Dqs annual report 2015 final version

Table of Contents Directorate of Quality and Safety

Annual Report 2015 Executive Summary ........................................................................................................... 1 Significant Achievements of the Directorate of Quality & Safety (DQS) ..................................... 2 KFHU Journey towards JCI Accreditation ......................................................................... 2 Accomplishments 2012 ............................................................................................. 2 Accomplishments 2013 ............................................................................................. 3 Accomplishments 2014 ............................................................................................. 8 Appointment of External Consultants ...................................................................... 8 Activities carried out by the External Consultants with DQS

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Guidance & Directions provided by the External Consultants...................................... 9 Highlights of our Performance for 2015 ............................................................................ 11 Activities accomplished from January – May 2015......................................................... 11 Tracer Activity...................................................................................................... 11 Leadership Safety Walk Rounds ............................................................................ 12 Key Performance Indicators & Performance Improvement Projects ............................. 13 Policies & Procedures, Job Descriptions ................................................................. 13 Occurrence Variance Reporting (OVR) System ........................................................ 14 General Hospital Orientation .................................................................................. 14 Environmental Safety Rounds ................................................................................ 15 Activities accomplished from June-September 2015 ...................................................... 15

................................................. 15 Education & Training Activities ............................................................................... 16 Official Initial Accreditation JCI visit (September 13-17, 2015) .................................... 21 Continuation of our Journey: Post JCI Accreditation Activities ......................................... 23 Commendations of JCI & Recommendation ................................................................. 23 104 Days before the initial JCI Accreditation Survey

Accreditation Unit Executive Summary ........................................................................................................... 25 Strengths ......................................................................................................................... 25 Opportunities for Improvement ........................................................................................... 26 Goals............................................................................................................................... 26 Recommendations ............................................................................................................ 26 Performance Measurement Unit Introduction ...................................................................................................................... 58 Purpose ........................................................................................................................... 58 Activities Accomplished by Performance Measurement Unit .................................................... 58 KFHU Key Performance Indicators (KPIs) .................................................................... 59 Executive Summary ............................................................................................. 59 Strength .............................................................................................................. 59 Opportunities for Improvement ............................................................................... 60 Medical Record Review ........................................................................................ 65 Executive Summary ......................................................................................... 65 Methodology ................................................................................................... 65 Other Performance Measurement Unit Activities....................................................... 69 Environmental & Safety Unit Executive Summary ........................................................................................................... 72 Accomplishment/s ............................................................................................................. 72 Environmental Safety Monitoring ..................................................................................... 72

JCI Accreditation........................................................................................................... 75 Committee Membership ................................................................................................. 77 Training & Education ..................................................................................................... 77 Mapping the Way Forward 2016 .......................................................................................... 79 Decision Support Unit Introduction ...................................................................................................................... 82 Health Service Statistics ..................................................................................................... 82 Key Initiatives in 2015 ........................................................................................................ 82 Documents Control Unit Executive Summary ........................................................................................................... 88 Policy & Procedures .......................................................................................................... 88 Job Descriptions ............................................................................................................... 89 Forms .............................................................................................................................. 90 Clinical Pathways .............................................................................................................. 91 Scope of Service ............................................................................................................... 93 Strategic Plan ................................................................................................................... 94 Action Plan ....................................................................................................................... 95 Credentialing & Privileging Unit Executive Summary ........................................................................................................... 98 SQE Required Measurement Standard ................................................................................ 98 Challenges to achieve 100% compliance .............................................................................. 107 Recommendation .............................................................................................................. 107 Risk Management Unit Executive Summary ........................................................................................................... 109 Introduction ...................................................................................................................... 110 Top Reported OVRs .......................................................................................................... 112 Left Against Medical Advice (LAMA) .................................................................................... 113 Overstaying of Patient in ER ............................................................................................... 114 Procedure Cancellation ...................................................................................................... 115 Break in Skin Integrity ........................................................................................................ 116 OR Cancellation ................................................................................................................ 116 Documentation or Records ................................................................................................. 117 Line, Tube, Drain or Catheter .............................................................................................. 118 Admission Related Issue .................................................................................................... 118 International Patient Safety Goals (IPSGs)............................................................................ 119 Goal 1: Identify Patients Correctly ................................................................................... 119 Goal 2: Improve Effective Communication ........................................................................ 121 Goal 3: Improve the Safety of High-Alert Medications......................................................... 122 Goal 4: Ensure Correct-site, Correct-patient & Correct-procedure surgery ............................ 123 Goal 5: Reduce the Risk of Health-Care Associated Infections ............................................ 124 Goal 6: Reduce the Risk of Patient Harm Resulting from Fall .............................................. 125 Sentinel Events ................................................................................................................. 127

List of Figures

Directorate of Quality & Safety Figure 1: Educational Activities carried out ............................................................................ 3 Figure 2: Joint Commission International (JCI) Mock Survey ................................................... 4 Figure 3: Booth Exhibitions during Healthcare Quality Week ................................................... 4 Figure 4: Ambulatory Quiz during Healthcare Quality Week .................................................... 5 Figure 5: Open House Pediatric Surgery during Healthcare Quality Week ................................ 5 Figure 6: Open House Day Surgery during Healthcare Quality Week........................................ 6 Figure 7: Open House Obstetrics & Gynecology .................................................................... 6 Figure 8: Open House Cardiac Care .................................................................................... 7 Figure 9: Posters presented Healthcare Quality Week ............................................................ 7 Figure 10: OVRs for 2012, 2013 & 2014 ............................................................................... 10 Figure 11: Sample of Tracer Schedule ................................................................................. 12 Figure 12: Leadership Safety Walk Rounds Announcement .................................................... 13 Figure 13: OVRs for 2014 & 2015 ........................................................................................ 14 Figure 14: Sample Calendar of General Hospital Orientation ................................................... 14 Figure 15: Daily JCI Tips for all the KFHU ............................................................................ 15 Figure 16: Education on Hospital Forms ............................................................................... 16 Figure 17: Education on Physician Order (Quadramed) .......................................................... 17 Figure 18: IPSG Education for Non-Arabic Speaking Staff ...................................................... 17 Figure 19: IPSG Education for Arabic Speaking Staff ............................................................. 18 Figure 20: Code of Ethics Lecture ........................................................................................ 18 Figure 21: Education on Radiation Safety ............................................................................. 19 Figure 22: Pre-Accreditation Education by External Consultants ............................................. 19 Figure 23: JCI Chapters Education ...................................................................................... 20 Figure 24: DQS Education .................................................................................................. 20 Figure 25: Leadership Exit Presentation ............................................................................... 21 Figure 26: KFHU Certification of Accreditation by JCI ............................................................. 22 Figure 27: Awarding of JCI Certificate .................................................................................. 23 Performance Measurement Unit Figure 28: KPI Dashboard .................................................................................................. 61 Figure 29: Inpatient Closed Record Review Dashboard .......................................................... 66 Figure 30: OPD Closed Record Review Dashboard ............................................................... 68 Environmental & Safety Unit Figure 31: Illustrates the total number of rounds conducted per year ........................................ 73 Figure 32: Illustrates a comparison of department compliance from 2013 to 2015 ...................... 73 Figure 33: Illustrates the environmental safety compliance from 2013 to 2015 ........................... 74 Figure 34: Illustrates Comparison of Overall Compliance from 2013 to 2015 .............................. 74 Figure 35: Illustrates Comparison of Number of Issues Identified ............................................. 75 Figure 36: Illustrates total percentage of safety related issues ................................................ 75 Figure 37: Status of Compliance to FMS Standards ............................................................... 76 Figure 38: Illustrates the total percentage of safety related issues closed .................................. 77

Figure 39: Illustrates the staff awareness for each FMS topic .................................................. 78 Figure 40: Illustrates overall staff awareness on FMS ............................................................. 78

Decision Support Unit Figure 41: Hospital In-Patients (IP) ...................................................................................... 82 Figure 42: Hospital Out-Patients (OPD) ................................................................................ 83 Figure 43: Hospital Emergency Patients ............................................................................... 83 Figure 44: Top 10 Surgical Procedures ................................................................................ 84 Figure 45: Top 10 Diagnosis ............................................................................................... 84 Figure 46: Average Length of Stay....................................................................................... 85 Figure 47: Bed Occupancy Rate ......................................................................................... 85 Figure 48: Birth Statistics ................................................................................................... 86 Documents Control Unit Figure 49: Percentage of Departments with Job Description .................................................... 90 Figure 50: Number of Clinical Pathways ............................................................................... 92 Figure 51: Percentage of Signed Scope of Service ................................................................ 94 Figure 52: Percentage of Signed Strategic Plans ................................................................... 95 Credentialing & Privileging Unit Figure 53: Curriculum Vitae Section 2015 ............................................................................. 100 Figure 54: License in Line with Job (Available & Non-Available) ............................................... 100 Figure 55: Orientation & Continuing Education 2015 .............................................................. 101 Figure 56: Performance Evaluation 2015 .............................................................................. 101 Figure 57: Employment Documentation 2015 ........................................................................ 102 Figure 58: Comparative Graph for 2014 and 2015 ................................................................. 102 Figure 59: License in Line with Job 2014 & 2015 ................................................................... 103 Figure 60: Performance Evaluation ...................................................................................... 103 Figure 61: Orientation and Continuing Education ................................................................... 104 Risk Management Unit Figure 62: OVR Received ................................................................................................... 110 Figure 63: Monthly OVR for 2015 ........................................................................................ 110 Figure 64: OVR versus Non-OVR ........................................................................................ 111 Figure 65: OVR by Reporter ............................................................................................... 111 Figure 66: Status Involvement in OVR .................................................................................. 112 Figure 67: 2015 Top Reported ............................................................................................ 112 Figure 68: Reasons for LAMA ............................................................................................. 113 Figure 69: Overstaying from 2013-2015................................................................................ 114 Figure 70: Reasons for Overstaying in ER ............................................................................ 114 Figure 71: Procedure Cancellation Statistics ......................................................................... 115 Figure 72: Reasons for Procedure Cancellation ..................................................................... 115 Figure 73: Types of Break in Skin Integrity ............................................................................ 116 Figure 74: OR Cancellation Statistics ................................................................................... 116 Figure 75: Causes of Cancellation ....................................................................................... 117 Figure 76: Documentation or Records Variances ................................................................... 117 Figure 77: Type of Line, Tube, Drain or Catheter ................................................................... 118 Figure 78: Types of Admission Related Issues ...................................................................... 118

Figure 79: Total Numbers of OVRs Received Related to IPSG 1.............................................. 119 Figure 80: IPSG 1 Related OVRs in 2015 ............................................................................. 120 Figure 81: Contributing Factors to “Others” ........................................................................... 120 Figure 82: IPSG 2 Related OVRs 2015 ................................................................................ 121 Figure 83: IPSG 3 Related OVRs 2015 ................................................................................ 122 Figure 84: IPSG 3 Related OVRs in 2015 ............................................................................. 123 Figure 85: IPSG 4 Related OVRs in 2015 ............................................................................. 123 Figure 86: Non-Compliance to 5 Moments of Hand Hygiene 2015 ............................................ 124 Figure 87: IPSG 5 OVRs Received in 2015 ........................................................................... 125 Figure 88: IPSG Falls 2015 ................................................................................................. 125 Figure 89: Falls 2015 ......................................................................................................... 126

List of Tables

Directorate of Quality & Safety Table 1: Tasks assigned to the External Consultants.............................................................. 8 Accreditation Unit Table 2: Strategic Improvement Plan ................................................................................... 27 Table 3: KFHU Tracer Tool ................................................................................................ 38 Performance Measurement Unit Table 4: Performance Improvement Projects ......................................................................... 64 Environmental & Safety Unit Table 5: Opportunities for Improvement/Priorities for 2016 ...................................................... 79 Documents Control Unit Table 6: List of Total Number of Policy & Procedures for each Department ............................... 88 Table 7: Job Descriptions submitted by each Department ....................................................... 89 Table 8: Number of Forms Available, Printed & Uploaded in the Intranet ................................... 91 Table 9: Number of Available Clinical Pathways .................................................................... 92 Table 10: Signed of Scope of Services for each Department ................................................... 93 Table 11: Signed Strategic Plans of each Department ............................................................ 94 Table 12: Strength and Opportunities for Improvement ........................................................... 105 Table 13: Improvement Action Plan ..................................................................................... 106 Risk Management Unit Table 14: Sentinel Events (Death of a Patient – March 24, 2015) ............................................. 127 Table 15: Sentinel Events (Death of a Patient-December 1, 2015 ) .......................................... 127

Executive Summary The Directorate of Quality and Safety (DQS) structure is guided by and framed within the framework of King Fahd Hospital of the University’s (KFHU) Mission, Vision and Values. DQS established in 2012 has a key leadership role in supporting the achievement of KFHU’s objectives.

It is our great pleasure to present the Directorate of Quality & Safety (DQS) Annual Report for 2015. This report is an opportunity to look back and celebrate DQS’s achievement through the years 2012 to 2015 – and see how far we have come.

