Available Not Applicable
Orientations & Continuing Education 5 4 3 2 1 0
Available Not Available Not Applicable
- Hospital Wide Orientation - Department Orientation - Job Specific Orientation - Continuing Education - Training in Specialty - Confidentiality Statement
56
-
Graph for personal file content of the Clinical Privilege.
Figure 17 – Granted Clinical Privileges
Granted Clinical Privileges - 2014
31% Privilege Non Privilege
80 70 60 50 40 30 20 10 0
69%
All Physician Privilege
57
- Graph Job Description for all staff. Figure 18 – Job Description for All Staff
Job Discription for All Staff 80.0% 70.0% 60.0% 50.0% 40.0%
Available
30.0%
Not Available
20.0% 10.0% 0.0% Job Discription
-
Graph for competency of Allied Medical Staff. Figure 19 – Competency of Allied Medical Staff
Competency of Allied Clinical Department 70% 60% 50% 40%
Available
30%
Not Available
20% 10% 0% Job Discription
II. # 1 2
3
Strength and Opportunities for improvement
Strength Recruitment Plan is available Job description was implemented in Academic Affairs, Training, Anesthesia, Dentistry, Dermatology, Emergency Room (ER), Family & Community Medicine Center, Health Information & Medical Records, Human Resources Department, Infection Control, Information Technology (IT) & Date Processing Department, Internal Medicine, Laboratory Medicine Department, Medical Supply &store, Neurology, Neurosurgery, Nursing, Nutrition-Dietary Therapy, Obstetrics & Gynecology, Department of Ophthalmology, Orthopedics, ENT, Pediatrics, Pharmacy, Physiotherapy, Psychiatry, Directorate of Quality & Safety, Radiology, Respiratory Therapy, Social –Medical Service, Surgery, Urology, Operation & Maintenance. The Departments that provide a uniform, consistent for processing staff evaluation as the following: I. The Competency evaluation implemented in Nursing, Physiotherapy, Laboratory and Pharmacy. II. The clinical and non-clinical Departments used MCS appraisal template for all their staff.
Opportunities for improvement Housekeeping, Security Service, Patient Relation & Right Administration, Security Services, Biomedical Services, Laundry Service, Telecommunication, Purchasing, Housing Department, General Store and Administrative Communication, Finance are not complying to submit Their specific Job description.
The process of staff evaluation (probationary and annual period ) did not yet implement in the following departments: I. The Competency evaluation did not implement in Respiratory Therapist, Radiology, Social Services, Dietary, Patient Relation and rights, Emergency Medical Services. II. The probationary & annual evaluation for new non-clinical staffs did not yet review. III. 9% new clinical staffs (January 2014December 2014) have probationary evaluation from the total new staff (clinical & non-clinical staff) in 2014. IV. 8% new clinical staffs (January 2014December 2014) have annual evaluation from the total new staff (clinical & non-clinical staff) in 2014.
59
# 4
Strength Staff orientation: most of clinical medical staffs, medical Interns, medical student and volunteers are oriented to hospital. There are department orientations.
5 6
Only subjective OPPE applied for most of clinical physicians (Consultants, Specialists, and Residents).
8 10 11 12 Privileging
Opportunities for improvement Staff orientation: non-clinical staffs and contract workers are not orient to hospital. There are no documents or statistical data of departments’ orientation for new non-clinical staff, contractor workers, medical Interns, medical student, volunteers. BLS/ ACLS/ATLS –80% of certification are not available in new personal file. There is no objective OPPE.
Staffing Plan Continues education There is no Occupational health safety manual for staff. Re-Privileging
60
V.
Improvement action plan.
# Issue 1 Process of staff evaluation (probationary and annual period )
2 Staff orientation
Action plan 1. Send follow up letter to all clinical specific departments to submit competency evaluation. 2. Send letter to all non-clinical departments to submit Job description specific appraisal. 3. Follow up with consider Department every two weeks. 1. Requesting from Purchasing Department to submit all the list of contract workers from different companies. 2. Send the list of contract workers to Academic affairs to assign them in Hospital orientation schedule. 3. Implementation & review Hospital orientation of nonclinical staffs. 4. Mentoring and staff development
-
Responsible C&P Unit. Human Resource Department.
-
Purchasing Department.
-
Administration Hospital departments
-
C&P unit Data analyst (Satiation) Clinical Department
Time frame Five-six month
Five-six months
and review Hospital orientation for contract workers & non-clinical.
5. Coordinate with Department heads and supervisors to provide department orientation of new non-clinical staff, contractor workers, medical Interns and medical student. 3 OPPE
1. Submit general indicator that apply to all medical department to be discuses with medical team for review and approve. 2. Hospital Director will review and give a feedback 3. Document preparation. 4. Education 5. Pilot the process 6. Implement in cooperate comment based on feedback 7. Go life with implementation 8. Compliance the process
-
Three-Six months
61
# Issue 4 BLS/ACLS/ATLS
1.
2.
Action plan Coordinate with Department heads and supervisors to provide BLS/ACLS/ATLS certification of new staffs. Require all health care providers to update BLS/ACLS/ATLS. Follow up with HR Department. Require to provide us monthly report.
5 Primary source verification (Medical – Nursing – Allied)
1.
6 Staffing Plan
1. Follow up individually to the remaining departments who did not submit the staffing plan. 1. Communication with Doctor in EHS clinic to do manual of staff Occupational health safety
7 There is no Occupational health safety manual for staff
2.
Responsible - C&P unit - Academic Affairs
Time frame Three–Four months
-
HR Department
Six months
-
C&P unit All Hospital Departments Employee Health Clinic (EHS)
Three months
-
Three months
62
VI.
Challenges to achieve 100% compliance: I phase problem to get the list of all contract employees in the hospital to make Hospital orientation. Speed of response of, HR, Medical Departments Allied Health Services, and Administrative Department.
VII. Recommendation The one of the representative from the following department I will coordinator with him/her to prepare evidence and implement them: 1. 2. 3. 4. 5. 6.
HR Department Nursing Department Medical Departments Allied Health Services Academic Affairs Contract employees
63
64
EXECUTIVE SUMMARY This annual report presents highly selective achievements for Environmental Safety Unit of the Directorate of Quality & Safety during 2014. In the face of challenges, the unit continued to pursue activities critical to the department’s mission, while prudently undertaking JCI implementation measures. Over the past three years, the unit has functionally consolidated numerous duties related to environmental safety oversight, thereby increasing efficiency of KFHU’s Facility Management And Safety (FMS) Programs. The unit has 2 primary areas of responsibilities, monitoring & controlling environmental safety and implanting and monitoring compliance to JCI standards on FMS. The responsibility of oversight of activities related to JCI implementation rests with the Director of the Directorate of Quality & Safety (DQS) who ensures that quality activities are carried out in accordance with strategies and policies determined by the hospital governance. This unit provided a leadership role and is a key partner in the implementation of FMS requirements of JCI. Environmental Safety Unit continued as an active participant in the environmental safety monitoring program and has positively contributed in establishing a safety environment for KFHU patients, visitors, staff & students. The unit audits are designed to provide baseline data to gauge the magnitude of compliance to safety requirements; to assist in identifying safety breeches in the environment of care; and to enhance deterrence.
ENVIRONMENTAL SAFETY MONITORING ROUNDS Number of audits carried out every year has increased steadily and this year the unit successfully covered all areas in the hospital. Some departments were audited twice during the past year. In 2014, environmental safety unity completed the second audit cycle carrying out 90 initial visits and numerous follow up visits. Figure 1& 2 illustrates the departments audited and frequency of audits during 2014. Figure 20: Areas Audited in 2014 Areas Audited Jan-14 1A (ICU), 1B, 1C, 1D Cardiology, Cath Lab Main OPD, Dental, Neurology Basement Offices
Feb-14 Building 510 Psychiatry Medical Supply Store RT, Urology, CSSD, PT Laundry
Mar-14
Apr-14
Dermatology
O&M Service Building
Radiology, ENT Ophthalmology Waste Collection Room Electrical Store Near Mosque
ER
May-14
Jun-14
Day Surgery
Pharmacy
Laboratory
July-14
Electro Mechanical Rooms
Nil
Blood Bank
Aug-14
EHS
Nil
Sep-14
Oct-14
4A, 4B, 4C, 4D, 4E Fire alarm control room, IT, MRD Biomedical Room, Communication (switch board) Roof top Housing Transportation Building, Project offices
3A, 3B, 3C, 3D, 3E Main OPD, Cardiology OPD Dental OPD Neurology OR
65
Nov-14
December-14
Lithotripsy, Laundry
Physiotherapy, RT
1A (2), 1B (2), 1C (2), 1D (2), 1E (2)
Emergency Room, Doctors Room
Diagnostic Laboratories main hospital & Building # 500 (2)
Psychiatry, EHS, Blood Bank
2A. 2B, 2C, 2D, 2E Service Buildings - Store Admin Other Offices
Figure 21: Frequency of audits in 2014
Frequency of Audits December November October September August July June May April March February January 0
2
4
6
8
10
12
14
16
A total of 76 audit reports were released (some areas were clubbed together while reporting) by the unit during this cycle. Cases where significant finding were identified, the unit conducted follow up visits to ensure that the findings had been properly addressed and that improvements was made on weaknesses identified. Some cases also required follow up visit to assess the effectiveness of remedial actions taken. Few cases of serious non-compliance were referred to the president for further action. The departments’ enthusiasm to implement the identified action plan focused at reducing safety risks within their area is evident from the following graphs. Figure 3 illustrates the level of compliance to safety requirements at various departments. Figure 22: Department compliance to safety requirements during 2014 100% 80% 60% 40% Basement…
EHS
O&M -…
Electrical…
Waste…
CSSD
Laundry
Urology
RT
Building 510
Cath Lab
1D
1C
Neurology
Dental
Cardiology
4E
4D
4C
4B
4A
0%
Medical…
20%
66
Departments with significantly low compliance to safety requirements were Medical Supply Store, Laundry, Waste Collection Room, Morgue, Building 510, Electrical Store Near Mosque, Service Building, Biomedical Room and Housing at Site 2. Various improvement initiatives were rolled out at many of these departments to address issues identified. However, there has been notable increase in some department’s compliance to safety compared to previous year. Figure 4 illustrates the improvements in level of compliance to safety requirements at various departments. Figure 23: Comparison of safety compliance during 2014 with previous year 100% 90% 80% 70% 60% 50% 40%
2013
30%
2014
20% 10% 0%
SOME OF THE SIGNIFICANT ACHIEVEMENTS 1. Revised the checklist for environmental rounds making it comprehensive and easy to use. 2. Facilitated to initiate renovation at laundry department through recommendations laid down in environmental rounds report. 3. Established guidelines for storage space 4. Compiled and finalized Hospital Disaster Manual & KFHU Safety Guidelines 5. Completed approximately 90% of FMS documentation 6. We have effectively collaborated with departments to implement FMS related initiatives like the following: a. Successfully coordinated to establish radiation protection program at radiology and dental department. b. Emergency eye wash stations were installed in area with risk of hazardous material splash hazard. c. Medical equipment maintenance program d. HazMat inventory management program
67
7. We closely worked with hospital disaster & safety committee to address all safety issue in the hospital and improve the hospital’s preparedness to manage emergencies. 8. We coordinated a 10 day consultation for FMS during March 2014 as an effort to evaluate safety of the environment of care and to analyze the preparedness for JCI accreditation. Most recommendations given by the consultant were reviewed and implemented as needed. 9. Training: We facilitated training sessions for 9 topics focused at FMS requirements in addition to general orientation training for new hire as illustrated in Figure 5. Figure 24: FMS Related Training in 2014
Emergency Preparedness (Code Responses)
36
Emergency Management, (Evacuation, RACE &…
16
Code Mr. Strong
23
Code Red
23
Code Pink
23
Safety
23
Hospital Lockdown
23
Safety for Housekeeping & Warehouse
44
Security Contract Monitoring
6 0
5
10
15
20
25
30
35
40
45
50
Number of Participnts
PLANS FOR 2015 1. JCI Accreditation: a. Direct all activities of the unit towards achieving 100% compliance to FMS standards of JCI. b. Complete FMS documentations as per JCI requirement c. Establish FMS-KPI Monitoring System d. Facilitate implementation of ‘Emergency Drill’ program. e. Closely monitor the various FMS programs in the hospital namely Safety Management Program, Security Management Program, Hazardous Materials Management Program, Emergency Management Program, Biomedical Equipment Management Program, Utility Systems Management Program and Fire Safety Management Program. 2. Training: a. Accomplish intensive training initiatives across the hospital to improve staff awareness on ‘Facility Management & Safety’ based on JCI requirements. b. Effectively implement ‘Train-The-Trainer’ program in the hospital c. Facilitate establishment of full-fledged ‘Occupational & Facility Safety Department’
68
3. Coordinate for up gradation of were Waste Collection Room & Morgue aimed at meeting national regulatory requirements. 4. Continue to be actively involved in the ongoing Environmental Safety Inspection Program.
69
70
EXECUTIVE SUMMARY This annual report covers the months of January to December 2014. It documents, with thanks, the vision and commitment of H. E. Dr. Abdullah Al-Rubaish, President of University of Dammam, to the Directorate of Quality and Safety, headed by Dr. Ahmed Al Kuwaiti. The report charts the completion of most of the policies and procedures, plans, forms, job descriptions, strategic plans, scope of service and other pertinent documents. Department Coordinators for Quality worked hard to complete the requirements of the JCI. These documents are now published in the intranet of the hospital making the information more accessible to hospital staff. With this progress, the hospital is now more equipped in attaining its goal which is to obtain JCI Accreditation in the near future. POLICY & PROCEDURES King Fahd Hospital of the University (KFHU) started to developed policies and procedures in 2013. These documents will help hospital staff in doing their work in accordance to the mission and vision of the hospital. They are there to ensure quality of service and to promote patient safety in its full standard. And for ease of accessibility, these policies are now uploaded in the intranet of the hospital. One can easily view them in any of the computers of KFHU. Most of the departments have completed their policies and procedures. However there are still few who have not submitted (see Table 1) the desired documents. The department is looking forward in completing the policies from the different departments of the hospital. Below is a summary of number of policy and procedure signed, approved and uploaded in the intranet.
71
Table 5: List of Total Number of Policy and Procedures in each Department
Department Administration Anesthesia Biomedical Dentistry Dermatology Dietary Directorate of Academic Affairs & Training Directorate of Quality & Safety Emergency Room Health Information System Housekeeping Infection Control Information Technology Internal Medicine Laboratory Medical Supply Store Neurology Neurosurgery Nursing Obstetrics & Gynecology Operations and Maintenance OPD Ophthalmology Orthopedics Otorhinolaryngology Pediatrics Pharmacy Physiotherapy Psychiatry Radiology Respiratory Therapy Safety and Occupational Health Security Surgery Urology TOTAL
Total 129 10 10 0 8 48 4 12 26 82 20 22 10 90 798 10 0 7 14 47 37 29 0 0 7 42 1 22 14 11 38 6 2 7 6
Signed 129 10 10 0 8 48 4 12 26 82 20 22 10 90 798 10 0 7 14 47 37 29 0 0 7 42 1 22 14 11 38 6 2 7 6 1569
72
JOB DESCRIPTIONS Every employee of the hospital must have a job description. Job descriptions of the medical and technical professionals are given to the respective departments and staff, duly signed by them and secured in the employee’s file in the Personnel’s Office. Signed job descriptions are distributed to the departments so employees can avail of the own. They are also uploaded in the intranet of the hospital for easy viewing. Non-medical job descriptions are still being generated and will be ready in few weeks. Table 6: Job Descriptions submitted by each Department
Department Departments with signed Job Descriptions
No Job Description Submitted
Anesthesia
Housekeeping
Dentistry
Patient Relations
Dermatology
Biomedical
Dietary
Laundry
Directorate of Quality & Safety
Telecom
Emergency Room
Purchasing
Health Information System
Housing
Internal Medicine
General Store
Infection Control
Communication
Information Technology
Finance
Laboratory
Personnel
Neurology
Support Services
Neurosurgery Nursing Obstetrics & Gynecology Ophthalmology Orthopedics Otorhinolaryngology Pediatrics Pharmacy Physiotherapy Psychiatry Radiology Respiratory Therapy Surgery Urology
73
Percentage of Departments with Job Description
NonSubmission 32%
Submitted 68%
Figure 25 – Percentage of Departments with Job Descriptions
FORMS With the evaluation of the JCI consultants on our forms, there was a recall of forms from all the units in the hospital. Revisions and reprinting were made several times. Then, finally, forms in its final version are now available in the Stationery Store. They are also uploaded in the intranet for easy viewing of its most up-dated version. Table below summarizes the number of forms, which are printed and can be viewed in the intranet. Currently there are 435 forms that are developed.
74
Table 7: Number of Forms Available, Printed and Uploaded in the Intranet
No. of Forms
Printed Priority Forms
Uploaded in INTRANET
Admin Form
144
78
78
Anesthesia
12
9
9
Clinics
21
18
18
ER
6
6
6
Internal Medicine
35
31
31
Neurology
5
4
4
Neurosurgery
5
5
Obstetrics & Gynecology
16
11
Orthopedics
3
3
Pediatrics
12
2
2
Psychiatry
7
7
7
Surgery
13
5
5
Urology
2
2
2
Dietary
4
3
3
Laboratory
17
12
12
Pharmacy
9
5
5
Physiotherapy
8
5
5
Radiology
9
8
8
Respiratory Care
9
8
8
Dental
12
7
7
DQS
3
3
3
Sociomedical Sevices
5
5
5
Infection Control
4
Nursing
74
74
74
TOTAL
435
311
303
Form Proponent
11
75
CLINICAL PATHWAYS Clinical pathways are care maps, integrated care pathways or guidelines used to manage the quality in healthcare concerning the standardization of care processes. Clinical pathways promote organized and efficient patient care based on evidence based practice. Clinical pathways optimize outcomes in the acute care and home care settings. Our hospital has developed several clinical pathways which are now being implemented. The table below shows the number of clinical pathways available. Table 8: No of Clinical Pathways Available
Form Proponent
No. of Clinical Pathways
Anesthesia
4
Dental
5
ER
7
Internal Medicine
2
Neurosurgery
5
Obstetrics & Gynecology
5
Orthopedics
3
Pediatrics
4
Surgery
8
Number of Clinical Pathways Anesthesia Dental ER Internal Medicine Neurosurgery Obstetrics & Gynecology Orthopedics Pediatrics Surgery
Figure 26 – Number of Clinical Pathways
76
SCOPE OF SERVICE The Scope of Service of a department or clinic defines the details of the services it provides. It is the detailed summary of what the department or clinic caters, what it offers to the public and its limitations. Most of the departments of KFHU have submitted their scope of service. Unfortunately, there are still some who lack this document. The table below shows the departments who submitted their scope of service and those who did not. Table 9: Signed Scope of Service of Each Department
Department Signed SOS
No SOS
Administration
Dermatology
Anesthesia
Dietary
Dentistry
Emergency Room
Directorate of Academic Affairs & Training
Health Information System
Directorate of Quality & Safety
Neurology
FAMCO
Neurosurgery
Infection Control
Obstetrics & Gynecology
Information Technology
OPD
Internal Medicine
Ophthalmology
Laboratory
Pharmacy
Nursing Operations & Maintenance Orthopedics Otorhinolaryngology Pediatrics Physiotherapy Psychiatry Radiology Respiratory Therapy Security Surgery Urology
77
Percentage of Signed Scope of Service
No SP 26%
Signed SP 74%
Figure 27 – Percentage of Signed Scope of Service
STRATEGIC PLAN Every department of KFHU has a plan for the future. In order to achieve their goals, every department must plot what they aim in a strategic manner. This way the status of the goal can be easily tracked or monitored. The table below shows the departments that have signed strategic plans and those who did not.
78
Table 10: Signed Strategic Plans of Each Department
Department Signed Strategic Plan
Not Signed Strategic Plan
Anesthesia
Administration
Allied Medical Services
FAMCO
Dentistry
Human Resources
Dermatology
Information Technology
Dietary
Laboratory
Directorate of Academic Affairs & Training
Neurology
Directorate of Quality & Safety
OPD
Emergency Room
Pharmacy
Health Information System
Security
Housekeeping
Support Services
Infection Control Internal Medicine KFHU Medical Supplies Neurosurgery Nursing Obstetrics & Gynecology Ophthalmology Orthopedics Otorhinolaryngology Patient Relations Pediatrics Psychiatry Radiology Respiratory Therapy Sociomedical Services Surgery Urology
79
Percentage of Signed Strategic Plan
No SP 26%
Signed SP 74%
Figure 28 – Percentage of Signed Strategic Plan
The ACTION PLAN for the Documents Control Unit: 1. Updated Job Descriptions that will expire in 2015. 2. Ensure that all staff had filled up the right job description for the position. 3. Complete the required documents such as Scope of Service and Strategic Plans from the departments who have not submitted yet. 4. Continue to update the Intranet of the hospital. 5. Ensure up-to-date documents in the stationery.
80
81
OVERVIEW In adherence with the mission, vision and values of the King Fahd Hospital of the University (KFHU), one of the key objectives of the organization is to provide exceptional healthcare in a safe and patient-centered environment, monitoring and continually improving patient care and safety. The Risk Management Unit of the Directorate of Quality and Safety conducts activities for the purpose of minimizing, if possible eliminating risks and potential harm thru the following components: 1. 2. 3. 4. 5. 6.