The report highlights our responsible achievements; establish our future commitments and serves as a benchmark to demonstrate our progress.

After beginning preparations as early as March 2012, King Fahd Hospital of the University (KFHU) was finally surveyed by the Joint Commission International (JCI) on13-17 September 2015 for its initial accreditation. JCI scored KFHU in some measurable elements as “Partially Met,” but no single measurable elements that were scored as “Not Met.” Getting the “gold seal of approval” from JCI is part of KFHU commitment to improve the way we deliver healthcare. JCI’s standards for academic medical center hospital clearly define the principles and processes needed to assess the key functions of acute care institutions and associated ambulatory settings.

What are the JCI standards?

It is a very comprehensive standard that comes in a thick 305-page manual. The key features are: 

It assesses the quality of patient care from the time a patient is admitted till discharge. This data can be utilized to plan and implement changes that create optimal care.

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It also assesses all aspects of management from clarity of leadership’s responsibility and accountability, to critical facility managed processes and broad strategic planning.

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There are 16 chapters, 304 standards, 1,211 measurable elements that must be totally met to achieve accreditation.

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It emphasizes and cultivates a culture of patient safety.

There are 16 chapters to the standards: 

Access to Care & Continuity of Care

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Quality Improvement & Patient Safety

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Anesthesia & Surgical Care

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Facility Management & Safety

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Assessment of Patients

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Staff Qualifications & Education

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Care of Patients

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Governance, Leadership & Direction

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International Patient Safety Goals

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Prevention & Control of Infections

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Medication Management & Use

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Medical Professional Education

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Patient & Family Education

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Human Subjects Research Programs

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Patient & Family Rights

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Management of Information

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Significant Achievements of the Directorate of Quality & Safety: This year, we celebrate a more significantly, a crowning glory, in the form of the distinguished Joint Commission International (JCI) accreditation for Academic Medical Center Hospital. This gold seal of approval has been bestowed to us after stringent measures and testing of our processes which must be above par in order to be ranked among the elite all over the world. We have been lauded as possessing the best in quality, care and safety, a fact no doubt, echoed by many who look to us for the best in healthcare.

This is indeed a reflection of how WE do things… with attention to detail, a commitment to excellence and above all, the resilience which sees us evolve and grow with the times.

The Directorate of Quality & Safety (DQS) has come this far primarily due to the tireless efforts of the DQS team and their dedication.

Our formal journey to achieving the Joint Commission International accreditation for Academic Medical Center Hospital began 21 months before the initial accreditation survey on September 13 to 17, 2015.

KFHU Journey towards Joint Commission International (JCI) Accreditation Accomplishments: Year 2012 The JCI Accreditation Journey of the King Fahd Hospital of the University of Dammam has started in the year 2012 where the Directorate of Quality & Safety (DQS) was established to oversee the quality management operations.

Upon obtaining the decision for the JCI accreditation from His Excellency, President of the University of Dammam and Supervisor General of King Fahd Hospital of the University (KFHU) Dr. Abdullah Al Rubaish, preparation and planning were started by DQS. On the onset of the preparation process, DQS used the Joint Commission International Standards for Hospitals (4th Edition) and it comprises of 14 chapters. To initiate the process, hospital wide standard committees were formed.

Further, a JCI steering committee was formed and a Quality Improvement Plan was developed. To address the practices related to each JCI Chapters, 14 JCI Chapters teams were formed. An intensive JCI awareness campaign was organized across the KFHU. A Strategic Planning task force was formed and it intensively worked to finalize a well-defined Mission, Vision and Values for KFHU. Authority and responsibilities were defined appropriately and an organizational structure for KFHU was formed and laid out in the Hospital. Department specific Self-assessments of the existing situation were conducted by DQS and multidisciplinary staff during the month of April 2012.

All KFHU staff was properly oriented with the JCI Standards and it was well communicated to them. A Gap analysis was conducted to assess the hospital’s compliance to the JCI Standards and appropriate solutions were designed to close the gap.

During the third and fourth quarter of 2012, the Quality Management Plan was implemented across KFHU. Accordingly, following activities were started as part of the JCI accreditation preparation process viz.     

Performance Improvement Projects (PIPs) Implementation of the Six International Patient Safety Goals (IPSG) AHRQ Culture of Safety Survey Monitoring of Performance Improvement Measures (KPIs) Patient Satisfaction Survey 2

Occurrence Variance Reporting (OVR) was launched to all KFHU departments and all the staff was educated to utilize OVR, in case of occurrence of the unusual events. DQS initiated the Continuous monitoring process to periodically check the Hospital’s compliance with the JCI standards Accomplishments: Year 2013 The Directorate of Quality & Safety and all KFHU departments have continuously worked run-the-clock towards the attainment of Accreditation as per the JCI standards.

Several Policies and Procedures were developed by the department leaders and it is reviewed by the respective steering committee through several group meetings to make sure that it complies with the JCI Standards. Job Descriptions for all the categories of employees were developed and distributed across KFHU. Moreover, the scope of service for each department/unit was developed. Likewise, clinical Pathways for all medical services were also created and some were implemented. All the forms and templates used in the hospital were revised and some of the existing ones are reformatted. Additionally, new forms were created and implemented to comply with the JCI Standards.

As a measure to provide strategic direction to each department, a strategic plan was developed in consultation with relevant stakeholders. In-depth analysis of KFHU’s current capability to meet JCI standards was continuously and meticulously studied by all units of DQS. Tracer activity started by DQS in collaboration with the Medical & Nursing Departments to identify and provide a high-level analysis of KFHU’s strengths and weaknesses, as well as to work on action plan to move forward towards final accreditation survey.

Various education activities to promote the Quality Improvement Project Methodology (FOCUS-PDCA) and other topics were started for all departments. The educational activity carried out during the year 2013 is depicted Figure 1.

Figure 1: Educational activities carried at various departments of KFHU during the year 2013.

During the fourth quarter of the year 2013, a Healthcare Quality Week was held and it was hosted by DQS highlighting the importance of quality and patient safety in healthcare. The official Mock Survey by the Joint Commission International (JCI) was held marking the 21 months stretch before the official accreditation survey (November 3-11, 2013).

Some of the highlights of the JCI Mock Survey include: 3

• • •

Provision of Training and education on JCI Standards and other selected topics identified during tracer activities Provision of guidance and Support through action planning process for selected areas of compliance King Fahd Hospital of the University will be surveyed based on the 5th Edition Standards (Expanded) to be released in April 2014. Two more additional standards were added:  Human Subjects Research Program (HRP)  Medical Professional Education (MPE)

Figure 2: Joint Commission International (JCI) Mock Survey

Figure 3: Booth Exhibitions held during Healthcare Quality Week at KFHU in the year 2013

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Figure 4: Ambulatory Quiz held during Healthcare Quality Week at KFHU in the year 2013

Figure 5: Healthcare Quality Week at KFHU showing Open House Pediatric Surgery exhibition held during the year 2013

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Figure 6: Healthcare Quality Week at KFHU showing Open House Day Surgery exhibition held during the year 2013

Figure 7: Healthcare Quality Week at KFHU showing Open House Obstetrics and Gynecology exhibition held during the year 2013

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Figure 8: Healthcare Quality Week showing simulated Open House Cardiac care unit at KFHU held during the year 2013

Figure 9: Posters presented during the Health care Quality Week

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Accomplishments: Year 2014 Establishment of New Units Decision Support Unit was established in December 2013 which aims to provide accurate and timely information that enables informed decision making. Further, it was decided to be able to cope with the demands of preparation for the final accreditation survey of the JCI, the Performance Improvement & Accreditation Unit were made into two separate units for Operational convenience. Credentialing & Privileging Unit was established in April 2014 to ensure that KFHU

patients receive safe high quality of care from providers with appropriate skills, training and experience.

Appointment of External Consultant To ensure full compliance with the Joint Commission International Accreditation Standards for Hospitals 5th Edition (Including standards for Academic Medical Center Hospitals), the Directorate of Quality & Safety decided to have assistance and guidance from external consultants. To facilitate that, an approval from the office of His Excellency, the President of the University of Dammam and Supervisor General of KFHU was received to appoint consultants who will provide consultancy services to KFHU. A team of four (4) external consultants were contracted and each one of them visited KFHU on different dates. Each consultant has been assigned with specific JCI Chapters and the details are given in Table 1.

Table 1: Tasks assigned to the External Consultants their dates of Visit to KFHU

#

Name of the Consultant(s)

Chapters assigned

1

Dr. Ahmad Al Khateib

GLD, SQE, MOI, MPE, HRP

2

Ms. Firyal Sayyed

ACC, PFR, AOP, PFE, PCI

3

Professor Seval Akgün

IPSG, COP, ASC, MMU, QPS

4

Dr. Riaz Akhtar

FMS

Dates visited 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 1st visit: February 24 – 28, 2014 2nd visit: March 30 – 31, 2014 3rd visit: June 15 – 17, 2015 4th visit: October 12 – 16, 2014 1st visit: March 2 – 6, 2014 2nd visit: April 13 – 17, 2014 3rd visit: June 22 – 26, 2014 4th visit: December 21 – 25, 2014 March 23 – 27 & 30 – 31, 2014

Activities carried out by the External Consultants with DQS a. Education The Directorate of Quality & Safety has conducted series of educational activities with an aim to communicate the concept of “JCI readiness” throughout the hospital and 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/training 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.

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b. Workshop / Meetings The Accreditation Unit of DQS conducted workshop and meetings after the receipt of the final report from Consultant who usually submits it after each consultation visit. The workshop & meetings included all representatives of each chapters and departments who were involved in the execution of the action plan. The workshop and meetings covered all findings that required corrective actions.

Guidance and directions provided by the External Consultants for preparation towards JCI Final Survey 1. 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 16 chapters’ binders, as well as the policies and forms binders, according to the JCI standards (5th Edition). The Accreditation Unit also ensures that the information contained in these binders were arranged systematically and organized to facilitate easy access / review by the external consultants.

2. Hospital Forms The Documents Control Unit (DCU) of the Directorate of Quality & Safety plays a significant role in the maintenance of all the hospital forms used. Specifically, its role starts from the creation & development of the forms to requesting for printing and finally to uploading the form in the Hospital Portal. All obsolete hospital forms were eliminated from the Stationery Store. Further, it was decided to limit the available forms that are relevant and required for existing hospital operations. In the year 2013, a total of 111 forms were printed and processed by DCU. During the year 2014, a total of 440 forms were developed. Out of this, 298 were approved, printed and uploaded to the hospital portal.

3. Policies and Procedures DQS ensures that there an established procedure for the development, review and approval of policies and procedures (P/Ps). In 2013, a total of 777 policies and procedures either new or revised, were developed. Among them, a total of 583 policies & procedures were approved and signed. However, a remarkable increase was noticed in 2014, as a total of 1536 policies and procedures were developed and signed. All these P/Ps were uploaded in the hospital portal. All the hospital employees are well oriented with these policies and procedures relevant to their work domain.

4. 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. Approximately, a total number of 21 Scope of Services was developed and is continuously being updated on a regular basis.

5. 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 & 9

Safety has been assigned with the responsibility to implement and monitor these plans in collaboration with the concerned departments to ensure that this five year plan is achieved.

Twenty eight (N=28) departments had submitted its strategic plan, dully signed by the respective department heads. Ten (N=10) departments have finalized its strategic plan, pending approved from the department chairpersons. Compared with year 2013 strategic plan (22%) an increase of 27% was obtained in collaboration with the departments’ chairpersons.

6. 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.

The reporting system that KFHU had introduced helped to capture increased 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.

Figure 10: OVRs for 2012, 2013 & 2014

During the consultation visits, the KFHU Risk Management Plan was reviewed and appropriate 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 higher administration should be involved in risk management and their 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.

7. 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 of 2014, the team had reviewed the medical records files, but was stopped to evaluate the effectiveness of the team. It was recommended that the team be reconstructed. Thereafter, the team was reformed 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.

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Highlights of our Performance for 2015 A team of 4 External Consultants continued to provide guidance and direction to the Directorate of Quality & Safety (DQS) in our quest to obtain and achieve the “Gold Seal of Approval” from the Joint Commission International. From the last Joint Commission International (JCI) Mock Survey (November 3-11, 2013), it was announced that the 5th Edition of JCI Standards for Hospitals will be released in April 2014. Two chapters were added as Standards for Academic Medical Center Hospitals. The chapters added were: (1) Medical Professional Education and (2) Human Subject Research Programs.

To become academic medical center hospitals, hospitals must meet the following additional requirements: (a) is organizationally or administratively integrated with a medical school; (b) is the principal site for the education of both medical students and medical specialty residents from the medical school noted in the previous criterion; (c) and conducts academic and/or commercial human subject research involving patients of the hospital.