Risk Identification Risk Prioritization Risk Reporting Risk Management Investigation of Adverse Event Management of Related Claims
This report provides a comprehensive summary of the Occurrence Variance Reports (OVRs) received by the Risk Management Unit for the year 2014. Data were collected, thoroughly analyzed and presented in a simple format. The aim of this report is to highlight the identified opportunities for improvement and come up with solutions for the system and process failures. This report provides an assessment of the actual and potential risks in the KFHU in addition to recommendations on how to prevent recurrence of these risks. The report consists of the following components:
Introduction Top 10 Reported OVRs Analysis of OVRs IPSG related OVRs Sentinel events and Near misses Initiatives Conclusions and Recommendations Goals for the year 2015
82
INTRODUCTION A total number of nine thousand one hundred fourteen (9114) Occurrence Variance Reports (OVRs) were received by the Risk Management Unit (RMU) for the year 2014. An increased number of reporting has been noted since year 2012, as shown in Figure 29, the year when reporting of OVR has been introduced by the Directorate of Quality and Safety. Increased awareness of OVR reporting and giving importance to the “culture of safety� approach, contributed significantly in the increase number of OVRs submitted to the Directorate of Quality and Safety - RMU. Figure 29: OVR received
Number of OVR Received Yearly 10000 8000
9114 7986
6000 4000
3520
2000 0 Year 2012
Year 2013
Year 2014
As shown in Figure 30, in the year 2014 during the month of July (Ramadan), only 663 OVRs were received in which it was the lowest. The top three months wherein the highest amount of OVRs received where January, May and August. Figure 30: Monthly OVR for 2014
OVRs Received Monthly for 2014 1000 900 800 700 600 500 400 300 200 100 0
878 756 726 767
827 786
802 663
669
743 740 757
The Risk Management Unit considers incidents that happened inside the hospital premises as reportable occurrences.
83
Out of the 9114 OVRs submitted, 591 were categorized as non-OVR. Break in skin integrity which included hematoma, peeling, and pressure ulcer upon admission were the most recurrent type of NonOVR reported. Figure 31: OVR vs Non-OVR
OVRs and Non-OVRs received 591
OVRs Non-OVRs
8523
Total OVRs: 9114
The most active reporter of OVR was the Department of Nursing Services with a total number of 8821 (97%) of the total OVRs received. It was followed by the Medical Services and the Allied Medical Services in which the Department of Laboratory Medicine and Physical Therapy were included. Increased awareness and education are still in progress to make non-reporting or not that frequent reporting departments partake further in Risk Identification.
Figure 32: OVR by Reporter
Reporting Departments Others
35
Infection Control
42
Support Services
10
Allied Medical
77
Medical Services
Total OVRs: 9114
125
Nursing
8821
OPD
4 0
2000
4000
6000
8000
10000
84
Figure 33: Status Involvement
In-patient variances were the top most reported OVR followed by the Emergency Room and Ambulatory. or Out-patient. “Others� pertains other than the Inpatients, Outpatients, ER patients, Visitor and employee.
Status Involvement in OVR Reports 3500 3000 2500 2000 1500 1000 500 0
3169 2840
1166 19
1131
157
41
TOP REPORTED OVRS
Figure 34: 2014 Top Reported OVR
Top 10 Reported OVRs for 2014 1800 1600 1400 1200 1000 800 600 400 200 0
1590 1289 812
699
568 330
242
186
159
145
In 2014, Overstaying of patient in ER and Left Against Medical Advice (LAMA) continued to be the top two (2) reported variance since 2012. Break in skin integrity, OR cancellation and Line, tube, drain or catheter reported variances had decreased in number, while Procedure cancellation was included in the top reported occurrence for 2014 and landed on the third spot.
85
Overstaying of patient in ER Overstaying of patient in ER pertains to cases wherein patients stay in the Emergency Room for more than 6 hours. Though there was a decrease of reported overstaying of patients as compared to 2013 (as shown in Figure 35), it is the third year that this category was the top most reported OVR. Seventeen percent (17%) of the OVRs received for the year 2014 were about the above said category. Figure 35: Overstaying from 2012-2014
Number of Reported Overstaying of Patient in ER 1800 1600 1400 1200 1000 800 600 400 200 0
1617
1590
Year 2013
Year 2014
784
Year 2012
Figure 36: Reasons for Overstaying in ER
Contributing Factors for Staying in ER for more than 6 hours 800
752
700
586
600
Total: 1590
500 400 300 200
92
100
80
56
24
0 medical reevaluation
bed unvailable
ICU bed not eligible unavailable
Others
isolation bed unavailable
As shown in Figure 36, it was noted that the top three reasons for patient’s overstaying in ER were due to medical re-evaluation (47%), bed in the ward is unavailable (37%) and ICU bed unavailable (6%).
86
A performance improvement (PI) project will be initated on February 2015 to increase the effectiveness of the current process and lessen its recurrence. Left Against Medical Advice (LAMA) Left Against Medical Advice (LAMA) stands for the cases where patients or their families refused treatment or decided to leave the hospital differing to the advice of the healthcare team that was deemed necessary. Out of the total OVRs received in 2014, 1277 (14%) were about LAMA. Three years consecutively, LAMA has been the second top reported OVR reported. Figure 37: Reasons for LAMA
Contributing Factors for LAMA Refused treatment
389
Refused admission
389
Refused to stay in-pt
272
Others
67
Personal
63
Refused to wait
47
Refused further evaluation
Total: 1277
30
Transfer hospital
20 0
50
100
150
200
250
300
350
400
450
Most of the reported LAMA cases were from the Emergency Department (ER). Top reasons for LAMA in ER were refused admission and refused treatment which both had 30% out of the all the reported OVRs in this category. In figure 37, it is further shown other contributing factors for patient leaving against medical advice, which includes refused to wait for results, further evaluation and wants to transfer to another hospital. Patients who went LAMA were asked to sign the KFHU.ADM 101046: Refusal of Admission/Treatment or Release from Hospital Against Medical Advice. A copy of the form is sent to Department of Social Services for follow-up.
87
Procedure Cancellation It was the first time that this category had been a part of the top reported OVRs. Procedure Cancellation pertains to procedures done in the Day Surgery and Short Stay Unit excluding the Procedure or Surgery done in the Operating Room. This includes but not limited to EGD, ERCP, Colonoscopy, IUD insertion, medication infusion (e.g. chemotherapy), excision, and biopsy. A total of 826 (9%) of the OVRs relates to this category. It was very evident in Figure 38 that there was an increased cancellation during the months of June and December. The lowest was during the month of July (Ramadan). Figure 38: Count of Procedure
Monthly Statistics for Procedure Cancellation 110
120
99
100 80 60
60
70
68
78 67
56
54
56
65
43
40
Total: 826
20 0
As shown in Figure 39, the top most contributing factor for Procedure Cancellation is “patient didn’t come” which is uncontrollable as patient’s are mostly ambulatory or Out-patient. Figure 39: Reasons for Procedure Cancellation
Contributing Factors for Procedure Cancellation Others Unfit for procedure Staff unavailable Procedure not required Procedue not required Poor preparation Patient refused Patient not NPO Patient didn’t come Needs further evaluation Patient's condition
34 7 12 12 5 25 38 7
Total:
826 616
18 52 0
100
200
300
400
500
600
700
88
Break in Skin Integrity Break in skin integrity refers to incidents were patients develop skin problems such as hematoma, redness, peeling, blister and pressure ulcer. The problem happened during patient’s hospital stay or acquired and were not upon admission. As shown in Figure 40, the top three types of break in skin integrity of patient here in KFHU were hematoma (51%), redness (19%) and peeling (13%). The causes of hematoma is shown in Figure 41. Redness, which is the second most reported type of break in skin integrity were due to fragile skin tugor or decreased mobility or immobility of patient. Peeling, on the other hand were due to fragile skin turgor or tape removal.
Figure 40: Break in Skin Integrity
Types of Break in Skin Integrity Hematoma
354
Redness
131
Peeling
92
Blister
52
Pressure ulcer
38
Others
20
Abrasion
Total: 699
12 0
50
100
150
200
250
300
350
400
Figure 41: Contributing Factors to Hematoma
Contributing Factors to Hematoma 250
201
200 150
113
100 50
3
16
11
7
3
0
89
As presented in Figure 41, the top contributing factor to hematoma is blood extraction and IV insertion. Patient’s were either on daily blood works, fragile vein or prolonged hospital stay. OR Cancellation This category is related to procedures or surgeries done in the Operating Room that were cancelled. The number of cancelled operations (elective) is a good parameter in assessing the quality of care given to a patient and quality of management system an institution has. As seen in Figure 42, there was a decrease in OR cancellation during the months of July and August and increased monthly upto its peak on December., wherein 79 incidents of cancelled cases were reported. Figure 42: OR Cancellation Statistics
Monthly Statistics of OR Cancellation 90 80 70 60 50 40 30 20 10 0
79 64
60 51 42 32
50 39
37
43 33
24
Total: 554
As shown in Figure 43, the top reasons for OR cancellation were patient didn’t come (16%), patient’s condition (16%) and patient needs further evaluation (12%). Patient’s condition refers to the present existing medical condition of the patient (e.g. with URTI, elevated PT/PTT, hypertensive, infection, elevated blood sugar) which poses increased risk to patient if operation will proceed. Patient needs further evaluation pertains that patient needs further clearance from other departments (e.g. Anesthesia, Cardiology).
90
Figure 43: Causes OR Cancellation
Contributing Factors of OR Cancellation Others
34 23
Time limit
56 13
Patient's condition
116 16
Patient didn’t come
116 13
Needs further evaluation
66 38
ICU/Bed unavailable
63 0
20
40
60
80
100
120
140
Figure 44 illustrates that Department of Surgery(34%), Orthopedic Surgery (17%) and Urology (14%) were the top departments identified involved in OR cancellation. Figure 44: OR Cancellation Involved Departments
Departments Involved in OR Cancellation Surgery
187
Orthopedics
96
Urology
77
Neurosurgery
64
ENT
53
Opthalmology
49
OB Gyne
16
Others
12 0
50
100
150
200
91
Line, tube, drain or catheter Figure 45: Type of Line, tube, drain or catheter
Type of Line, Tube, Drain or Catheter 250
221
200 150 100 50
35
29
18
15
11
NGT
Wound drain
Foley catheter
0 IV Central line infiltration
Others
Table 11: Location of IV infiltration
Location 4B ER 4A OR 4E 2E 3D 4D 1B 1D 3C 4C MICU PICU SICU 2B: NICU 2C 2D 3E RR 1C 3A 3B Cath lab Total:
Total 62 55 16 11 9 8 7 7 5 5 5 4 4 4 4 3 2 2 2 2 1 1 1 1 221 92
Patient’s central line, IV line, NGT, Foley catheter, or wound drain must be regularly assessed for proper placement or checked for patency prior to use. Variances like IV infiltrations, dislodged lines, accidental removal and removal of line by patient were the 6th most reported OVR for the year 2014. 329 (4%) of the reported incidence via OVR were about Line, tube, drain or catheter. As seen in table 11, IV infiltration mostly happens in 4B (Pediatric Medical Ward), Emergency Room and 4A (Pediatric Surgical Ward). IV infiltration is typical for pediatric patients as they have multiple risk factors which includes small or fragile veins, receive medication (e.g. antibiotics) and ambulatory. Fire Protection Fire protection pertains to equipment or system instigated in KFHU that helps in the suppression of fire or risk thereof. In 2014 this category became included in the top most reported occurrences. As shown in Figure 46, the highest reported variance for this category was with the fire alarm wherein it rang even there was no “Code Red” but due to the sensitivity of the alarm to dust, humidity and other factors. Figure 46: Type of Fire Protection Occurrence
Fire-Protection Related OVRs 250
220
200 150 100
Total: 241 50 1
1
12
1
6
Smoke detector
Exit door
0 Education
Fire alarm
Fire alarm Fire glass broken extinguisher
As illustrated in Figure 47, the months with most reported incidence of false fire alarm where during the months of January, wherein there was an ongoing construction or renovation in the hospital, and July and August, wherein there was an increased humidity.
93
Figure 47: Number of False Fire Alarm Monthly
Monthly Number of False Fire Alarm 50 45 40 35 30 25 20 15 10 5 0
44 39
37 23
17
16
15 10
8 3
7 1
Figure 48: Location of False Fire Alarm
Location of False Fire Alarm 100
81
80 60 40 20 20
18 3
21
24
29
23 1
0
The area with the highest incidence of false fire alarm is in the fourth (4 th) floor, wherein 37% of the variance occurred. It was followed by the VIP building (13%) wherein the 2E (Coronary Care Unit) 3E (Male Surgical Ward) and 4E (Female Surgical Ward) are located, and the Psychiatry building (10%).
94
Non Clinical Equipment This category pertains to equipment or devices used not directly with patient care. Examples of these are steel cabinets, call bell, ID band printer, refrigerator, sink, toilet, ice maker, etc. A total of 178 (2%) reported occurrence relates with non-clinical equipment. It meant that the equipment either malfunctioned, needs replacement or repair. The staff informed the Maintenance Department of the problem and job order number will be provided as a reference. Figure 49: Types of Non Clinical Equipment
Non-Clinical Equipment 120 100
98
Total: 178
80 60 40 20
31 15
9
8
6
6
5
0
As shown in Figure 49, the most reported non-clinical equipment malfunctions were from the call bell, ID band printer and refrigerator. Included in the “others� were hand showers, bidet, wall clock, faucet, sink, door bell, copier machine, computer, emergency light, curtain rod and venetian blind. Gas, Power, Water or HVAC In this category relates to the utility systems in King Fahd Hospital of the University. It includes interrupted or unannounced power or water shutdown. It may also pertains in instances wherein an announcement was made but the hours of interruption was prolonged. It could either mean gas (e.g. medical gas, oxygen) or HVAC (Heating, Ventilation and Air Conditioning) variances. For the year 2014, Gas, power, water or HVAC occurrence was included in the ten (10) most reported occurrences in KFHU. A total of 159 (2%) submitted OVRs fell in this category. As seen in Figure 50, the most reported variances were about water shutdown, AC malfunction and power shutdown.
95
Figure 50: Contributing Factors to Gas, Power, water or HVAC
Gas, Power, Water or HVAC related incidents 80 70 60 50 40 30 20 10 0
67
Total: 159
46
26 10
6
4
AC Treated Oxygen leak Power and Power malfunction water issue water shutdown shutdown
Water shutdown
Figure 51: Location of Water Shutdown
Location of Water Shutdown VIP Psychiatry Hospital Ground Floor Basement 4th 3rd 2nd 1st
8 3 3 8 1 12 12 10 10 0
2
4
6
8
10
12
14
Seen in Figure 51 are the areas wherein water shutdown happened. It was frequently reported in the main hospital building from 1st floor up to fourth floor. The factor that caused water shutdown was broken pipe as the hospital was built since 1980’s. There were reported incidences of non-availability of hot water supply. Another top reported variance was the AC malfunction. As shown in Figure 52, the month with most reports were during the month of August wherein humidity was reported to be at its peak and caused problem with the HVAC.
96
Figure 53: AC malfunction reported a month
Number of AC Malfunction a Month 25
20
20 15
9
10 5
6 0
1
0
2
3
2
3 0
0
0
Figure 54: Location of AC malfunction
Location of AC Malfunction 3E OR 1D Medical Store 4A 4E 4C Others 4D
2 3 3 4 5 6 7 8 8 0
2
4
6
8
10
As seen in Figure 54, the area wherein frequent AC malfunction happened on units 4D, 4C and 4E. Admission Related Issue Admission is the process of accepting patients for care and/or treatment. Any variance in the admission process or occurrences that deviates the admission process or procedure in the hospital are considered as an occurrence and reported as an OVR. For the year 2014, this category was included on the most reported OVRs. Out of all the OVRs received, 146 (2%) were about this category. In Figure 55, it is seen the different contributing factors. “No MRSA screening� (26%) was the most reported variance related to admission issues. Included in the list of contributing factors were no MRSA and Acinetobacter screening and poor endorsement or handover communication.
97
Figure 55: Types of Admission Related Issues
Contributing Factors to Admission Related Issues 6
Incomplete MRSA screening
7
Isolation bed unavailable No Acinetobacter screening
8
Incomplete MRSA and Acinetobacter screening
8 9
Patient for further observation
14
Poor endorsement
26
No MRSA and Acinetobacter Screening
30
Others
38
No MRSA screening
0
10
20
30
40
Figure 56: Departments with no MRSA screening result
Departments Involved in No MRSA Screening Result 10
8
8 6 4 2
5
4
4
4
4
3
3 1
1
1
0
Figure 56 shows the Departments wherein transferred cases from other hospitals were accepted without MRSA screening result.
98
INTERNATIONAL PATIENT SAFETY GOALS (IPSG) The International Patient Safety Goals promotes patient safety. It highlights the measures needed to ensure safe care is implemented. In the year 2014, a total of 280 received OVRs were related to IPSG. IPSG 1: Identify Patient Correctly Patient identification is a process used to reliably identify the individual as the person for whom the service or treatment is intended and to match the service or treatment to that individual. As per policy ADM-Gen 01-035: Patient Identification, two identifiers are used for the proper identification of patient which includes patient’s three names (last, first and middle) and the patient’s medical record number. The patient is asked regarding the identifiers and checked against the ID band. Table 12: Contributing Factors to IPSG 1 related OVRS
IPSG 1 related OVRs Others Incorrect name or medical record number Missing ID band Incorrect demographics Filed in wrong medical record Incorrect ID band Incorrect labeling Grand Total
Total 75 21 16 10 1 1 1 125
Table 12 shows the identified variance related to “Identify Patients Correctly (IPSG 1). The most frequent reported type of occurrence associated with IPSG 1 were connected with ID band, either it was unreadable or cut (please see figure 57), Incorrect name or medical record number registered in the patient’s facesheet and ID band was missing. ID band is essential in identifying the patients as it is where the nurse will check the details the patient was verbalizing. Figure 57: Types of “Others”
Contributing factors to "Others" Refused to wear ID band
2
No ID presented
1 1
Incomplete ID band Manual ID band
3
Label incomplete
2
ID band removed by patient
9
Unreadable ID band
29 28
Cut ID band
0
5
10
15
20
25
30
35
99
IPSG 2: Improve effective communication Effective communication should be timely, accurate, unambiguous and well understood by the recipient, reduces errors and results in improved patient safety. Communication can either be electronic, verbal or written. Patient care circumstances that can critically impair effective communication include verbal and/or telephone orders, reporting of critical results and handover communication. Policies had been prepared as a guide to improve effective communication within King Fahd Hospital of the University which includes the following: Goal:
Policy:
IPSG 2: Verbal and/or Telephone
ADM Gen 01-029: Verbal-Telephone Order
IPSG 2.1: Reporting of critical results
ADM Gen 01-034: Timeliness of Reporting of Critical Values ADM Gen 01-054: Radiology Panic Results
IPSG 2.2: Handover Communication
ADM Gen 01-153: Handover Communication (SBAR)
Figure 58: IPSG 2 related OVRs
IPSG 2 related OVRs 35 30 25 20 15 10 5 0
33
14
Poor handover
Critical result reporting
In the year 2014, a total number of 47 reported variances pertains to IPSG 2: Improve Effective Communication. Thirty-three (33) occurrences were about delay in Critical Result Reporting in which the Laboratory personnel was not able to relay to the physician the result within thirty (30) minutes. Fourteen (14) reported variances pertain to “Poor handover” wherein pertinent information about the patient was not relayed by the healthcare staff to the receiving staff. Poor handover of patient includes “precautions” associated with the patient not relayed or the transferring staff not aware, patient being transferred to the unit without informing the unit staff about it and not knowing the present situation of the patient.
100
IPSG 3: Improve the Safety of High Alert Medication Medications are part of the patient treatment plan. Appropriate management is critical to ensuring patient safety. Any medication, even those purchased over the counter or without prescription, if used improperly can cause injury. High Alert medications cause harm more frequently and the harm they make is likely to be more serious when given in error. King Fahd Hospital of the University’s Department of Pharmacy had developed policies and procedure to improve the safety of high alert medications and managing the safe use of concentrated electrolytes. For the year 2014 there was no reported incidence related to IPSG 3 which may include but not limited to inappropriate labeling or storage, dispensing, administration, and documentation. IPSG 4: Ensure Correct-Site, Correct-Procedure, CorrectPatient Surgery Wrong site, wrong procedure, wrong patient surgery is an alarming occurrence in hospitals and included in the list of reportable Sentinel Events. These errors results from ineffective or inadequate communication between members of the surgical team, lack of patient involvement in site marking and lack of procedures for verifying the operative site. King Fahd Hospital of the University has formulated a policy ADM-Gen 01-036: Surgical Site Verification to ensure a process for ensuring correct site, correct procedure and correct patient surgery. Figure 59: Department Involved with IPSG 4 related OVRs
Department Involved with IPSG 4 related OVRs 3.5
3
3 2.5
2
Total: 9
2 1.5
1
1
1
1
General Surgery
Urology
Opthalmology
Internal Medicine
1 0.5 0 Vascular Surgery
ENT
As seen in Figure 59 are the involved Departments wherein there was non-compliance to the above stated policy. There was no site marking on the patient or the site marking form was not completed. Strict compliance to the policy was reiterated to the involved Departments and close monitoring was done.