The external consultants’ on-site consultation services are composed of:              

Organizational Gap Assessment Study Collaborative development of a Joint Work Plan Documentary system preparation (e.g. Policies, Plans, plans, programs, manuals, job descriptions, scope of services) Formulation of clinical pathways & clinical practice guidelines Processes and Documentation Review and Approval Design & development of key performance indicators and managerial indicators Implementation of quality tools (FMEA, OVRs, and Risk Assessment) Train the Trainers Program Periodical Readiness assessment Conduct various Audits (Environmental Safety, Medical Records (Open & Closed Record Review)) System tracer activities Individual patient tracer activities IPSG Tracer Activities Mock Survey (by external Surveyor)

ACTIVITIES ACCOMPLISHED FROM JANUARY – MAY 2015 DQS and the external consultants continued to do a self-assessment for the entire KFHU according to all chapters (16) related to patient-focus and organizational management standards. The assessment covered the International Patient Safety Goals and identified the gaps and expectations of the goals.

Tracer Activity In preparation for the JCI initial accreditation and to ensure that all patient’ units are in compliance with the JCI standards, tracer activities were conducted.

Tracer activities in collaboration with the Department of Medical & Allied Medical Services, Department of Nursing Services, and other departments of KFHU were carried out on a daily basis to determine and ensure full compliance of the 16 chapters of the JCI manual. Monthly Tracer Report was prepared by the Accreditation Unit and submitted to the office of His Excellency, Dr. Abdullah Al Rubaish (President of the University of Dammam and Supervisor General of King Fahd Hospital of the University).

These tracers are designed to “trace” the care experiences that a patient had while at King Fahd Hospital of the University (KFHU). It is a way to analyze KFHU’s system of providing care, treatment or services using actual patients as the framework for assessing standards compliance.

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The tracer activity was done also as a practice tracer meant to simulate an actual JCI tracer. During the tracer, the tracer team plays the role of the surveyors.

The purposes of the tracer activity are:   

To evaluate the effectiveness of KFHU’s policies and procedures To engage KFHU staff in looking for opportunities to improve processes To be certain KFHU has addressed compliance issues and is ready for JCI survey at any time

Figure 11: Sample of Tracer Schedule

Leadership Safety Walk Rounds One of the significant steps in fostering a culture of patient safety, the Accreditation Unit on approval of the higher administration has initiated regular Leadership Safety Walk Rounds. These provide a forum for the KFHU leaders to visit patient care and supporting services areas and engage front line staff in dialogue on the topic of patient safety. The goal is to bring patient safety issues to the forefront of everyone’s agenda.

Leadership Safety Walk Rounds after it was introduced, was well attended by representative from multidisciplinary areas (including clinicians, nurses, interns, students and support personnel).

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Figure 12: Leadership Safety Walk Rounds Announcement

Leadership Rounds were attended by various stakeholders viz.      

Vice Dean for Hospital Affairs & Director General, KFHU Department of Medical Services, Medical Director Department of Allied Medical Services, Director Department of Nursing Services, Director Department of Operations & Maintenance, Director Department of Pharmacy Services, Director

Key Performance Indicators & Performance Improvement Projects Several Key Performance Indicators (KPIs) has been generated and it is being monitored on a continual basis to improve quality. Also, the KPIs are constantly updated to ensure continuous quality improvements. In the year 2014, 35 KPIs are used by KFHU whereas it has been increased to 68 in the year 2015. Further, a number of Performance Improvement Project (PIPs) was conducted in some of the departments at KFHU with a focus to improve Performance viz.     

Decrease rate of patients falls.

Increase compliance of influenza vaccination by KFHU personnel.

Reducing the percentage of radiology report turnaround time outlier rate.

Decrease the percentage of patients who stay longer than 6 hours in Emergency room.

Decrease the percentage of OR cancellation on the day of the procedure.

Policies & Procedures, Job Descriptions All the existing Policies and Procedures were reviewed by the external consultants and consultation was also held with authors and policy owners to ensure compliance with the external consultants.

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The Job descriptions, scope of services, strategic plans, clinical pathways and guidelines were finalized as per external consultants’ recommendations. Gaps were identified in terms of those processes and procedures that were not documented, needed to be improved and to be set up. Several training and workshops were conducted in collaboration with different departments of KFHU. All related documents are all downloaded and available in the KFHU portal.

Occurrence Variance Reporting (OVR) System Occurrence variance reporting (OVR) is very essential for ensuring patient and staff safety, quality of care and risk management at King Fahd Hospital of the University (KFHU). Variance is any event or circumstance not consistent with the standard routine operations of the hospital and its staff or the routine care of a patient/visitor.

During 2015 a total of 8,995 OVRs were reported to the Risk Management Unit of the Directorate of Quality & Safety. Compared to 2014 (total reported OVRs 9,111), it showed decreased in reporting.

Figure 13: OVRs for 2014 & 2015

General Hospital Orientation The Directorate of Quality & Safety has participated in the General Hospital Orientation program organized by the Directorate of Academic Affairs & Training. Quality, Accreditation, Risk Management & Environmental Safety initiatives are highlighted and the importance of promoting a culture of patient safety is discussed with new staff, physicians, interns and students.

14

Figure 14: Sample Calendar of General Hospital Orientation

Environmental Safety Rounds Under the supervision of the Environmental & Safety Unit, an Environmental & Safety Team makes rounds on a regular schedule to determine all areas of King Fahd Hospital of the University are in compliance with best practice and regulatory agencies.

The team members are from Directorate of Quality & Safety, Safety Officers, Department of Nursing Services, Housekeeping & Laundry Services, Support Services, Infection Control Department and Security Personnel. The purpose of the rounds is to identity facility and system problems that place barriers to JCI compliance.

ACTIVITIES ACCOMPLISHED FROM JUNE – SEPTEMBER 2015 (104 days before the initial Accreditation Survey of the Joint Commission International (JCI) After affirmation of readiness of KFHU to JCI Accreditation, an application was submitted to the Joint Commission International and accordingly, a schedule was received for the final accreditation site visit. The initial JCI survey visit was scheduled during September 13-17, 2015.

An Internal / Practice Mock Survey were conducted by the external consultants in May 31 – June 4, 2015. The practice Mock Survey was very beneficial as the external consultants provide in-depth survey that was exactly the same as the final JCI accreditation survey.

Countdown was started on 1st of June 2015 and a daily tips were sent to all KFHU staff via email (Figure 9).

Figure 15: Daily JCI Tips for all the KFHU Staff (an example)

Employees’ files were reviewed to ensure completeness and to verify whether the licenses of healthcare providers are up-to-date as per standards of Staff Qualification & Education (SQE) chapter. Likewise, the credentials and privileges of all medical staff were also reviewed as per JCI Standards. A JCI Frequently Asked Questions (FAQs) were distributed among all KFHU staff.

15

Various handbooks were distributed to all staff at KFHU to educate them in the following topics viz.

• • • • • •

Risk Management Handbook International Patient Safety Goals (IPSGs) Mr. Strong Codes Orange, Pink, Red, White & Yellow Hazardous Materials Evacuation

Additionally, education/training regarding Risk Management Program (i.e. Risk Assessment, Sentinel Event, Near Miss, Adverse Event and Occurrence Variance Reporting [OVR]) was also provided on continuous basis to all the relevant staff at KFHU. Education & Training Activities In line with our initial Joint Commission International (JCI) accreditation, the Directorate of Quality & Safety (DQS) collaborate various education and training programs, as seen below: Hospital forms were formatted as per the JCI standards. Education was conducted to ensure that all departments were educated and introduced to the new hospital forms.

Figure 16: Education on Hospital Forms

King Fahd Hospital of the University (KFHU) is on the process of replacing paper forms and other handwritten notes. For this an education for the new system in filling the physician’s order via the Quadramed System was done by the Information Technology (IT) Department in collaboration with DQS.

16

Figure 17: Education on Physician Order (Quadramed)

To ensure that all KFHU employees were educated and aware of the International Patient Safety Goals (IPSG) as per the JCI standards, the Risk Management Unit of the Directorate of Quality & Safety and the Team Leader of the IPSG Chapter has conducted an education on IPSG both in English and Arabic languages.

Figure 18: IPSG Education for Non-Arabic Speaking Staff

17

Figure 19: IPSG Education for Arabic Speaking Staff

The Ethics Committee also provides an education regarding the Code of Ethics of KFHU. The education was well attended by the KFHU departments.

Figure 20: Code of Ethics Lecture

18

Education on Radiation Safety was collaborated by the Environmental Safety Unit with the Department of Radiology Services.

Figure 21: Education on Radiation Safety

Pre-Accreditation education and trainings were provided by our external consultants. The aim of this education is to prepare all KFHU staff during the initial and actual accreditation survey by the JCI consultants.

Figure 22: Pre-Accreditation Education by External Consultants

19

JCI Chapters team leaders also conducted series of education in preparation for the initial JCI accreditation survey.

JCI Chapters Education SQE, 27 MPE, 9

ASC, 115

MMU, 411

Figure 23: JCI Chapters Education

The Directorate of Quality & Safety education programs were also carried out during the preparation for the survey.

Figure 24: DQS Education

20

Official Initial Accreditation site visit of the Joint Commission International took place in September 13 to 17, 2015.

The initial JCI survey visit was held from September 13-17, 2015. The JCI review team is comprised of:    

A well-experienced Administrator (Mr. Robert Christmas) acted as the Team Leader of the team.

A clinician with over 30 years’ experience in healthcare (Mr. Elijah Gilreath), member.

A nurse with 22 years of experience in comprehensive tertiary healthcare facility (Ms. Salma S. Jaffer), member.

A physician with over 15 years of expertise in Quality Improvement and High Reliability (Dr. Bonny Chen), member.

After thorough exploration of the quality of services existed at KFHU, the JCI Surveyors completed their findings.

On the final day of the survey, an exit interview was held with His Excellency, Dr. Abdullah Al Rubaish, President & Supervisor General and other KFHU leaders. The surveyors scored each measurable element as to either Met; Partially Met and Not Met. It was worth reporting that KFHU did not receive a “NOT MET” score from the surveyor. KFHU demonstrated an overall acceptable compliance. The survey visit ended on Thursday, September 17, 2015 with Leadership Exit Report during which the surveyors expressed their appreciation for the high quality with which KFHU and its staff is delivering towards patient care.

Accordingly, King Fahd Hospital of the University officially celebrated its first “Gold Seal of Approval” JCI Accreditation on September 17, 2015. KFHU was able to have a stellar result of 98% and was accredited as an Academic Medical Center Hospitals, the first University Hospital in the Eastern Province of Saudi Arabia.

This accreditation reflects the excellent professional level, and compliance of KFHU with international standards in the provision of medical services to patients visiting the various departments of the Hospital. Members of the panel of JCI have affirmed that KFHU enjoys high levels of quality that contribute to raising the degree of security and safety in healthcare provided to the patients.

Figure 25: Leadership Exit Presentation held at KFHU during September 17, 2015

21

The final Survey report was received from JCI headquarters on October 4, 2015, it granted the KFHU, the status of ACCREDITED as an ACADEMIC MEDICAL CENTER HOSPITAL for three (3) years. The JCI accreditation certificate was officially awarded by the President, Chief Executive Officer of JCI, Ms. Paula Wilson to His Excellency, Dr. Abdullah Al Rubaish, President of the University of Dammam & Supervisor General of King Fahd Hospital of the University) last 18th of October 2015.

H.E the President of UOD and Supervisor General of KFHU, Dr. Abdullah Al- Rubaish expressed his satisfaction with accreditation of the Hospital. He further explained that it is one of the highest specialized international accreditations in the quality of healthcare organizations. Dr. Rubaish went on to say that JCI accreditation is only awarded to hospitals after meeting defined and strict standards that focus on improving the safety of patient care.

JCI also examines the consultative and educational services to assist and support health organizations to implement practical solutions centered on the patient.

The JCI standards also focus on the management and organization of activities needed to ensure international quality in the provision of health care. The JCI accreditation certificate has been awarded in more than 80 countries since 1424.

Figure 26: KFHU Certification of Accreditation by JCI

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Figure 27: Dr. Abdullah Al Rubaish, President of the University of Dammam & Supervisor General of King Fahd Hospital receiving KFHU JCI-Accreditation Certificate from Ms. Paula Wilson, President & CEO of JCI.

Continuation of Our Journey: Post JCI Accreditation Activities A Strategic Improvement Plan (SIP) was prepared and it is a required written plan of action that KFHU develops in response to “partially met” findings identified in the JCI official survey findings report 2015. The due date of the SIPs is 45 days after notification. It was already submitted to JCI and was evaluated by the JCI. Presently, we are planning and working for the triennial re-accreditation due on September 2018 and this means that KFHU will continue on its journey towards enhancing a patient safety culture and provision of high quality care by creating an environment that is patient-centered, transparent, and focused on improvement at all levels.