101
IPSG 5: Reduce the risk of healthcare associated infection Infection prevention and control is a big challenge in most health care settings and rising rates of healthcare associated infections are a major concern for patients and health care practitioners. Infections common to all healthcare settings include catheter associated urinary tract infection, bloodstream infections, and pneumonia often associated with mechanical ventilator. Hand hygiene is important in preventing transmission of infectious microorganisms. ADM Gen 01-028: Hand Hygiene policy was made to provide indications and techniques for proper hand hygiene. The hospital adopted and implements current evidence-based hand hygiene guideline wherein it is posted in appropriate areas (i.e. sink or scrub sink), and staff are well educated of proper hand washing and hand
IPSG related Figure530: IPSG 5OVRs related OVRs 20 18 16 14 12 10 8 6 4 2 0
19
disinfection procedure.
4
In year 2014, a total of 23 variances were reported as an OVR related to IPSG 5.
Healthcare Associated Infection Non compliance to Policies and Procedures Figure 60: IPSG 5 related OVRs
As seen in Figure 60, nineteen (19) OVRs pertains to Non-compliance to Policies and Procedures particularly Hand Hygiene and wearing of personal protective equipment (PPE). Four (4) OVRs were about Healthcare Associated Infection wherein a clean patient contracted MDRO or pseudomonas. It is very evident that the reason why it happened is due to poor hand hygiene compliance of staff caring for the patient. IPSG 6: Reduce the risk of patient harm resulting from falls Many injuries in hospitals to both in-patients and out-patients are a result of fall. The risk for falls is related to the patient, the situation and/or the location. Risks associated with patients may include patients’ history for falls, medication use, gait or balance disturbances, and altered metal status. Patients who have been initially assessed for low risk for falls may suddenly become at high risk. ADM Gen 01-038: Fall Risk Assessment and Intervention Policy is implemented in the KFHU in order to identify patients with risk for falls, establish a process for assessing and re-assessing of patient (both inpatients and ambulatory or out-patients), ensure prompt assessment and intervention of all patient fallrelated injuries, and reduce patient harm from falls by implementing the Universal Fall Precaution to all patients.
102
Figure 61: IPSG 6 related OVRs
IPSG 6: In Patient Falls With Injury 26
Without injury
Out of seventy-six (76) variances received pertaining to patient falls, both in-patient and outpatient, 66% were without injury and 34% were with injury. This is demonstrated in Figure 61.
50
Total: 76
The classification of injury obtained of the patient related to fall is shown in Figure 62. The injuries identified were categorized into three, namely: cut- wound (73%), hematoma or trauma (19%) and fracture (8%).
Injuries Obtained Related to Fall
5 2
19 cutwound
fracture
hematoma
Figure 62: Injuries obtained related to fall
In figures 63 and 64, incidence of fall were correlated or connected to patient’s age and gender. Out of 76 received incident of patients falls, sixty-one percent (61%) or 46 occurrence concerns male and thirty-nine percent (39%) or 30 incidents relates to female. For both male and female the highest numbers of reported variance related to falls were within that range of age as well (ages 19-35, highlighted in red). Illustrated in figure 64, the highest number of falls both for male and female happened within ages 1935 (highlighted in red).
103
Figure 63: Fall Incidence related to Gender and Age
Incidence of Fall in Relation to Gender and Age 16
14
15
14 12
10
9
10 8 6
5
8
Male
6
5
Female 3
4 1
2 0
0-18
19-35
36-50
50-60
61-above
Figure 64: Fall Incidence related to Age and Injury
Incidence of Fall in Relation to Age and Injury 18 16 14 12 10 8 6 4 2 0
17
12
11
10
8 5
4
w/o injury 4
3
2
0-18
19-35
36-50
w/injury
50-60
61-above
SENTINEL EVENTS AND NEAR MISSES For the year 2014, two (2) Sentinel events and 1 Near Miss were reported. Reported Sentinel Events ďƒ˜ Unexpected death of a Patient – On March 16, 2014 at 1112H, patient was brought to the Ultrasound room via stretcher with oxygen inhalation of 5L/min. Vital signs were stable upon transfer. Upon completion of the procedure, it was noted that patient was pulseless. Code blue was activated and was wheeled in to ER as there was no available Crash Cart in the area. Patient was revived but failed. Patient pronounced dead at 1408H.
104
Findings: 1. Non availability of Crash cart in some areas of the Radiology Department.
Action Taken
Crash carts were made available in Radiology Department.
2. Policy & procedure RAD 28-010 vague and unclear.
3. Poor documentation (incomplete) in the referral form
The RAD 28-010: Patient Transfer Policy was revised and for strict implementation. A form was generated KFHU.RAD 28002: Radiology Transfer and Procedure Checklist. It is completed by the referring physician to ensure that patient assessment is done prior to radiological procedure.
Birth Trauma (Injury to Neonate) – On March 23, 2014 at 940H a patient who was primigravida and 28 weeks of gestation gave birth. During the delivery the newborn’s head was accidentally detached from the body. Findings: 1. No existing process or protocol on identifying “High Risk Delivery” or “Shoulder Dystocia.” 2. No consultant available during delivery or no proper channel of communication “Call for Help.” 3. Poor initial assessment of the patient.
Action Taken
A policy was written OBG 18-078: Shoulder Dystocia was made and for strict implementation.
The OBG 18-002: Communication Policy was improved and revised.
The use of form KFHU.OBG 18002: Physician’s Admission History and Physical Assessment – Obstetrics was implemented. Education on filling the form was made for all concerned staff.
Reported Near Miss Incorrect Procedure Documented in the Informed Consent – On December 23, 2014 at 0900H, patient came for a procedure. It was written in the informed consent form that patient was for “Circumcision.” In the Operating Room during the Sign In, during the Assessment of Anesthesia, it was noted that patient already circumcised. Upon review of the admission paper, it was written that patient is for “Bilateral Orchiodopexy.”
105
Findings: 1. Limited OPD time and overbooking as 14-16 patients are seen.
Recommendations
Additional clinic time and staff.
2. Limited Pre-Anesthesia clinic time. (One clinic existing at this time.)
Additional Pre-Anesthesia Clinic
3. Violation of Policy and Procedure ADM-Gen 01-060: Informed Consent. (Informed Consents were pre-filled)
Reinforce, implement and monitor compliance of staff to the policy.
4. Violation of Policy and Procedure ADM-Gen 01-035: Patient Identification.
Reinforce, implement and monitor compliance of staff to the policy.
Reinforce, implement and monitor compliance of staff to the policy.
5. Violation of Policy and Procedure ADM-Gen 01-055: Patient Assessment and Re-assessment.
106
INITIATIVES Risk Management Process
Bilingual OVR Form
Sentinel Event Policy
FMEA: Tube Insertion
Under reporting of Sentinel Events and Near Misses
ADM-Gen 01-095: Occurrence Variance Reporting System has been updated. A “culture of safety” approach was introduced wherein a blame-free or non-punitive environment is applied in King Fahd Hospital of the University to facilitate reporting of errors and near misses. The process of using the results of OVR for improvements was included. The results will be shared to Performance Improvement Unit and other concerned departments for development of action to prevent recurrence. The Directorate of Quality and Safety – Risk Management Unit had updated the OVR form and had it as bilingual (Arabic and English). This change will help the Department to identify more risks happening in the King Fahd Hospital of the University. It was facilitated to encourage Arabic staff to report OVRs. ADM-Gen 01-096: Sentinel Events was updated. A flowchart of the Sentinel Event process was created to simplify and for healthcare staff to better understand the process. The role of leadership was included and explained in the process. The Directorate of Quality and Safety (Accreditation and Risk Management Unit) in collaboration with the Department of General Surgery and Nursing Services had conducted a Failure Mode and Analysis (FMEA) regarding “Chest Tube Insertion in In-Patient Units” to ensure the use of correct technique is done to prevent damage to the lung and surrounding tissue, contamination of the wound and leakage of fluid. Chest tube insertion is a potentially high-risk procedure which can cause infection, bleeding or death if not done properly. The education given during the General Orientation Program was updated and the list of reportable Sentinel Events were enumerated and the reporting of Near Miss was expounded and given more importance. The Risk Management booklet which demonstrates the Risk Management Program in KFHU and includes the list of reportable Sentinel Events and examples of Near Miss will be distributed hospital-wide.
Development of the ADM – Gen 01-111: Responsibilities of Department Head’s in Managing Risks
The policy was developed to define the responsibilities of department heads for managing, controlling and preventing risks or losses, and ensuring a safe workplace.
International Safety Goals
The Directorate of Quality and Safety (Risk Management Unit) and in cooperation with the IPSG Chapter Team, had launched a
Patient (IPSG)
107
Education Campaign
hospital-wide Educational Campaign regarding IPSG. The campaign was being given in both languages, Arabic and English to cater to all hospital employees. A brochure is given to the attendees to guide them and help them better understand what IPSG is all about. The existing policies of the hospital was briefly explained and transcribed in the brochure in a simple manner.
108
CONCLUSIONS AND RECOMMENDATIONS FINDINGS:
RECOMMENDATIONS:
The total number of OVRs increased by 14% this 2014 as compared to 2013. It was due to the continuous education of the OVR reporting system and reaching out to departments who has been identified as not active reporters for the previous year.
Continue conducting and strengthen educational presentation about reporting of Occurrence Variance. Provide continuous feedback to the OVR reporter. Encourage the other departments identified as not active reporters. Reach out and stress out the importance of reporting OVRs as a means in identifying risks. Respiratory Therapy Dietary Social Service Patient Relations and Rights Operations and Maintenance CSSD Dental Biomedical Engineering Promote and implement “Culture of Safety” to encourage staff to report Extreme Risk, Sentinel Event and Near Miss. Exemplify a blame-free or non-punitive environment to encourage staff to report errors or near misses without fear of reprimand or punishment. The result will be shared with the Performance Improvement Unit (PIU) and a Performance Improvement (PI) project will be proposed.
Under reporting of Sentinel Events and Near Misses
An increase of 202% in reporting of Procedure Cancellation. “Patient didn’t come” is the highest contributing factor accounting to 75%. Although there was a decrease in reported “Overstaying of patient in ER” by 2%, it has been the third year of being the top most reported variance in the hospital.
The result will be shared with the Performance Improvement Unit (PIU) and a Performance Improvement (PI) project will be proposed.
220 (2%) of reported OVRs were about false fire alarm occurrence.
Identify the causes and prevent recurrence of false fire alarm. Improve the current system (fire alarm). Encourage all healthcare staff to report all medication related OVRs (i.e. Dispensing, Prescribing, Storage, Administration, Wastage & Documentation) including Near Miss. Work closely and hand-in-hand with the Department of Pharmacy to identify incidents and near misses related to medication. Assignment of OVR liaisons by each department who will work closely with the
Under reporting of Medication-Related OVRs
Feedback not allocated time
submitted
within
109
280 (3%) of the total OVRs received were related to IPSG.
Risk Management Unit (RMU). The RMU will conduct educational sessions to all OVR liaisons about the OVR system and process, including how to respond to letters or request for feedback. Chairmen and department heads needs to reinforce compliance to the policy and provide feedback and action plans within the specified time. Strengthen the awareness of staff about International Patient Safety Goals. Facilitate continuous education thru campaign, tracer activity, and workshop.
GOALS FOR 2015
1 . Improve the occurrence variance system reporting thru: 1 . 1 Implementation of the Electronic OVR (E-OVR) system. 1 . 2 Increased awareness of staff regarding Risk Management strategies (i.e. Risk Management Plan) existing in KFHU and continuous cooperation from all departments. 2 . Increase in reporting of variances, Sentinel Events and Near Misses. 2.1 Facilitating a “culture of safety.”
110
111
INTRODUCTION OVERVIEW: The Performance Measurement Unit of Directorate of Quality and Safety is responsible in general for monitoring the overall Hospital Key Performance measure in both clinical and managerial areas, highlighting areas with improvement opportunity, facilitate the performance Improvement Projects, as well as facilitating some Hospital Committees and some Joint Commission Chapters. The Directorate of Quality and Safety is collaborating with heads of all hospital departments to establish and implement KPIs for all areas with measurable performance. KPIs are an essential tool as they enable the healthcare providers to have reliable information on current and desired standards in healthcare services. KPIs are used to identify where performance is good and meeting desired standards, and where performance requires improvement. PURPOSE: The purpose of this report is to analyze KFHU performance measures for the year of 2014, and compare it with the 2013 performance, to see whether our efficiency in delivering patient care is improving. This report focuses on clinical departments that provide direct patient care as well as nonclinical departments that provide supporting services. KFHU Key Performance Indicators Road Map Road map steps 1. KFHU Key Performance Indicators Selection Criteria: a) Consider the identified hospital priority function in QPS Plan b) Balanced ( covering different aspects of performance) c) Covers one or more of quality dimensions including : Appropriateness Availability Continuity Effectiveness Efficiency Respect and covering Safety Timeliness d) Covers structure, process and outcome e) Prior use in the literature if possible f) Each KPI should be structured to the SMART test; Specific: Goals should be simplistically written and clearly define what you are going to do. Measurable: Exact amount estimated for meeting the goal should be stated. Attainable: Determine how the goal can be reached Realistic: A goal must represent an objective toward which you are both willing and able to work Timely: A goal should be grounded within a time frame 112
2. Define the selected KPI: This should be done through KFHU KPI definition form (Attachment) which includes: KPI name - Performance Measure Description – Code - Data source - Type of measure (structure/ process/ outcome) - Dimension of Performance - Data collection method (retrospective/concurrent) Data collection frequency – Rationale - Operational definition (numerator and denominator/ number/ average/ ratio……) - Benchmarking type (internal/external) 3. Data collection plan: Data collection plan includes the following elements • • • • • •
Person responsible Source of data collection (Automated/ Manual) Tools for data collection (e.g. Checklist/Survey…..) Types of data collection (retrospective /concurrent) Frequency of data collection Data sampling if required: this include sample size calculation
4. Data validation : The data validation process will be done according to defined criteria to determine whether information gathered during the process of data collection is consistent, complete and accurate. For indication and methodology refer to data Validation Policy (ADM-GEN 01-100). 5. Data analysis and interpretation: The process of data analysis includes: 1. Identify Data analysis strategy that includes Compare the performance against a pre-planned target (Target gap analysis). Study data over time to identify trends as well as special cause variations. Benchmarking of data with best practice or with similar organizations either national or international, or from the analysis of previous performance results . 2. Identify data analysis methodologies these include but not limited to Descriptive analysis Frequency Central tendency (Mean/median and mode.( Distribution (e.g. slandered deviation SD.( Statistical process control (control and run charts.( Regression. Correlations. 3. Tools and graphs which include but not limited to Tables Pie chart/Bar chart Histogram Control chart/run chart Pareto diagram Flow chart 113
Fish bone diagram Scatter diagram Box plot 6. Data reporting and communication This includes reporting and communicating the analyzed meaningful information with the data owners, then send the comments, conclusions and recommendations to the decision makers and stakeholders of related processes to improve and sustain performance. PM Unit Annual Report 2014: The following report represents a summary of all above mentioned activities by the Performance Measurement (PM) Unit for year 2014, the report includes the following: 1. 2. 3. 4. 5.
KPI Dashboard (2014( JCI library of measures analysis and interpretations KFHU KPIs ,analysis and interpretation Performance improvement projects conducted in 2014 and there outcomes. Other PI unit activities: a. Committees and JCI Chapters facilitated by PI Unit. b. Record Review Activities (Open and close). c. Hospital Orientation Program. d. Tracer for hospital departments. e. Attending RCA and Sentinel Events Meeting with Risk Management Unit.
114
KFHU Key Performance Indicators (KPI) EXECUTIVE SUMMARY: This key performance indicators report has been constructed to demonstrate the progress of KFHU services towards meeting the targets. With the release of each quarterly report, KFHU reaffirms our commitment to provide quality of care to the patients. In summary, there is increase in the number of the KPIs for the year of 2014 compared to the last year was;  2013: 16 KPIs were implemented  2014: 34 KPIs were implemented. Strength: The following KPI showed positive special cause variations over the past 4 quarters: 1. 2. 3. 4. 5. 6. 7.
Aspirin within 24 hours of arrival for all MI patients Venous thromboembolism prophylaxis (VTE). Use of relievers of children inpatient asthma. Hospital Acquired Healthcare associated Infection. % of resolved Patient complaints within 5 days. % of Laboratory Critical values reporting within 30 minutes. % in patient satisfaction.
Opportunities for Improvement: The following measures showed negative special cause variations over the past 4 quarters which need improvement: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.
Average Length of Stay (ALOS). Bed occupancy rate. Mortality rate. Hospital Acquired MRSA rate per 1000 pts days. Hospital Acquired MRAB rate per 1000 pts days. ICU- CAUTI incidence per 1000 device days. ICU - CLABSI Incidence per 1000 device days. % of hand hygiene compliance. ICU Ventilator-associated pneumonia (VAP) rate. Per 1000 patients days. % of patients who stay longer than six hour in the ER. Pressure Ulcer. Falls Rate. Compliance to patient Identification (%) Blood Culture Contamination rate. Cross match Transfusion ratio. Cesarean Deliveries. % inappropriate patient surgical site marking. 115
19. 20. 21. 22. 23. 24. 25. 26. 27. 28.
Unplanned recovery room stay longer than 1 hour. % OR cancelled. % of OVR for housekeeping in a month. % of soiled linen post wash. % Radiology Report Turnaround Time outlier Rate. KTV Measure for all hemodialysis patient above 1.3% Staff Turnover Rate. % Patient satisfaction (outpatient). % of OVR. % Zero stock level in medical supply.
Figure 65 - KPI Dashboard (2014)
116
KPI Dashboard (2014) cont.…
Figure 66 – KPI Identified versus Implemented
Figure 67 – Improvement levels
117
CARDIOLOGY DEPARTMENT
1. Aspirin within 24 hours of arrival for all MI patients (JCI library of measures)
Figure 68 – Aspirin within 24 hours of arrival
Numerator: number of AMI patients in a month who received aspirin within 24 hours before or after hospital arrival. Denominator: number of AMI patients in a month Target/ Benchmark: (JCI 100%) Analysis: continues stability in the performance in the 4 quarters achieving the target indicating good practice and performance. Recommendation / action plan: keep maintain the same practice and monitoring improvement
118
ICU
2. % Venous Thromboembolism prophylaxis (JCI library of measures)
Figure 69 - % Venous Thromboembolism Prophylaxis
Numerator: number of patient who received VTE prophylaxis or have documentation of why no VTE prophylaxis is given X 100 Denominator: number of patient admitted or transferred to ICU (18 years old and above( Target/ Benchmark: 100% (JCI) Analysis: the performance is improved but still not achieve the target. Recommendation / action plane: The performance is stable but not capable. Need more improvement.
119
OB/GYN
3. % Cesarean Deliveries in Nulliparous with a term singleton baby in vertex presentation (JCI library of measures)
Figure 70 - % of Cesarean Deliveries
Numerator: number of Nulliparous patients delivered of a live term singleton newborn in vertex presentation by cesarean section Denominator: number of Nulliparous patients delivered of a live term singleton newborn in vertex presentation Target/ Benchmark: 30% (WHO) Analysis: the graph indicating that there is stability in the process but still not achieving the target, because our hospital is a teaching and referral hospital Recommendation / action plan: keep the improvement until we reach the target
120
PEDIATICS DEPARTMENT
4. Use of relievers of children’s inpatient asthma (JCI library of measures)
Figure 71 – Use of relievers of children
Numerator: # of pediatric asthma patients who received relievers during hospitalization Denominator: # of pediatric asthma inpatients (age 2 years through 12 years) who were discharged with diagnosis of asthma Target/ Benchmark: 100% Analysis: there is stability in the performance of the KPI achieving the target which is 100%.
121
Recommendation / action plan: to maintain theDEPARTMENT same practice and monitoring NURSING 5. Falls Rate per 1000 patients days (IPSG 6)
Figure 72 – Falls Rate per 1000 patients days
Numerator: # of patient falls in a month (with or without injury) X 1000 Denominator: number of patient days. Target/ Benchmark: < 2.53 National Database of Nursing Quality Indicators (NDNQI). Analysis: There is decline in patients falls rate in the last 3 quarters with stability in the process, this improvement was achieve because of: Implementing the policy for patientsâ&#x20AC;&#x2122; falls. Use the falls material: (Morse Scale & Humpty Dumpty). Use of falls ID band (yellow with black print for high risk falls). Recommendation / action plan: An officially quality improvement project has been initiated with the nursing department to improve the fall rate using the FOCUS PDSA quality tools.
122
6. Hospital Acquired Pressure Ulcer Rate (JCI library of measures)
Figure 73 â&#x20AC;&#x201C; Hospital Acquired Pressure Ulcer Rate
Numerator: number of patients identified with hospital acquired pressure in a month Denominator: number of patient admissions Target/ Benchmark: < 5.21 National Database of Nursing Quality Indicators (NDNQI). Analysis: the rate of pressure ulcer is still high due to lacking of wound management team and shortage of nurses staff. Recommendation / action plan: To initiate a wound care team. Start a PI Project using FOCUS PDCA Methodology to decrease the incidents of pressure ulcer. Pressure Ulcer Staging will be started and the nurses will be educated about it, and the Pressure Ulcer Policy and Procedure will be updated accordingly,
123
NURSING DEPARTMENT, Cont.