Commendations of JCI and Recommendations for our continuous quest to Quality & Patient Safety During the exit presentation of the JCI Survey Team, it was indicated that KFHU have put in place processes that will improve the quality of care. It has been quite an experience for King Fahd Hospital of the University. We have learnt to look at healthcare from patients’ point of view. The safety climate of KFHU has changed and will improve in the future.

We can confidently say that we are providing patient care that meets international standards, and that we will continue to improve.

23

Accreditation Unit

24

Executive Summary It is our privilege to present this Annual Report of Accreditation Unit for the year 2015. As a benchmarked leader in the healthcare sector we have championed to newer heights and the conferring of the Joint Commission International Accreditation (JCIA) this year was a crowning glory for us. We are now among an elite collective of just 4 academic medical center hospitals in Saudi Arabia and 794 hospitals around the world to have this prestigious accreditation. Throughout the years, we have continued to garner international (CAP, NCAAA, JCI) awards. We have now surpassed our vision “to be a leading University Hospital in healthcare provision, education and scientific research according to international standards”. Our industry leadership, pioneering strategy, unsurpassed service, knowledge management and operational excellence has enabled us to be unique in the healthcare sector.

KFHU continues to grow and develop at an exceptional rate and this rapid change brings its own set of challenges that, as healthcare providers, constantly work to address. This report is an update on some of the major initiatives and developments of the year 2015. This year has been marked by changes, successes, growth, and re-positioning and development of our delivery system.

KFHU embraced the new era of healthcare delivery. It reflects the changes in the delivery system that we have been implementing over the last few years and points to our vision and values. This new era is symbolized by a culture of patient-centered care and teamwork and the relentless pursuit of excellence in three pillars – health, education and research, upon which KFHU’s development is based. The new system also further supports our decentralization efforts by conferring a unique identity to each department which reflects the type of services they offer. The positive reception and adoption of this new system reflects KFHU’s employees’ commitment to excellence and to realizing the values of our new identity.

Many initiatives culminating successfully this year were targeted to addressing a wide variety of areas – such as improving patient access, quality of care and the range of services we deliver. All our initiatives were conceived with the objective of raising performance, providing the highest quality of care to our patients and making their stay with us safe and comfortable.

The Accreditation of our hospitals received international recognition. Our successful gold seal of approval on the quality of our services came from the highest overall hospital international accreditation body, the Joint Commission International (JCI) accreditation.

Strength: 

Obtain the Gold Seal of Approval from Joint Commission International (Accredited)



97% Compliance to JCI standards and measurable elements



Five JCI Chapters full compliance: o

Access to Care and Continuity of Care

o

Patient and Family Education

o

Quality and Patient Safety

o

Medical Professional Education

o

Human Subject Research Program



SQE.9.1 ME #3 Strategic Improvement Plan Accepted by JCI



49% of JCI Partially Met Strategic Improvement Plan Completed

25

Opportunities for improvement 



Eleven (11) JCI Chapters with Not met Compliance (3%) o

International Patient Safety Goals

o

Patient Family Rights

o

Assessment of Patients

o

Care of Patients

o

Anesthesia and Surgical Care

o

Medication Management and Use

o

Prevention and Control of Infection

o

Governance Leadership and Direction

o

Facility Management and Safety

o

Staff Qualification and Education

o

Management of Information

Poor compliance on documentation standards.

Goals To be accredited by the following organization: 

Magnet for Nurses



American College of Radiology



Intersocietal Accreditation Commission – Adult Echocardiography



Planetree International

Recommendation 

Implement the Strategic Improvement Plan and monitor thru tracer



Follow-up the installation of clock to monitor the time for surgical scrub and magnetic controlled exit doors for vulnerable population area.



Monitor the established primary source verification in Human Resource Department



Monitor the physician’s compliance to revised ADM-Gen 01-046 Approved Abbreviation Policy



Satisfaction survey on Electronic Health Record to assess the effectiveness of HER



Satisfaction survey on Pain Management



Continue to review the hospital forms by the Medical Records Committee and revise if necessary.

Monitor for compliance thru tracer.



Complete implementation of Electronic Health Record

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Table 2: STRATEGIC

IMPROVEMENT PLAN

STD

Score

IPSG.2.1 ME1 The hospital has defined critical values for each type of diagnostic test

Partially Met

The hospital did not define critical values for cardiology test

Partially Met

Labeling of high –alert medication were inconsistent throughout the hospital.

Example were as follows: 1. On the medication cart in Day Surgery, 9% Normal Saline injectable was labeled as a high- alert medication; however this medication was not on the organization’s list of high-alert medications 2. Adrenalin was inconsistently labeled as high-alert 3. Concentrated electrolytes such as potassium chloride and calcium were not labeled as high-alert medications.

IPSG.3 ME3 the location, labeling, and storage of high alert medications, including look-alike / sound alike medications, is uniform throughout the hospital.

IPSG.3.1 ME 2 Concentrated electrolytes are present only in patient care units identified as clinically necessary.

IPSG.4 ME 1 The hospital uses an instantly recognizable mark for surgical and invasive procedure site identification that is consistent throughout the hospital

IPSG.4 ME 2 Surgical and invasive procedure site marking is done by the person performing the procedure and

Partially Met

Partially Met

Partially Met

JCI Findings

Concentrated electrolytes such as Potassium Chloride ampoules were present in OBGYN and Female Surgical Wards; however, the clinical necessity of the concentrated electrolytes was not identified.

The hospital used a piece of tape for facial site marking, a circle and dot to mark the needle entry point for anesthetic local / block procedures, and an arrow for the remainder of the surgical and invasive procedural site-markings.

In one of five open and closed records reviewed, surgical site marking was completed by the physician who performed the surgery.

In the other cases, a resident who was not the primary surgeon performed the site marking. The

What and Where (Plan of Action(s) and Areas for Improvement) •

• • • • •

• •

•

•

•

Who Owner – Staff Name/ Title

When (Completion Date)

Develop a policy to define critical values for Cardiology Test

Dr. Akram

November 15, 2015

Done

Remove the high-alert sticker in the 9% normal saline injectable Update the high-alert Medication checklist Monitor and ensure that all adrenalin is labeled.

Define performance indicator for high alert medication labeling and storage Monitor the indicator

Pharmacy – Dr. Nadia Dr. Nasser

November 15, 2015

Done

Remove the concentrated electrolytes in OBGYN and Female Surgical Monitor during tracer

Review and revise the policy ADM Gen 01-036 SITE MARKING/ SURGICAL SITE VERIFICATION /TIME-OUT Pre-Procedural Patient Safety (Site Verification; Laterality; Time Out-Process) Micropore tape to be used

Review and revise the policy ADM Gen 01-036 and send letter to the chairman of surgical department.

Pharmacy – Dr. Nadia

Outcome

Done

Tracer Team

Surgery – Dr. Yasser Al Jehani, Dr. Nasser

Surgery – Dr. Yasser Al Jehani, Dr. Nasser

November 15 2015

Done

Done

27

involve the patient in the marking process

IPSG.5 ME 2 The hospital implements an effective hand hygiene program throughout the hospital

IPSG.5 ME 3 Hand washing and hand disinfection procedures are used in accordance with hand-hygiene guidelines throughout the hospital

patients were involved in the site marking process.

Partially Met

Partially Met

1. The hospital implemented a hand-hygiene program throughout the hospital; however, alcohol hand gel soap and hand drying facility were not ensured in Ward 2C and 2D and Delivery Room 2. Treatment and soiled utility rooms in these units did not have alcohol hand gel or soap and hand drying facilities Hospital policy “Hand Hygiene ADM GEN 01-028� required a minimum of three to five minutes for surgical scrub; however, there was no means to measure the time for a surgical scrub in the Burn Unit Operating Theater.

Fix adequate alcohol hand gel dispensers and soap dispensers in all wards & dirty utility rooms in the hospital especially in Wards 2C, 2D, and delivery room Provide hand drying facility next to the hand washing area.

Install small clock/ stop watch/ timer above the sink used for surgical scrub at all operating theaters (Main OR, ER, Day Surgery, Burns OR & Delivery OR) in the hospital.

Ms. Enas Al Shuwayer (Infection Control Team) & Mr. Saif Al Awad (Director of Housekeeping )

Ms. Enas Al Shuwayer (Infection Control Team)

15 November 2015

Done

Only in OR Ongoing in other area

28

STD PFR.1.5 ME 3 The hospital develops and implements a process to protect vulnerable populations from other safety issues

PFR .5.3 ME 1 Patients are informed of elements a) through H) in the intent as relevant to their condition and planned treatment

AOP.1.4 ME 1 Qualified individuals develop and implement criteria to identify patients who require further nutritional assessment AOP.5.7 ME 2 Procedures are established and implemented for the collection and identification of specimens AOP.5.7. ME 3 Procedures are established and

Score

JCI Findings

Partially Met

The Hospital did not take adequate measures to safeguard the pediatric patients against infant abduction.

There was no monitoring of a locked exit door with a key that was hung on the adjacent wall.

Partially Met

During patient tracers in the Radiology Department, it was observed that all patients who underwent procedures in the MRI and CT that included the administration of contrast were required to sign informed consents.

The consents that were use did not inform patients of the required elements b), d), and e). the consent form narrative simply stated that the procedure was explained to the patient.

Partially Met

The hospital did not develop and implement nutritional screening criteria for the pediatric population.

The nutritional screening for adults was used for neonates and pediatric patients

Partially Met

Three blood specimen bottles were found without labels in the specimen refrigerator of the Delivery Room. It was not in compliance with the • hospital policy IPP-14-HIST-052

Partially Met

The hospital policy IPP-14-HIST 052 required specimens to be immersed in 10% buffered formalin within one

What and Where (Plan of Action(s) and Areas for Improvement)

Who Owner – Staff Name/ Title

When (Completion Date)

Either all emergency exit doors or at least the emergency exit doors of neonatal/pediatric ICUs, nursery, pediatric wards and delivery room shall be installed with magnetic controls connected to the fire alarm system.

Maintenance Eng. Ali

30 November 2015

Radiology Dr. Bandar Mr.Hussam Ms. Ezdihar

November 15 2015

Done

Ms. Nada Ms. Sausan

October 29, 2015

For printing

October 27, 2015

Policies and Procedure revised uploaded in KFHU intranet

Outcome

•

Review and revise the MRI consent form that will reflect the following: 1. Benefits of the procedure 2. Potential risk of not carrying out the procedure 3. Possible alternative modalities • Develop Patient and Family Education specific to diagnostic test / Invasive procedure

•

Review and revise the Pediatric and Neonatal Assessment form

Blood specimen policy discussed Investigate by using the tool RCA

Laboratory Nursing OBGYN Consultant

29

STD

Score

implemented for the transport, storage, and preservation of specimens.

AOP.6.3 ME 3 Identified radiation safety risk are addressed by specific processes or devices that reduce safety risks (such as lead aprons, radiation badges and the like).

COP.2.1 ME 3 The plan of care is updated or revised and reviewed by the multidisciplinary team based on the reassessment of the patient by the healthcare practitioners.

ASC.7.2 ME 1 Surgical reports, templates, or operative progress notes include at least a) through h) from the intent.

JCI Findings

What and Where (Plan of Action(s) and Areas for Improvement)

Who Owner – Staff Name/ Title

When (Completion Date)

Outcome

hour of a biopsy or resection procedure; however, two containers of biopsy specimen that were not immersed in 10% formalin were stored in the specimen refrigerator for more than five hours.

Partially Met

Partially Met

Partially Met

In the operating Theater and Cardiac Catheterization Lab, lead thyroid shields were not individually labeled, so it was not possible to track of the shields

The organization had a “Individualized Integrated Care Plan” for each patient requiring a Multidisciplinary Health Care Team input. Twelve of the 20 (60%) records reviewed included documented entries and signature s of physicians. This was not in compliance with the organization’s policy requiring input from the physicians.

In three operative reports reviewed, 20 of 24 % (83% compliance) elements were recorded. Some elements e), and h), that were not recorded included specimens and the date and time that the operative note was completed.

All lead apparels including thyroid shields, gonad shields and/or other types of shields shall be included in the inventory of radiation protection equipment. Their ID numbers shall be affixed on them and the quality control (QC) testing records shall be available at radiology department and the respective department where these shields are being used.

•

• •

Re-emphasize to the physician /consultant the importance of their signature in Integrated Care Plan.

Define Performance Measure Monitor compliance

Revise the OPERATIVE NOTES KFHU.SUR 30003 to include the date and time the form is completed, add a tick box “yes” or “no” and the type of specimen send

Dr. Bandar Al Dhafiri (Director of Radiology) 30 November 2015

Done

Tracer Team

ongoing

ongoing

Yolanda Margilyn

08 October 2015

Done Electronic

Hussam Shamassi Ali Al Suhaimi

30

STD MMU.1 ME2 All settings, services and individuals who manage medication processes are included in the organizational structure MMU.3 ME 2 Controlled substance is accurately accounted for according to applicable laws and regulations.

MMU.4.1 ME 2 The hospital develops and implements a process to manage medication order that are incomplete, illegible, or unclear.

MMU.5.2 ME 2 After preparation, medications not immediately administered are labeled with the name of the medication, dosage / concentration the date prepared, the expiration date and the patients name

Score

JCI Findings

Partially Met

Intravenous contrast media was used in Radiology and Cardiac Catheterization Lab; However, Radiology and Cardiology were not included in the organizational structure for medication management.

Partially Met

In operating Theater, unused narcotic medications were discarded in the sharps container instead of in the sink as per Saudi DFA guidelines.

What and Where (Plan of Action(s) and Areas for Improvement)

Who Owner – Staff Name/ Title

When (Completio n Date)

Outcome

Dr. Nadia Ismail Dr. Bandar Dafery Dr. Abdullah AlShehri

Developed a policy regarding, how to discard of excess narcotic

Dr. Nadia Ismail Dr. Al Ghamdi

ongoing

Partially Met

During tracers to the Emergency Department Pharmacy, it was observed that one of 12 (8% compliance) prescriptions contained all the elements of a complete medication order. The other prescriptions were missing elements such as legibility, route, prn indications, dosage quantity, and / or directions. Outpatient prescription comprised the majority of the hospital’s total prescriptions volume.

OPD Electronic prescription

Dr. Nadia Ismail Dr. Shahrani Dr. Hosni

Ongoing

Partially Met

In the Operating Theater, six syringes containing medications were labeled only with the name of medication and dosage, and two syringes were unlabeled. On the scrub nurses’ tables, four containers with clear liquids were unlabeled.

To put a label on medication syringes

Dr. Al-Ghamdi Dr. Nadia

Done

31

What and Where (Plan of Action(s) and Areas for Improvement) • Request machine that indicates the load number and expiration date

Who Owner – Staff Name/ Title Dr. Huda Ms. Nada Ms. Sausan

When (Completio n Date) 30 November 2015

During tracer activities on Female Surgical Unit 12 of 15 (80% compliance) intravenous fluids bags observed had not expired, and were in compliance with organization’s process of management of consumables. Multiple expired medical surgical supplies such as EET tubes, electrode gel, Laryngoscope blades were found in the Cardio Pulmonary Department.

Intravenous fluids bag replaced Cardiac lab to change all expired disposables such as ETT tubes, electrode gel, Laryngoscope blades, suction tubes, etc.

Nursing Cardiac Lab

15 October 2015

Done

In the Main Operating Theater and Burn Unit Operating Theater, humidity was not monitored.

Install humidity monitoring system and initiate routine monitoring by department staff. Supervisors shall ensure that the monitoring records are regularly reviewed.

15 November 2015

Eng. Ali didn’t receive the materials

STD

Score

JCI Findings

PCI.7.1 ME 1 Methods for medical technology cleaning, disinfection, and sterilization address the principles of infection prevention and control.

PCI.7.1.1 ME 1 The hospital implements a process consistent with national laws and regulations and professional standards that identifies the process for managing expired supplies PCI.7.5 ME 1 Engineering controls are implemented to minimize infection risk in the hospital.

Partially Met

Instruments sterilized in CSSD did not have a load numbers on the packages; therefore, it was not possible to track instruments in case of an infection

Partially Met

Partially Met

Outcome The product does not meet the needs. Lot number and expiration date will be computerized

by February 2016

Tracer Team Continuous monitoring

Engr. Ali Al Ali (Operations & Maintenance Director) & Ms. Nada Al Amri (Nursing Director)

32

STD

Score

JCI Findings

GLD.3 ME 4 Hospital Leadership ensures that policies and procedures are followed

Partially Met

SQE.1.1 ME 2 Those individuals identified in a) through d) in the intent, when present in the hospital have job descriptions appropriate to their activities and responsibilities or have been privileged if noted as an alternative.

Partially Met

During patient tracer activities a copy of a patient’s medication orders were found in a trash basket in the hallway below the inpatient pharmacy window containing confidential patient information including name and medical record number. This manner of disposal of the compliance with the organization’s policy The following policies were inconsistently implemented, including but not limited to the following: • Equipment cleaning • Medication Prescribing • Use of abbreviations • Hand Hygiene • Safe handling of Specimen Nurse had job description appropriate to their activities and responsibilities. All nurses, irrespective of their areas of work, had similar job descriptions. Job descriptions of other category of staff were found appropriate.

What and Where (Plan of Action(s) and Areas for Improvement) 1. Review the policies and procedures 2. Educate the staff 3. Define Performance Indicator 4. Monitor and collect data

Who Owner – Staff Name/ Title Dr. Khalid Dr. Jumaan

When (Completion Date) November 2015

Review and revise the nursing Job description especially in critical areas

Nursing Department Ms. Nada Ms. Sausan Ms. Jenny

November 26, 2015

Outcome Ongoing

Done

33

STD SQE.1.1 ME 2 Those individuals identified in a) through d) in the intent, when present in the hospital have job descriptions appropriate to their activities and responsibilities or have been privileged if noted as an alternative.

SQE.8.2 ME 3 The hospital provides evaluation, counseling, and follow-up of staff exposed to infectious diseases that is coordinated with the prevention and control program.

SQE.9.1 ME 1 Education, licensure / registration, and other credentials required by law or regulation or issued by recognized education or professional entities as the basis for clinical privileges are verified from the original source that issued the credential

What and Where (Plan of Action(s) and Areas for Improvement)

Who Owner – Staff Name/ Title

When (Completion Date)

Partially Met

Nurse had job description appropriate to their activities and responsibilities. All nurses, irrespective of their areas of work, had similar job descriptions. Job descriptions of other category of staff were found appropriate.

Review and revise the nursing Job description especially in critical areas

Nursing Department Ms. Nada Ms. Sausan Ms. Jenny

November 26, 2015

Done

Partially Met

Hospital Policy INF 12 – 015 required contact tracing, screening and follow-up of staff who were exposed to tuberculosis smear positive patient was not done as per the hospital policy.

Revise the Policy add the time frame for follow-up

Infection Control – Dr. Huda

November 15, 2015

Done

Partially Met

One of two (50% compliance) physician required education and other credentials were all verified from the original source

Human Resource Department Mr. Jamal

March 2016

On going

Score

JCI Findings

Outcome

34

STD SQE.9.1 ME 3 When third-party verification is used, the hospital verifies that the third party for example, a government agency) implements the verification process as described in policy or regulations and that the process meets the expectations described in the intent.

SQE.11 ME 3 The clinical results of data and information available on medical staff members are reviewed with objective and evidence –based information as available, for external benchmarking.

Score

JCI Findings

Not Met

The hospital used the Saudi Commission for Health Specialties for the third party primary source verification but did not verify that the process met the expectations described in the intent

Partially Met

Five of Eight (63% compliance ) physicians had an objective ongoing professional practice evaluation (OPPE) that was externally benchmark

What and Where (Plan of Action(s) and Areas for Improvement)

Who Owner – Staff Name/ Title

When (Completion Date)

1. Established primary source verification unit in HR department 2. Authenticate the primary source verification done by Saudi Council 3. Review and Revise the primary source verification policy 4. Define the Performance Indicator 5. Integrate the new primary source verification process to the recruitment plan

Human Resource Department Mr. Jamal

March 2016

Ongoing

Nadia AlAssiri

February 2015

Done 9 OPPE indicator

Review the physicians indicator

Outcome

35

STD

MOI.4 ME 4 Standardized symbols are used, and those not to be used are identified and monitored.

MOI.4 ME 5 Standardized abbreviations are used, and those not to be used are identified and Monitor

Score

Partially Met

Partially Met

JCI Findings

What and Where (Plan of Action(s) and Areas for Improvement)

The organization had identified a list of symbols to be not used and not to be used in the medical documentation; however, the organization had multiple use of the symbols that were identified as not to be used. For example; the use of slash mark (/), in /CD = complete mandibular denture, CD/ = complete maxillary denture, g/L = grams per liter. The use of symbols could lead to confusion in the documented medical record.

1. The organization had identified a list of abbreviations to be used and list not to be used in the medical documentation; however, the organization had multiple use of the same abbreviations representing different terms e.g. RT – Radiation Therapy, RTRespiratory Therapy. Multiple definitions of the same abbreviations could lead to confusion in the documented medical record.

2. During open and closed record reviews, unapproved abbreviations such as SYX, DEX, IU, u, and cc, were observed. Abbreviations on consent forms such as PCI, LP, ACG, and RCA were also noted, which were not in compliance with hospital policy. In addition, in the hospital policy, approved abbreviations such as RF, RT, PVD, R, and CD had multiple meaning

1. Review the ADM-Gen 01-046 Approved abbreviations policy and revised if necessary 2. Define Performance Indicator 3. Monitor for compliance

Who Owner – Staff Name/ Title

Medical Records Committee PI Unit

When (Completion Date)

November 19, 2015

Outcome

Revised ADM-Gen 01-046 Approved Abbreviation Policy uploaded

36

STD

MOI.10.1.1 ME 3 The clinical records of discharged emergency patients include the patient’s condition at discharge.

MOI.11 ME 3 There is a process that addresses how entries in the patient records are corrected or overwritten.

Score

Partially Met

Partially Met

MOI.11.1 ME 2 The date of each patient clinical record entry can be identified

Partially Met

MOI.11.1 ME 3 The time of each patient clinical entry can be identified

Partially Met

JCI Findings

Four of six (67% compliance) clinical records of discharged emergency patients included the patient’s condition at discharge.

1. The organization had a policy and process about how entries in the patient record were to be corrected or overwritten. In a review of multiple records, 10 of 20 (50% compliance) were in compliance with organization policy and process.

2. During open and closed record reviews, zero of 15 (0% compliance) entries were correctly overwritten with a line, the word “error” Initials and employee number as per hospital policy “ Patient Medical Record & Documentation Standards ADMGen 01 – 062 “ During review of open and closed medical records the General Consent Forms 13 of 25 (52% compliance) were dated in compliance with the organization’s policy.

During review of open and closed medical records of patient Surgical Operative Report, six of 11 (55% compliance) reports had time of entries documented

What and Where (Plan of Action(s) and Areas for Improvement) 1. Review and revise the ER form if Necessary 2. Educate ER Physicians to include condition of Patient at discharge 3. Define Performance Indicator 4. Monitor and collect data 5. Send monthly result to the leadership and chairman of the department

1. Review and revise the ADMGen 01 – 062 Patient Medical Record & Documentation Standards 2. Re-emphasize to all physician the importance and legal aspect of correction of entries and overwritten 3. Define Performance Measure 4. Monitor and collect data 5. Send monthly result to the leadership and chairman of the department

Who Owner – Staff Name/ Title

When (Completion Date)

Dr. Khalid Otaibi Dr. Mohye Wahhas Medical Record Review Committee PI Unit

November 26, 2015

Ongoing Agenda in Medical Records Committee In the process of paper less environment

Dr. Khalid Otaibi Dr. Mohye Wahhas Medical Record Review Committee PI Unit

November 26, 2015

Transition phase of paper less environment

Re-emphasize to the admission office and ER receptionist to indicate the date and time of patients / relative signing the consent Review and revise the Operative Notes to include the date and time of entries

Outcome

Ongoing monitoring during tracer

Yolanda Margilyn

October 8, 2015

Done Electronic (dictation Dragon)

37

Table 3: KING FAHD HOSPITAL OF THE UNIVERSITY TRACER TOOL Standard Medical Record Number Diagnosis Consultant Department / Service Unit Y

N

NA Comments

Y

N NA Comments

Consent IPSG.4

PFR.5 PFR.5.1 PFR.5.2

ASC.5.1 ASC.7.1

1. Document, before the procedure, that the informed consent is appropriate to the procedure; that the correct site, correct procedure, and correct patient are identified; and that all documents and 2. General consent for treatment is obtained.

3. Informed consent completed with Date and Time 4. Surgical or invasive procedures consent completed with date and 5. Anesthesia and moderate and deep sedation consent completed 6. Blood and blood products consent completed with date and time 7. High-risk treatments and procedures consent completed with 8. Risks, benefits, and alternatives of thbenefits, i 9. Risks, potential

complications, and alternatives of 10. The identity of the individual(s) providing the information and obtaining the consent is noted in the patient’s record; consent is documented in the patient’s record Assessment

GLD.18

38

Table 3: KING FAHD HOSPITAL OF THE UNIVERSITY TRACER TOOL Standard Medical Record Number Diagnosis Consultant Department / Service Unit Y

N

NA Comments

Y

N NA Comments

IPSG.2.1 11. Critical results of diagnostic tests available in patients’ health record AOP.1.2.1 12. Initial medical assessment of emergency patients documented 13. Initial nursing assessment of emergency patients documented AOP.1.2 14. Patient’s needs identified from nursing initial assessments, which are initiated within 30 mins after admission as an inpatient and 15. Patient’s medical needs identified from history and physical assessments which are completed ithi 24 h includes ft d i i AOP.1 16. Assessment physical, psychological and social status (includes spiritual and cultural AOP.1.3 17. Initial assessment updated if greater than 30 days old.