7. Nursing Staff Compliance on Patient Identification during medication administration (IPSG 1)
Figure 74 â&#x20AC;&#x201C; Nursing Staff Compliance on IPSG 1
Numerator: number of nurses observed compliant with patient identification policy in a month during medication administration. Denominator: number of nurses observed in the same month. Target/ Benchmark: 100% Analysis: Monitoring of this indicator was started on the 3rd quarter of 2014. There is low compliance in patient identification during the medication administration in the in the 4th quarter, on November and December the result is outside the control limit. Recommendation / action plan: To increase awareness of complying with patient identification through education.
124
INFECTION CONTROL DEPARTMENT 8. Hospital Acquired Healthcare associated Infection (IPSG 5)
Figure 75 â&#x20AC;&#x201C; Hospital Acquired HAI (IPSG 5)
Numerator: hospital acquired healthcare associated infection Denominator: patient days Target/ Benchmark: 5.7 (CDC) Analysis: From June to December there is performance variation due to increase of CLABSI, surgical site infection of post cesarean, and one MRSA outbreak in NICU cause an eye infection. Also it might be because of housekeeping stop working for 2 days. In over all we are in the control chart limits. Recommendation / action plan: to maintain monitoring the infection rate in the hospital to keep it in this range through good practice. To break it down to ICU and other hospital wards.
125
9. ICU Ventilator-associated pneumonia (VAP) rate per 1000 patients days
Figure 76 â&#x20AC;&#x201C; ICU Ventilator-associated pneumonia
Numerator: Number of VAP in a month x 1000 Denominator: Number of device days Target/ Benchmark: <2.2 (National Health Safety Network, CDC) Analysis: The graph shows that there is decrease in the variation noted in the last quarter were the rate of VAP was zero indicating an improvement. Recommendation/ action plan: Improvements are due to proper education to the concern unit and implementation Infection prevention bundle
126
10. % of hand Hygiene Compliance (IPSG 5)
Figure 77 - % of Hand Hygiene Compliance
Numerator:
hand hygiene successes (total number of observed opportunities when hand hygiene
was indicated and was successfully performed) X100 Denominator: hand hygiene opportunities (total number of observed opportunities during which hand hygiene was indicated). Target/ Benchmark: 75% Analysis: The graph shows that there is stability in the process with little increase in the rate, but we did not achieve the target yet, the reason is due to limited # of sinks and alcohol dispenser in the point of care, and noncompliance in attendance of the infection control lectures Recommendation / action plan: 1. Plan to conduct a hand hygiene campaign by the infection control.. 2. Continue reporting the noncompliance of hand hygiene to the general director 3. Provide an alcohol dispenser in all hospital area.
127
11. Hospital Acquired MRSA rate per 1000 pts. Days
Figure 78 â&#x20AC;&#x201C; Hospital Acquired MRSA
Numerator: number of new cases of hospital acquired MRSA Denominator: number of patientsâ&#x20AC;&#x2122; days Target/ Benchmark: 0.38% Analysis: The graph indicate that on July there was outbreak link to staff colonization with MRSA in orthopedic ward, and another outbreak on November from a staff in NICU ward. Recommendation / action plan: to do an annual checkup for all healthcare providers and continue monitoring the process Action plan done: 1. Staff with positive MRSA was excluded from work and decolonized 2. Do staff screening 3. Environmental screening 4. Terminal cleaning 5. Patient with positive MRSA result are cohorted
128
12. Hospital Acquired MRAB rate per 1000 pts. Days
Figure 79 â&#x20AC;&#x201C; Hospital Acquired MRAB
Numerator: number of new cases of hospital acquired MRAB Denominator: number of patients days Target/ Benchmark: 1.2% Analysis: The graph shows there is increase in the rate on December because of the recurrent outbreak specially from ICU because of environmental contamination, unavailability of isolation room, lack of responsibility for cleaning the medical equipment, and staff to patient ratio. Recommendation / action plan: Cohorting of patients with positive MRAB Appropriate using of antibiotic by physicians in surgical prophylaxis and carbapenems Improve hand hygiene compliance Reemphasize environmental cleaning procedure.
129
13. ICU- CAUTI incidence per 1000 device days
Figure 80 – ICU – CAUTI incidence per 1000 device days
Numerator:
Number of CAUTI in a month x1000
Denominator: Number of device days Target/ Benchmark:
≤5.2
Analysis: The graph shows that there is unstable performance from June to December, but it did not exceed the rate of February. Recommendation / action plan: 1. Reemphasize on the indication of fully catheter use. 2. Implementation of CAUTI bundle 3. Add the CAUTI bundle elements to the nursing daily assessment
130
14. ICU-CLABSI Incidence per 1000 device days
Figure 81 â&#x20AC;&#x201C; ICU-CLABSI Incidence
Numerator:
number of CLABSI in a month x1000
Denominator: number of device days Target/ Benchmark: â&#x2030;¤3.0 Analysis: the graph shows that there was decrease in the rate on July since it was Ramadan where the number of patient admission was low. On August, the rate was sharply increase because the unavailability of central line dressing (chlorhexidine) Recommendation / action plan: 1. Reemphasize on the indication of fully catheter use 2. Implementation of CLABSI bundle 3. Add the CLABSI bundle elements to the nursing daily assessment
131
UTILIZATION MANAGMENT 15. Average Length of Stay (ALOS)
Figure 82 â&#x20AC;&#x201C; Average Length of Stay
Numerator: Number of patients days Denominator: Total discharges Target/ Benchmark: 8 days (KFHU) Analysis: compared to the best practice or benchmark, we observed that the ALOS is fluctuating and unstable, this is due to that the beds are not properly utilized; the patients are going out on pass and reserve the beds, also because our hospital is a teaching and referral hospital were many critical cases will be referred. Recommendation / action plan: To have a proper bed utilization; to activate a clinical practice guideline out on pass policy, and have a discharge planning when admitting the patient will decrease the ALOS. Conduct a meeting with the nursing department, DSU unit, and IT department to find a good mechanism and fixed formula to be used by everybody.
132
16. Bed occupancy rate
Figure 83 â&#x20AC;&#x201C; Bed Occupancy (%)
Numerator: number of patients days Denominator: number of active bed days in a month Target/ Benchmark: 75% Analysis: the graph indicating decrease in the occupancy rate which is not reasonable. The BOR is affected by the admission number and ALOS. Number of unoccupied bed in well born unit is one of the factors for decreasing of bed occupancy rate . Recommendation / action plan: review the utilization care process. Review the data collection to obtain the accurate result to monitor the bed utilization. Such discrepancy between the decreased bed occupancy rate and the hospital overflow can be solved by having a bed utilization manager(case manager)
133
17. Mortality rate
Figure 84 â&#x20AC;&#x201C; Mortality Rate per 1000 patients
Numerator: number of deaths Denominator: total patients discharged including deaths. Exclusion: baby still birth Analysis: the rate sudden increase in the 3rd and 4th quarter compared to the 1st and 2nd quarters. Critical cases are referred to our hospital since it is a referring and teaching hospital Recommendation / action plan: Physicians (Consultants) manpower has to be reviewed during such period. To review the data collection, and to keep monitoring
134
PATIENT RELATION
18. Inpatient Satisfaction Rate
Figure 85 â&#x20AC;&#x201C; Inpatient Satisfaction Rate
Numerator: number of patients satisfied Denominator: Total patients completed the survey Target/ Benchmark: 80% Analysis: The graph shows a high level of satisfaction. No data was received for the 3rd and 4th quarters by the Patientsâ&#x20AC;&#x2122; Relation Department due to shortage of staff Recommendation / action plan: coordinate with the patient relation for data collection process
135
19. Out patient Satisfaction Rate
Figure 86 â&#x20AC;&#x201C; Out-patients Satisfaction Rate
Numerator: number of patients satisfied Denominator: Total patients completed the survey Target/ Benchmark: 80% Analysis: The graph shows a moderate level of satisfaction. No data was received for the 3rd and 4th quarters by the Patientsâ&#x20AC;&#x2122; Relation Department due to shortage of staff. Recommendation / action plan: meet with the OPD director and the patient relation and review the process in the clinic.
136
20. % of resolved Patient complaints within 5 days
Figure 87 - % of resolved patient complaints
Numerator: number of complaints resolved within 5 days x 100 Denominator: total number of reported complaints Target/ Benchmark: 100% Analysis: the graph indicates a good performance stability in the 3rd and 4th quarters. In the 2nd quarter the result was outside the control chart limit. Recommendation / action plan: to keep monitoring the improvement
137
RISK MANAGMENT
21. % of Inpatient OVR per 100 admission in a month
Figure 88 - % of inpatient OVR per 100 admission
Numerator:
Number of inpatient OVR X100
Denominator: Total number of admission Data owner:
patient safety unit
Analysis: The graph indicate that the OVR's are in the same rate for the whole year 2014. Recommendation / action plan: Need more education to the staff to increase their awareness in reporting the OVRs to have a good safety culture.
138
HUMAN RESOURSE % Staff Turnover Rate
Figure 89 â&#x20AC;&#x201C; Staff Turnover Rate
Numerator:
Number of staff final exit
Denominator: Total number of staff during the quarter Data owner:
Human resource department
Analysis:
The monitoring of this KPI is started on the 2nd quarter. Need more
Recommendation / Action plan: To wait for the 4th quarter and keep monitoring.
139
LABROTARY DEPARTMENT
22. Cross match Transfusion ration (CT ratio)
Figure 90 â&#x20AC;&#x201C; Cross match Transfusion ratio
Numerator: number of cross matched blood Denominator: number of transfused blood Target/ Benchmark: 1.5% (CAP) Analysis : The graph indicate a high improvement and decreasing in the ratio, achieved the target 1.5, and reach up to 1.2 on December. The cause for this improvement was through: 1. Sending a memo letter to all clinical department to request first the type in screen test then accordantly request the cross match. 2. OVR for the physician who request cross match test and did not use the blood. 3. Start sending thank letters to the department with less number of request cross match test. Recommendation / action plan: keep maintain and monitoring the improvement 23. Blood Culture Contamination rate
Figure 91 â&#x20AC;&#x201C; Blood Culture Contamination Rate
Numerator: number of contaminated blood cultures Denominator: total number of routine blood cultures accessioned Target/ Benchmark: 3% Analysis: the graph show sudden increase in the rate above the benchmark in the 3rd and 4th quarter compared to the 1st and 2nd quarter. Main wards with high BCR are: MICU, NICU, PICU, CCU, Ortho, and female (medical and surgical) Recommendation / action plan: break down the hospital wards to know exactly which ward was the reason of increase the BCR Demonstration by the laboratory to re-educate and train the nurses about the collection of the BCR samples and add it to their assessment. 140
24. % of Laboratory Critical values reporting within 30 minutes (IPSG 2)
Figure 92 â&#x20AC;&#x201C; Critical Values reporting within 30 minutes
Numerator: number of documented critical value notified within 30 min Denominator: number of total critical value reports released Target/ Benchmark: 100% Analysis: the graph show stabile performance and continues on comply with the benchmark cause of Memo to start hotline to ER department. Special mobile number for internal medicine department after working hours. Recommendation / action plan: keep the maintained the improvement. Lab has suggest to update the ROTA data (physician monthly ROTA schedule) to achieve the target 100%
141
EMERGENCY DEPARTMENT
26. The percentage of patients who stay longer than six hours in the ER
Figure 93 - % of patients who stay longer than six hours in ER
Numerator: number of patients staying in ER more than 6 hours Denominator: total number of patients seen in ER Target/ Benchmark: Analysis: the graph indicating that the % for patients who are staying in the emergency department more than 6 hours is increasing, and our goal is not to have any patient waiting more than 6 hours in ER. The most reasons found are beds unavailability and medical reevaluation. Recommendation / action plan: to have a bed utilization manager (case manager) to have a proper bed utilization a performance improvement project will be conducted with emergency department to improve the patients staying in ER more than 6 hours rate using the FOCUS PDCA Quality Tools.