AOP.1.3.1 18. A preoperative assessment is documented before anesthesia or surgical treatment and includes the patient’s medical, physical, AOP.1.4 19. Nutritional screening done according to age specific 20. Patient at risk to nutritional problems receive nutritional assessment from 21. Functional screening done according to age specific 39

Table 3: KING FAHD HOSPITAL OF THE UNIVERSITY TRACER TOOL Standard Medical Record Number Diagnosis Consultant Department / Service Unit Y

N

NA Comments

Y

N NA Comments

22. Patients in need for functional assessment are referred.

AOP.1.5 23. Screening for pain on admission t d initial assessments for AOP.1.6 24. d Individualized special populations documented AOP.1.7 25. Assessment and reassessment for special populations done AOP.1.8 26. Early screening for discharge planning documented AOP.2 27. Reassessments based on condition are documented in the patient’s Integrated Care Plan and Progress Notes COP.2.1 28. Initial plan of care is documented in the patient's record it reflects the patient’s current condition and has 29. Nursing plan of care is documented in the patient's record it reflects the patient’s current condition and has 30. The plan of care reflects the participation of all appropriate 31. Plan of care states measurable and meaningful goals, and signed by the consultant with the date and time.

COP.2.2 32. Orders are found in a uniform location in patient records COP.2.3 33. Clinical and diagnostic procedures and treatments performed, and the results or outcomes are documented 40

Table 3: KING FAHD HOSPITAL OF THE UNIVERSITY TRACER TOOL Standard Medical Record Number Diagnosis Consultant Department / Service Unit Y

N

NA Comments

Y

N NA Comments

COP.5

34. Patient’s response to nutrition therapy is monitored and 35. Daily progress notes reflects progress towards goals defined in ACC.1.2 36. Any delay in treatment is recorded in patients’ health record Patient and Family Education Form PFE.2 PFE.2.1

37. Educational needs assessment findings are recorded in the patient’s Assessment includes: 38 The patient’s and family’s beliefs and 39. Their literacy, educational level, and 40. language Emotional barriers and motivations 41. Physical and cognitive limitations

42. The patient’s willingness to receive information Surgical Safety Checklist IPSG.4.1 43. The full surgical team conducts and documents a time-out procedure in the area in which the surgery/ invasive procedure will be performed, just before starting a surgical/ invasive procedure Transfer Form / Transfer summary ACC.2.3 44. Admission to and discharge or and transfer from specialized programs ACC.2.3.1 are documented in the patient’s 41

Table 3: KING FAHD HOSPITAL OF THE UNIVERSITY TRACER TOOL Standard Medical Record Number Diagnosis Consultant Department / Service Unit Y

N

NA Comments

Y

N NA Comments

ACC.3.1 45. The process identifies how individuals assume the transferred responsibility and document their ACC.5.2 46. A patient clinical summary document is transferred with the patient.

ACC.5.3 47. The transfer process is documented in the patient’s record.

Anesthesia and Postoperative Notes ASC.5

48. Anesthesia plan documented

ASC.5.1

49. The anesthesiologist or another qualified individual provides and 50. Pre-sedation assessment completed and documented.

51. Monitoring during sedation completed and documented 52. Recovery criteria completed and documented 53. Pre-anesthesia and pre-induction assessments completed and documented 54. Each patient’s physiological status during anesthesia and surgery is monitored according to professional practice guidelines and documented 55. Each patient’s post-anesthesia status is monitored and documented, and the patient is discharged from the recovery area by a qualified individual or by using established

ASC.3– ASC.3.2

ASC.4 ASC.6

ASC.6.1

42

Table 3: KING FAHD HOSPITAL OF THE UNIVERSITY TRACER TOOL Standard Medical Record Number Diagnosis Consultant Department / Service Unit Y ASC.7

ASC.7.1

ASC.7.2

N

NA Comments

Y

N NA Comments

56. Assessment information that supports the planned procedure t d idiagnosis ti t ’documented h lth 57. d Preoperative in patients’ health record 58. Planned surgical procedure is documented in patients’ health 59. The patient’s surgeon or other qualified individual provides and documents the education.

60. Written surgical report contains the following: Postoperative diagnosis 61. Name of operative surgeon and 62. assistants Perioperative complications 63. Procedures performed and description of each procedure 64. Surgical specimens sent for amination 65. e Amount blood loss and amount

ASC.7.3

f number d bl d of all implantable 66. tRegistry devices 67. Date, time, and signature of responsible physician 68. The medical post-surgical plan documented with measurable goals 69. The nursing postsurgical plan of care documented with measurable goals 70. Postsurgical plan of care by others as appropriate 43

Table 3: KING FAHD HOSPITAL OF THE UNIVERSITY TRACER TOOL Standard Medical Record Number Diagnosis Consultant Department / Service Unit Y

N

NA Comments

Y

N NA Comments

Medication Management and Use MMU.4

71. List of current medications taken prior to admission (Medication Reconciliation Form)

MMU.4.3 72. Medications prescribed or ordered and administered are written in the patient’s record. (MAR) MMU.7 73. Adverse effects are documented and reported Management of Information MOI.4

74. Only approved abbreviations, and symbols used

MOI.7

75. Patient records and other data and information are secure and protected t llhospital ti 76. The initiates and maintains a

MOI.10

clinical record for every patient assessed or treated, and the record’s specific content and format is MOI.11 77. The author, date, and time of every entry documented 78. Wrong entries in patients’ medical record are corrected appropriately and not overwritten MOI.11.1 79. Entries in medical records are legible MOI.12

80. The hospital regularly assesses patient clinical record content and the completeness of patient clinical 44

Table 3: KING FAHD HOSPITAL OF THE UNIVERSITY TRACER TOOL Standard Medical Record Number Diagnosis Consultant Department / Service Unit Y

N

NA Comments

Y

N NA Comments

Others

IPSG.2

81. Advance Directive (DNR): Staff can identify whether an advance directive exists or not; when it does exist, where it is located in the chart; what they do if patient has an advance directive but patient or patient’s 82. Staff can articulate the process for read-back of critical test results in response to question: What would you do if the lab or radiology called 83. Restraint orders are limited to 24 hours 84. Patient is assessed for alternatives to restraint intervention.

85. The patient in restraints is monitored according to the reason for the 86. Describe your competency for providing care for this patient (e.g.

Nursing; Dietician; Physiotherapy; Social Work; Pharmacy; Respiratory) 87. How can you find out if a physician is credentialed to perform a procedure or treatment?

88. How do you know what procedures by virtue of their level of education residents are allowed to perform?

89. Awareness to sentinel events, near miss, and adverse events 90. Staff able to explained Hand-off communication process 45

Table 3: KING FAHD HOSPITAL OF THE UNIVERSITY TRACER TOOL Standard Medical Record Number Diagnosis Consultant Department / Service Unit Y

N

NA Comments

Y

N NA Comments

91. Emergency Crash Cart checklist upto-date and complete.

92. Staff observed using appropriate hand-washing techniques 93. PPE (Personal Protective Equipment) is present in the designated areas in the department.

Isolation techniques initiated as 94. Medications (including IV solutions) and syringes are secured.

95. High Alert medications including LASA, if ordered, are secured.

96. Food Refrigerator temperature is being monitored and recorded (NICU 97. Medication Refrigerator temperature is monitored and recorded.

98. ID badges on staff are present and visible

46

Table 3: KING FAHD HOSPITAL OF THE UNIVERSITY TRACER TOOL Standard

Medical Record Number Diagnosis Consultant Department / Service Unit Y

N

NA

Comments

Y

N NA

Comments

Consent IPSG.4

99. Document, before the procedure, that the informed consent is appropriate to the procedure; that the correct site, correct procedure, and correct patient are identified; and that all documents and equipment needed are on hand, correct, and functional.

PFR.5

100. General consent for treatment is obtained.

PFR.5.1

101. Informed consent completed with Date and Time 102. Surgical or invasive procedures consent completed with date and time.

103. Anesthesia and moderate and deep sedation consent completed with date and time 104. Blood and blood products consent completed with date and time 105. High-risk treatments and procedures consent completed with date and time 106. Risks, benefits, and alternatives of anesthesia

PFR.5.2

ASC.5.1 ASC.7.1

107. Risks, benefits, potential complications, and alternatives of surgery.

GLD.18

108. The identity of the individual(s) providing the information and obtaining the consent is noted in the patient’s record; consent is documented in the patient’s record by signature or record of verbal consent.

47

Table 3: KING FAHD HOSPITAL OF THE UNIVERSITY TRACER TOOL Standard

Medical Record Number Diagnosis Consultant Department / Service Unit Y

N

NA

Comments

Y

N NA

Comments

109.

Assessment IPSG.2.1

110. Critical results of diagnostic tests available in patients’ health record

AOP.1.2.1

111. Initial medical assessment of emergency patients documented 112. Initial nursing assessment of emergency patients documented

AOP.1.2

113. Patient’s needs identified from nursing initial assessments, which are initiated within 30 mins after admission as an inpatient and completed within the shift.

114. Patient’s medical needs identified from history and physical assessments which are completed within 24 hours after admission as an inpatient

AOP.1

115. Assessment includes physical, psychological and social status (includes spiritual and cultural variables)

AOP.1.3

116. Initial assessment updated if greater than 30 days old.

AOP.1.3.1

117. A preoperative assessment is documented before anesthesia or surgical treatment and includes the patient’s medical, physical, psychological and spiritual/cultural needs.

48

Table 3: KING FAHD HOSPITAL OF THE UNIVERSITY TRACER TOOL Standard

Medical Record Number Diagnosis Consultant Department / Service Unit Y

N

NA

Comments

Y

N NA

Comments

AOP.1.4 118. Nutritional screening done according to age specific 119. Patient at risk to nutritional problems receive nutritional assessment from Clinical Dietician 120. Functional screening done according to age specific 121. Patients in need for functional assessment are referred.

AOP.1.5

122. Screening for pain on admission documented

AOP.1.6

123. Individualized initial assessments for special populations documented

AOP.1.7

124. Assessment and reassessment for special populations done

AOP.1.8

125. Early screening for discharge planning documented 126. Reassessments based on condition are documented in the patient’s record.

AOP.2

Integrated Care Plan and Progress Notes COP.2.1

127. Initial plan of care is documented in the patient's record it reflects the patient’s current condition and has been revised if necessary.

128. Nursing plan of care is documented in the patient's record it reflects the patient’s current condition and has been revised if necessary.

129. The plan of care reflects the participation of all appropriate multidisciplinary caregivers.

49

Standard

Medical Record Number

Diagnosis Table 3: KING FAHD HOSPITAL OF THE UNIVERSITY TRACER TOOL Consultant Department / Service Unit Y

N

NA

Comments

Y

N NA

Comments

130. Plan of care states measurable and meaningful goals, and signed by the consultant with the date and time.

COP.2.2

131. Orders are found in a uniform location in patient records

COP.2.3

132. Clinical and diagnostic procedures and treatments performed, and the results or outcomes are documented in the patient’s record.

COP.5

133. Patient’s response to nutrition therapy is monitored and documented in the patient record.

134. Daily progress notes reflects progress towards goals defined in plan of care 135. Any delay in treatment is recorded in patients’ health record

ACC.1.2

Patient and Family Education Form PFE.2

136. Educational needs assessment findings are recorded in the patient’s record.

PFE.2.1

Assessment includes: 137. The patient’s and family’s beliefs and values 138. Their literacy, educational level, and language 139. Emotional barriers and motivations 140. Physical and cognitive limitations 141. The patient’s willingness to receive information

Surgical Safety Checklist 50

Table 3: KING FAHD HOSPITAL OF THE UNIVERSITY TRACER TOOL Standard

Medical Record Number Diagnosis Consultant Department / Service Unit Y

IPSG.4.1

N

NA

Comments

Y

N NA

Comments

142. The full surgical team conducts and documents a time-out procedure in the area in which the surgery/ invasive procedure will be performed, just before starting a surgical/ invasive procedure.

Transfer Form / Transfer summary

ACC.2.3 and ACC.2.3.1 ACC.3.1

143. Admission to and discharge or transfer from specialized programs are documented in the patient’s record 144. The process identifies how individuals assume the transferred responsibility and document their participation or coverage.

ACC.5.2

145. A patient clinical summary document is transferred with the patient.

ACC.5.3

146. The transfer process is documented in the patient’s record.

Anesthesia and Postoperative Notes ASC.5

147. Anesthesia plan documented

ASC.5.1

148. The anesthesiologist or another qualified individual provides and documents the education.

ASC.3– ASC.3.2

149. Pre-sedation assessment completed and documented.

150. Monitoring during sedation completed and documented 151. Recovery criteria completed and documented.

ASC.4

152. Pre-anesthesia and pre-induction assessments completed and documented

51

Table 3: KING FAHD HOSPITAL OF THE UNIVERSITY TRACER TOOL Standard Medical Record Number Diagnosis Consultant Department / Service Unit Y

N

NA

Comments

Y

N NA

Comments

153.

ASC.6

ASC.6.1

ASC.7

154. Each patient’s physiological status during anesthesia and surgery is monitored according to professional practice guidelines and documented in the patient’s record.

155. Each patient’s post-anesthesia status is monitored and documented, and the patient is discharged from the recovery area by a qualified individual or by using established criteria. (Anesthesia print out) 156. Assessment information that supports the planned procedure documented in patients’ health record 157. Preoperative diagnosis documented in patients’ health record 158. Planned surgical procedure is documented in patients’ health record

ASC.7.1

159. The patient’s surgeon or other qualified individual provides and documents the education.

ASC.7.2

160. Written surgical report contains the following: Postoperative diagnosis 161. Name of operative surgeon and assistants 162. Perioperative complications 163. Procedures performed and description of each procedure findings 164. Surgical specimens sent for examination

52

Table 3: KING FAHD HOSPITAL OF THE UNIVERSITY TRACER TOOL Standard

Medical Record Number Diagnosis Consultant Department / Service Unit Y

N

NA

Comments

Y

N NA

Comments

165.

166. Amount blood loss and amount transfused blood 167. Registry number of all implantable devices 168. Date, time, and signature of responsible physician ASC.7.3

169. The medical post-surgical plan documented with measurable goals 170. The nursing postsurgical plan of care documented with measurable goals 171. Postsurgical plan of care by others as appropriate

Medication Management and Use MMU.4

172. List of current medications taken prior to admission (Medication Reconciliation Form)

MMU.4.3

173. Medications prescribed or ordered and administered are written in the patient’s record.

(MAR)

MMU.7

174. Adverse effects are documented and reported

Management of Information MOI.4

175. Only approved abbreviations, and symbols used

MOI.7

176. Patient records and other data and information are secure and protected at all times.

53

Standard Medical Record Number Table 3: KING FAHD Diagnosis HOSPITAL OF THE UNIVERSITY TRACER TOOL Consultant Department / Service Unit Y

N

NA

Comments

Y

N NA

Comments

177.

MOI.10

178. The hospital initiates and maintains a clinical record for every patient assessed or treated, and the record’s specific content and format is determined by the hospital.

MOI.11

179. The author, date, and time of every entry documented 180. Wrong entries in patients’ medical record are corrected appropriately and not overwritten

MOI.11.1 181. Entries in medical records are legible MOI.12

182. The hospital regularly assesses patient clinical record content and the completeness of patient clinical records.

Others 183. Advance Directive (DNR): Staff can identify whether an advance directive exists or not; when it does exist, where it is located in the chart; what they do if patient has an advance directive but patient or patient’s family does not provide the advance directive.

IPSG.2

184. Staff can articulate the process for read-back of critical test results in response to question: What would you do if the lab or radiology called with a critical test result?

185. Restraint orders are limited to 24 hours.

54

Standard

Medical Record Number Diagnosis

Table 3: KING FAHD Consultant HOSPITAL OF THE UNIVERSITY TRACER TOOL Department / Service Unit Y

N

NA

Comments

Y

N NA

Comments

186. Patient is assessed for alternatives to restraint intervention.

187. The patient in restraints is monitored according to the reason for the intervention 188.

189. Describe your competency for providing care for this patient (e.g. Nursing; Dietician; Physiotherapy; Social Work; Pharmacy; Respiratory) 190. How can you find out if a physician is credentialed to perform a procedure or treatment?

191. How do you know what procedures by virtue of their level of education residents are allowed to perform?

192. Awareness to sentinel events, near miss, and adverse events 193. Staff able to explained Hand-off communication process 194. Emergency Crash Cart checklist up-to-date and complete.

195. Staff observed using appropriate hand-washing techniques 196. PPE (Personal Protective Equipment) is present in the designated areas in the department.

Isolation techniques initiated as appropriate and practiced.

55

Standard

Medical Record Number Diagnosis Consultant Department / Service

Table 3: KING FAHD HOSPITAL OF THE UNIVERSITY TRACER TOOL Unit Y

N

NA

Comments

Y

N NA

Comments

197. Medications (including IV solutions) and syringes are secured.

198. High Alert medications including LASA, if ordered, are secured.

199. Food Refrigerator temperature is being monitored and recorded (NICU breast milk) 200.

201. Medication Refrigerator temperature is monitored and recorded.

202. ID badges on staff are present and visible.

56

Performance Measurement Unit

57

Introduction The Performance Measurement Unit of Directorate of Quality & 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 give an overview of all activities done by Performance Measurement Unit of Directorate of Quality and Safety.

ACTIVITIES ACCOMPLISHED BY PERFORMANCE MEASUREMENT UNIT: The following report represents a summary of all activities accomplished by the Performance Improvement (PM) Unit for year 2015, the report includes the following: 1.

2.

3.

4.

Monitoring of KFHU Key Performance Indicators (KPIs).

Conduct Performance Improvement Project with some of hospital departments that their performance needed improvement , PI project were conducted on 2015: a) Decrees rate of patients falls. b) Increase compliance of influenza vaccination by KFHU personnel. c) Reducing the percentage of radiology report turnaround time outlier rate. d) Decrease the percentage of patients who stay longer than 6 hours in Emergency room. e) Decrease the percentage of OR cancellation on the day of the procedure.

Record Review Activities (Open and close).

Other PI unit activities: a) Committees and JCI Chapters facilitated by PI Unit. . b) QPS Education and Training Plan. c) Hospital Orientation Program. d) Weekly Tracer for Hospital Departments. e) Attending RCA and Sentinel Events Meeting with Risk Management Unit.

58

KFHU Key Performance Indicators (KPI) Executive Summary In Key Performance Indicators Quarterly Report, it demonstrates 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 2015 compared to the last year was: • 2014: 35 KPIs were implemented • 2015: 68 KPIs were implemented.

Strength: The following KPI showed positive special cause variations over the past 4 quarters: 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

Aspirin within 24 hours of arrival for all MI patients % ECG Measured within 10 min of arrival %Venous Thromboembolism prophylaxis % Cesarean Deliveries in Nulliparous with a term singleton baby in vertex presentation Compliance rate for prophylaxis antibiotics prior to C/S % Use of relievers of children’s inpatient asthma % Falls Rate per 1000 patients days % Compliance on Patient Identification during Medication Preparation. % Compliance on Patient Identification during Medication Administration. % Completion of Fall Risk Assessment Form % Compliance to Newborn Identification (During Delivery, Rooming in, and Discharge) Hospital Acquired Healthcare associated Infection Rate ICU- CAUTI incidence per 1000 device days ICU Ventilator-associated pneumonia (VAP) rate per 1000 patients days % In-patient Satisfaction % Awareness of Staff to Patient Safety Culture Staff Turnover Rate Cross match Transfusion ration (CT ratio) Blood Culture Contamination rate % of Laboratory Critical values reporting within 30 minutes % discrepancies between preoperative and postoperative diagnoses The % of patients left ER without being seen % of patient who stay in recovery room longer than 1 hour % inappropriate patient surgical site marking (IPSG4) % Compliance to Time Out (IPSG4) % of needle stick OVR by housekeeping staff % of patient satisfaction with room cleaning Average Turnaround Time of isolation room terminal cleaning % of refused delivered linen by all patients’ units after laundry wash % Radiology Report Turnaround Time outlier % In-patient satisfaction about dietary Services

59

32.

33.

34.

35.

36.

37.

38.

39.

Daily Air Removal Test (DART) of sterilizer machine 1,2 and 3 Daily Biological indicator test Emergency eyewash station operational monitoring Leak test % In patient satisfaction about dietary Services % of completed meal card identification for male and female medical wards Mortality Rate.

The % of patients who stay longer than six hours in the ER

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.

19.

20.

21.

22.

Pressure Ulcer Incidence Rate Hospital Acquired MRSA rate per 1000 pts. Days Hospital Acquired MRAB rate per 1000 pts. Days % of Hand Hygiene Compliance ICU-CLABSI Incidence per 1000 device days Average Length of Stay (ALOS) Bed occupancy rate % Out-patient Satisfaction # of Near miss (non-drug related) Sentinel events % OR Cancellation % Foreign objects found in linen received % KT/V measurement % Zero stock level in drug pharmacy # of adverse drug reaction % of out-Patient Satisfaction about pharmacy services # of Near misses (drug related) Total number of clinical pharmacist interventions.

Average of out-patient waiting time. % Compliance to the use of SBAR form during handover Blood Transfusion Reaction Rate % Unplanned readmission for OR after 72 hours

60

Figure 28: KPI Dashboard (2015)

61

KPI Dashboard (2015)cont,

62

KPI Dashboard (2015) cont.

63

Table 4: Performance Improvement Projects

Performance Improvement Project

Responsible Department

Status

Out come

Completed

Reduce the rate of patients falls from 7.2 to 1.0/ 1000 patients days

Completed

Increase vaccination rate of healthcare workers especially in critical areas from 190 to 2736

Radiology Department Completed

Reduce the percentage of Radiology Report Turnaround Time from 70% to 15%.

4. Decrease the percentage of patients who stay longer than 6 hours in Emergency room

Emergency Department

Completed

Decrease the rate of patient who are staying in Emergency Department more than 6 hours from 9.8/ 1000 patients to 8.8/1000 patients

5. Decrease the percentage of OR cancellation on the day of the procedure.

Anesthesia Department

Completed

Reduce the percentage of OR cancellation on the day of procedure from 12.8% to 8.35%.

1. Decrease rate of patients falls

2. Increase compliance of influenza vaccination by KFHU

3. Reducing the percentage of Radiology report turnaround time outlier rate

Nursing unit

Employee healthcare service (EHS)

64

Medical Record Review a. 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 Measurement 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 for both (Open & Closed Record Review). 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. b. 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). c. Record Review Activities:

i.

Closed Record Review Activity: Performance Measurement Unit start closed record review process activity at 2015, 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.

ii.

Open Record Review Activity: Performance Measurement 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.

65

Figure 29: Inpatient Closed Record Review Dashboard (2015)

66

Figure 29: Inpatient Closed Record Review Dashboard (2015)

cont.

67

Figure 30: OPD Closed Record Review Dashboard (2015)

68

4.

Other Performance Measurement Unit Activities a) Committees and JCI Chapters: Performance Measurement 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)

Medical Record and Health Information Committee. ( MRHIC)

3)

Ethics Committee (EC).

4)

Infection Control Committee (ICC).

5)

Mortality & Morbidity Committee (MMC)

JCI Chapters are:

b)

1)

Quality and Patient Safety (QPS) Chapter.

2)

Management of Information (MOI) Chapter.

3)

Prevention and Control of Infections (PCI) Chapter.

Quality improvement and patient safety plane(QPS Plan) Performance Measurement Unit has prepared the (Quality Improvement and Patient Safety Plan & Education calendar) which cover all the hospital staff with four kinds of staff level and category.

c)

Orientation program : Performance Measurement 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).

69

d)

Weekly Tracer Activity : Performance Measurement 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.

e)

Attending RCA and Sentinel Events Meeting with Risk Management Unit:

Performance Measurement 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.

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Environmental & Safety Unit

71

Executive Summary Whilst the last 12 months have remained challenging, with an ever increasing demand on departments and staff, KFHU has remained committed to providing services to the highest standard. The last year has seen notable achievements within the Environmental Safety Unit. A new staff was joined our unit who brought with her We would particularly like to bring to your attention the following which you can read about in further detail within the body of this report.

Environmental Safety Monitoring is a quality improvement tool that involves measurement of the effectiveness of safety protocols against agreed and proven standards of high quality & safety, and taking action to bring practice in line with these standards so as to improve the safety of environment of care and thereby improve health outcomes.

The function provides the internal co-ordination and response to these activities that demonstrate whether KFHU is meeting standards, identifies any gaps and supports services to understand and agree the actions required to meet standards.

Organized FMS consultations carried out during the first and second quarter of 2015 by subject experts has facilitated the triangulation of knowledge and provided an opportunity for further improvements in compliance and effectiveness of systems and processes related to facility management and safety. This initiative provided staff at all levels of the organization with the opportunity to experience what it is like to be surveyed by JCI and additionally, generate action plans in response to the feedback on the safety of the environment of care.

A comprehensive initial survey by the JCI took place from 13th to 17th September 2015. This then provided the focus of activity for the compliance function for the last quarter of the year. There has been an ongoing review of actions against a number of action plans related to various observations from the JCI initial Survey report.

Throughout the year this team has reviewed some of its training and information sharing methods. This had led to the introduction of Train-The-Trainer program that was well received among staff. This is a formalized program of training for safety coordinators and potential trainers from all departments and included various aspects of the facility management and safety programs at KFHU. This created an opportunity to train all members of staff in their local workplace thereby increasing staff participation in training activities.