142
OPERATING ROOM 27. Unplanned recovery room stay longer than 1 hour
Figure 94 â&#x20AC;&#x201C; Unplanned recovery room stay longer than 1 hour
Numerator: number of patients who have an unplanned stay in the post anesthesia Denominator: number patients receiving post anesthesia care Target/ Benchmark: 0% Analysis: Start monitoring this indicator only on the 3rd quarter. There is stability in the performance in the 3rd and 4th quarters . Recommendation/ action plan: keep monitoring the improvement. 28. % Inappropriate patient surgical site marking (IPSG 4)
Figure 95 - % inappropriate patient surgical site marking
Numerator:
number of surgical patient with an inappropriate surgical markings
Denominator: number of surgical patients requiring surgical marking Target/ Benchmark: 0% Analysis: The graph indicate variation in the performance Recommendation/ action plan: keep monitoring, more education for the surgeon during the tracer round.
143
29. % OR Cancellation
Figure 96 - % OR Cancellation
Numerator:
number of cancelled cases on the day of procedure in a month
Denominator: number of scheduled cases in a month Target/ Benchmark: 5% Analysis : the graph indicate increasing of the rate of OR cancellation, in month of July there was decrease in the rate to 5.6 this due to July was Ramadan month and the number of admission was low accordingly reducing the OR scheduling number . Recommendation / action plan: to start PI project with OR department using FOCUS PDCA tools to decrease the % of OR cancellation.
144
HOUSEKEEPING
30. % of OVR for housekeeping in a month
Figure 97 - % of OVR for housekeeping in a month
Numerator: number of OVR for housekeeping X 100 Denominator: total number of OVR Analysis: the average number for housekeeping OVR is 3 in each month . Recommendation / action plan: More education should be conducted by the infection control to the housekeeping staff to improve their performance
145
LAUNDRY
31. % of soiled linen post wash
Figure 98 - % of soiled linen post wash
Numerator: Number of soiled linen post wash x 100 Denominator: Total number of linen washed Target/ Benchmark: 0% Analysis: In average of 400 soiled linen in each month. Recommendation / action plan: A meeting was done between the PI unit and the director and the senior staff for the laundry to review the washing process, it found that the soiled linens are discarded due to either infection or stains that were difficult to be removed.
146
HEMODIALYSIS 32. KTV measure for all hemodialysis patient above 1.3% (K= Clearance, T= Treatment time, V= Body water volume)
Figure 99 - % KT/V Measurement
Numerator: number of KT/V below the target 1.3 Denominator: number of KT/V test performed Target/ Benchmark: 20 % Analysis: the graph indicates that the performance for this indicator is always more than the acceptable Threshold which is 20% Recommendation / action plan: keep monitoring and reviewing the process
147
RADIOLOGY DEPARTMENT 33. % Radiology Report Turnaround Time outlier Rate
Figure 100 â&#x20AC;&#x201C; Radiology Report Turnaround Time
Numerator: Total number of radiology report TAT exceeding the benchmark for radiology report TAT Denominator: Total number of radiology report TAT in a month Target/ Benchmark: 20% Analysis: it is showing that the percentage for radiology report is taking long time for the radiology department to finish the report within the time mentioned in the policy. During the last quarter there is improvement in the performance due to proper use of voice recognition system, and proper Radiologist schedule distribution Recommendation/ action plan: to meet and review with the chairman and the chief of technology for radiology department the reporting process to know where the defect is. To conduct a PI project with radiology department using FOCUS PDCA tools to improve the radiology process and reduce reporting TAT.
148
MEDICAL SUPPLY DEPARTMENT
25. % Zero stock level in medical supply
Figure 101 - % Zero stock level in Medical Supply
Numerator: Number of not available medical supply items requested * 100 Denominator: Total number of items requested Target/ Benchmark: 0% Analysis: This KPI was started to be monitored on the 3rd quarter of 2014 Recommendation/ action plan: Keep monitoring the KPI for more months.
149
Performance improvement projects PI Project conducted in 2014:
Reducing patients’ Falls. (with Nursing Department).
Ongoing Quality Improvement Project:
Low compliance to Influenza Vaccination. (With EHS Department).
Overstaying of patients in Emergency Department (with Emergency Department)
Upcoming Quality Improvement Projects:
Reducing OR Cancellation Rate (with Anesthesia Department)
Reducing Pressure Ulcer Rate (with Nursing Department)
Reducing Radiology Report Turnaround Time outlier rate (with Radiology Department)
Other Performance Measurement Unit Activities A. Committees and JCI Chapters: PI unit staff are responsible to facilitate certain committees and JCI Chapters through: 1. Coordinate with the chairman of the committee or JCI chapter to prepare the agenda for the next meeting. 2. Communicate with the members of the committee or JCI chapter to call them for the meeting by sending them a calendar e mail or by calling them by mobiles. 3. Prepare the meeting minutes and send it to the members. 4. Prepare the annual statistics for the committees.
Committees are: 1. Quality and Patient Safety Committee.(QPS) 2. Mortality and Morbidly Committee. (MMC) 3. Medical Record and Health Information Committee. ( MRHIC) 4. Trauma Committee.(TrC) 5. Ethics Committee (EC). 6. Infection Control Committee (ICC). 7. DVT Task force
150
JCI Chapters are: 1. Quality and Patient Safety (QPS) Chapter 2. Management of Information (MOI) 3. Management of Information (MOI) 4. Patient and Family Education (PFE) 5. Patient and Family Rights (PFR)
151
Other Performance Measurement Unit Activities, cont. B. Record Review Activities: 1. Closed Record Review:
PI unit start closed record Review process activity in first and second quarter of 2014, the process was reviewed 10% of discharge patients file in the previous month following our Record Review Policy (ADM-Gen 01-020 MEDICAL RECORD REVIEW PROCESS) and using the JCI Review Tools. Prepare the data analysis and the report quarterly and submitted to the Hospital Administrative, QPS Committee, MOI committee and the concerned department. In third quarter, freeze the activity to reorganize the team to sure that have a representative from all department, and Restart the work in the last quarter 2014. 2. Open record review Activity: PI unit will start the open record review on February 2015: our unit organize a team with a representative from each clinical department to review the patient file while the patient still admitting to the hospital, following our Record Review Policy (ADM-Gen 01-020 MEDICAL RECORD REVIEW PROCESS) Sample size: the team will be go to the Inpatient Unit and review 10% of the population for week period in a month but not less than 58 sample size.
C. Orientation Program: PI unit are part of the hospital orientation program, which is conducted twice a month for the all New Staff and Medical student to introduce them about our hospital regulations and roles. Orientation Topics are: 1. Introduction for QI (by Ms. Susan Al-Yami) 2. Documentation Standard (by Ms. Khadija Al-Hijab). D. Tracer: PI unit is part of the weekly Tracer Activity of the hospital. The purpose of this activity is to assure that our hospital staff are following the hospital roles and regulations in their work. Every month a tracer schedule is prepared by the Accreditation Coordinator for different hospital department.
152
E. Attending RCA and Sentinel Events Meeting with Risk Management Unit: PI unit staff are attending the Root Cause Analysis (RCA) and Sentinel Events meeting with the Risk Management Unit to share with them the recommendations and action plan for the discussed problem.
153
Closed Record Review Report November-December 2014 Executive Summary There are various reasons why documentation is important. A patient’s file should accurately and clearly reflect assessment of the patient, plan of care, progress, evaluation of care, and education provided . Using JCI documentation requirements, Performance Improvement Unit developed a set of criteria that enables us to monitor compliance and identify opportunities for improvement. These criteria are segmented into Physician, Nursing, and Allied Health. In our attempt to review a patient’s file consistently and objectively, an auditing process was established. Representatives from various services were trained on what and how to audit, as well as the proper use of the closed record review database. This process is continuously evaluated to include lessons learned and other improvement opportunities related to documentation. This report summarizes the sub topics included in the closed record review. A graph for each criterion is also available for drill down. Methodology Data is collected retrospectively. The Medical Records Department prepares all files of discharged patients. In order to our guidelines, we need to review 100 files each month (a figure based on 10% of the discharge patient In that month following our policy “ADM-Gen 01-020 MEDICAL RECORD REVIEW PROCESS” the number of discharge patient every month around 1000 patient ). Closed Record Review Process 2014 •
January – March 2014, PI unit start Closed Record Review for the first quarter.
•
Stop to reorganize the team, and restart a new Closed Record Review Team in the Last quarter
•
Total Number of Files Reviewed in 2014 :
Inpatient Files: 179.
Outpatient Files : 700
154
Data Collection Tool
Using Medical Record Review Tools from the JCI “5th Edition” (Figure 102)
155
Data Collection Tool, “Inpatient Tool “
156
Data Collection Tool, “Outpatient (OPD) Tool”
157
Medical Records Review Compliance Rate ( In-Patient)
In- Patient Out from 179 Files reviewed in the 2014 (November and December) Figure 103 â&#x20AC;&#x201C; Overall Compliance rate (%)
Figure 104 â&#x20AC;&#x201C; Consent Form
158
Figure 105 – History & Physical Assessment Form
Figure 106 – Anesthesia Form
159
Figure 107 â&#x20AC;&#x201C; Operative Notes
Figure 108 â&#x20AC;&#x201C; Post-Operative Orders Form
160
Figure 109 – Multidisciplinary Progress Note
Figure 110 – ER Form
161
Figure 111 – Patient & Family Education Form
Figure 112 – Different Forms
162
Figure 113 â&#x20AC;&#x201C; Standard Documentation Entries in All
163
Medical Records Review Compliance Rate (Out – Patient OPD) Out- Patient OPD Out from 700 Files reviewed in the 2014 Overall compliance rate = 53.8% Figure 114 – Consent Form
Figure 115 – Outpatient Clinic Treatment Record Form
164
Figure 116 – Significant Data Sheet
Figure 117 – Standard Documentation Entries in All Form
165