Accomplishment/s The unit has responded to and delivered a number of key achievements during 2015, namely: A. Environmental Safety Monitoring Comprehensive multidisciplinary rounds were conducted hospital wide during the current year with semiannual visits to patient care areas. Number of environmental rounds carried out every year has increased steadily from 36 in 2012 to 116 in 2015 (Figure 01) in addition to over 95 follow up rounds that were carried out to track safety issues that are pending in the departments.

72

No. of ESR, 116 120 100 80 60 40 20 0

2012

2013

2014

2015

Number of Environmental Safety Rounds each year

Figure 31: Illustrates the total number of rounds conducted per year.

In view of the JCI initial survey that was scheduled during the year, members of the environmental safety team focused on monitoring each department’s compliance to safety requirements and applicable policies and procedures.

Compliance scores were issued to every department that was inspected.

It is exciting to note that compared to previous years, the number of departments that scored above 90% compliance has increased from 0% in 2013 to 57% in 2015 (Figure 02). Similarly, the number of departments with compliance rate below 70% has reduced from 14% in 2013 to 1 % in 2015.

100 90 80 70 60 50 40 30 20 10 0

57 11 0 21

32

14

8

2013

2014

Dept with above 90 % Dept between 70% to 90%

32

Dept with below 70%

1 2015

Figure 32: Illustrates a comparison of departmental compliance to environmental safety from 2013 to 2015.

73

Improvements in environmental safety compliance of some departments over the past 3 year can be noted in the following graph (Figure 03).

DEPARTMENTAL SAFETY COMPLIANCE SCORE Blood Bank Pharmacy Radiology Dental Neurology

100

ER

1A (ICU) 1B

80

2A

2B 2C

60

2D

40

Cardiology

2E - CCU

20

Dermatology

3A

0

Ophthalmology

3B

ENT

3C

Main OPD Peritonieal Dialysis EHS

OR Day Surgery 4E

2013 2014 2015 - 1st 2015 - 2nd

3D

4D 4C

4B

4A

3E

Figure 33: Illustrates the environmental safety compliance of some departments from 2013 to 2015.

Success of the Environmental Safety Monitoring Program can be evidently observed in the following graph (Figure 04). The overall compliance to safety at KFHU has increased from 71% in 2013 to 89% in 2014. With continuous efforts and support of all departments in the hospital we were able to upsurge the safety compliance to a whopping 91% in 2015.

100.00 90.00 80.00 70.00 60.00 50.00 40.00 30.00 20.00 10.00 0.00

71.03

2013

80.94

2014

91.03

2015

Figure 34: Illustrates a comparison of overall compliance to safety from 2013 to 2015.

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B. JCI Accreditation Compliance to FMS as part JCI accreditation initiative was focused at providing internal co-ordination and response to related activities that demonstrate whether KFHU is meeting standards, identifies any gap and supports services to understand and agree the actions required to meet standards.

To accomplish this objective, the Environmental Safety Unit of Directorate of Quality & Safety coordinated to organize two consultations with subject experts during the first quarter of 2015. These consultations were carried out

by Mr. Muhamed Fuad Awwad who guided all departments through the process of JCI implementation. A gap analysis was initiated during January 2015 based on JCI’s ‘Facility Management & Safety’ standards during his initial visit, which subsequently helped to generate action plans in response to the feedback on safety of the environment of care. The number of safety noncompliance noted during each assessment steadily reduced over the year (Figure 05).

Safety related issues observed during external assessment (2015) 2nd Mock Survey Consulttion 2 Consultation 1 0

50

100

Issues Incomplete

150

200

250

300

Completed Issues

Figure 35: Illustrates the comparison between the number of issues identified during various assessments

Various initiatives and continuous follow up efforts of this unit facilitated closure of most issues that were identified (Figure 06).

Safety related issues closed during the year (2015) Issues Incomplete 16%

Completed Issues 84%

Figure 36: Illustrates the total percentage of safety related issues closed during the year under review.

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All documentation related to FMS compliance was reviewed and some were revised further to meet the requirements of the 5th edition of JCI accreditation standards. Annual plans for implementing various FMS programs were newly created during this time. All departments streamlined their activities to grove in with these established annual plan.

Many processes and forms were revised and various facilities up gradation projects were initiated to achieve this common goal of JCI accreditation. There has also been an ongoing review of actions against a number of action plans related to the environmental safety governance framework and previous inspection and consultation reports.

Facility inspection program was newly launched during the first quarter of 2015 which gave an opportunity for the safety department to monitor the level of facility safety at KFHU. This program assisted in ensuring that KFHU is delivering care against internal and external standards. It cuts across all services with in KFHU to ensure that all current regulations related to building and life safety are being met. The reports of these inspections were used to plan further improvement projects.

Management of hazardous materials in the hospital was regularized during this period under review. This unit successfully compiled a comprehensive list of all hazardous materials used across the hospital. This inventory was subsequently used to ensure availability of relevant Safety Data Sheets (SDS) and appropriate personal protective equipment (PPE) for the safety of staff dealing with these materials. This also gave us an opportunity to identify and mitigate risk associated with the storage, handling, disposal and exposure of these materials. The unit also coordinated to conduct two ‘Code Orange’ drills in coordination with Lab and Medical Supply Department.

Environmental Safety Unit worked closely with Hospital disaster committee to review and finalize KFHU’s Disaster Management Manual and facilitated for conducting education and drills. We successfully coordinated with National Guard Hospital to establish a MOU for cooperating and sharing resources with each other during disasters.

The following graph (Figure 07) illustrates the status of compliance to FMS standard requirements accomplished at various points during the year.

Status of Compliance to FMS Standards 100%

4

80%

9 19

60% 40%

19

14

20% 0%

0 April Not met

4 0

0 August

JCI Initial Survey

Partially Met

Fully Met

Figure 37: Status of Compliance to FMS Standards

The JCI Mock Survey that was conducted at the end of second quarter provided staff at all levels of the organization with the opportunity to experience what it is like to be surveyed by JCI.

76

The steady rise in FMS score from the end of first quarter until JCI Initial Survey (Figure 08) was a reflection of the achievements of this unit in coordination with Maintenance, Biomedical, Security Safety and other departments in the hospital.

Progress of FMS Chapter Score 120 100

96.1

80 60

86.7

73.2

40 20 0 April

August

JCI Initial Survey

Figure 38: Illustrates the total percentage of safety related issues closed during the year under review.

A comprehensive initial survey by the JCI took place from 13th to 17th September 2015. In response to the data requests from JCI, the Environmental Safety Unit coordinated the collation and submission of separate pieces of evidence as part of document review process.

The JCI initial survey report then provided the focus of activities for the last quarter of the year where in there has been an ongoing review of action plans related to various observations from the report.

C. Committee Memberships The unit successfully collaborated with the following committees in the capacity of secretary or member to accomplish the assigned tasks. a. Hospital Safety Committee b. Hospital Disaster Committee c. Quality & Patient Safety Committee d. FMS Chapter Team e. Quality Improvement & Patient Safety Chapter Team f. Downtime Committee g. Critical Care Committee h. Morbidity & Mortality Committee D. Training & Education During this year Environmental Safety Unit had reviewed some of its training and information sharing methods. This had led to the introduction of Train-The-Trainer program that was well received among staff. This is a formalized program of training for safety coordinators and potential trainers from all departments and included various aspects of the facility management and safety programs at KFHU. This created an opportunity to train all members of staff in their respective workplace thereby increasing staff participation in the training activities.

As a new initiative, the unit pioneered the concept of post training evaluation to assess the level of staff awareness following each training. A multiple choice questioner was developed for each training undertaken by the unit. The outcome of the evaluation (Figure 09 & 10) was published to all departments.

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93.97

Medical Equip. Mgmt.

Fire Safety Mgmt. (Fire Prevention & Protection) Hazmat Mgmt. (Medical Gas Safety) Hazmat Mgmt. (Code Orange & Chemical Safety) Code White Code Pink Disaster Preperdance Hospital Codes Safety & Utility Mgmt. (Facility & Electrical Safety) Security Mgmt. (including hospital Lockdown)

97.31 98.17 96.03 98.03 97.26 96.19 98.75

82.95 75

80

85

93.65 90

95

100

Figure 39: Illustrates the staff awareness for each FMS topic

5% Staff with above 80% awareness Staff with lesser awareness

95%

Figure 40: Illustrates the overall staff awareness on FMS (out of 105 registrations)

The new staff was trained on facility management and safety programs through the orientation training that is managed by the Academic Affairs Department.

Various educational brochures and pocket cards related to facility management and safety were prepared and distributed across the hospital which aimed at improving the staff awareness on the subject.

78

MAPPING THE WAY FORWARD IN 2016 KFHU has made important strides in adopting a culture of safety and accountability, bringing about meaningful progress for our patients. The Environmental Safety unit of the Directorate of Quality and Safety (DQS) will continue to work for measurable improvements in the environment of patient care as we respond to the changing needs of the hospital.

Our priorities for 2016 reflect in three main domains: Environmental Safety Initiatives focused at FMS (JCI), KPI Monitoring and Staff Education.

Table 5: Opportunities for Improvement/Priorities for 2016

OPPORTUNITIES FOR IMPROVEMENT 1.

PRIORITIES FOR 2016

Environmental Safety Initiatives focused at FMS (JCI) a. Facility Safety at Psychiatric Department • Install panic button system inside all OPD rooms, registration & reception area of Psychiatric Department.

• Need to replace all plumbing fittings in all patient toilets and patient beds of Psychiatric Units with safer options.

• All electrical panels shall be kept locked at all times when not in use. b. Emergency doors and other doors in the • Review security concerns associated with installation emergency egress cannot be easily accessed of panic system for emergency doors at Psychiatry during an emergency and are not fire rated. and Pediatric areas (based on OSHA standard 29 CFR 1910.36 as enclosed) with concerned departments before such installations.

• All emergency exit doors shall be fire rated for 2 hours, it must open from inside to outside by push and must close automatically.

• All automatic and magnetic doors shall be equipped with manual overriding system and all staff of the area shall be trained to operate this (as applicable).

• Roof top - Install panic system on the door facing the roof. c. Fire zoning measures are insufficient - Multiple • Seal all penetrations (small & big) between fire zones penetrations exist on the fire wall across the using fire rated materials. hospital.

• Externally indicate the fire boundaries so that it is easily identifiable. Train all staff on fire boundaries of their respective department.

• Maintain positive pressure in all emergency exit stairways to prevent the smoke from entering. d. Fire Safety training and drills are inadequate.

• Conduct multiple drills to familiarize staff in the area to implement their fire escape plan. All staff of the department shall be trained to respond effectively 79

•

e. Lack of patient call bell in some essential location.

•

f.

•

Cover for panel of gas shut off valve cant not be easily opened during emergency.

g. Maximum speed limit within the hospital premises is not established.

•

a. Medical Supply Store:

• • • •

2.

KPI Monitoring Untimely analysis of FMS KPI date owing to delayed submission.

• •

3.

Staff Education Need to improve the quality and frequency of FMS related training.

• •

4.

Environmental Safety Rounds a. Junior staff unable to effectively evaluate risks with in the departments. b. Need for maintaining the code of conduct by members during rounds.

during a fire emergency.

Practice vertical evacuation at all wards to train staff on effective evacuation during an emergency situation.

Install patient call bell system in all toilets that patients can access (include ER, OPDs, Day Surgery, Radiology, Lab, etc) Replace the glass cover of all oxygen shut off panels in the hospital with any collapsible material that can be removed easily during an emergency.

Speed limit for cars to be displayed at multiple locations in the hospital Install panic system for all emergency exit doors.

Sprinkler system to be present.

Install temperature & humidity monitoring system inside medication store.

Fix self-luminous direction signs in the Medication store to guide staff to exit during emergency. These direction signs should be visible from all aisles.

Encourage all data owners to collate and submit KPI data by the 10th of every month.

Complete analysis and circulate report to all concerned by end of month and discuss during monthly HSC meeting.

Coordinate with FMS trainers to improvise their training presentation.

Coordinate with all departments to complete the departmental training and post training evaluations.

Rounds shall be conducted by leaders of each function and they shall maintain the code of conduct during rounds.

Members on the team shall utilize their skills & knowledge to identify evident risks with in the care environment, areas for improvement related to their own functions and monitor compliance to established policies and standards that apply to each department.

Progress and achievement of goals in relation to all priorities will be monitored by the Environmental Safety Unit of the Directorate of Quality & Safety. Progress will also be reported to the Hospital Safety Committee and the FMS chapter team will also be presented to the PPI Committee and Council of Governors.

80

Decision Support Unit

81

Introduction The collection of meaningful statistics is an important function of a hospital or clinic. Decision support unit is the primary source of data used in compiling health care statistics.

Health service statistics are used for:    

Comparison of current and previous performance of the hospital or clinic Guide for planning future development of the hospital or clinic Preparation of statistics for Ministry of Health Research

Primary objective of this unit is to collect various data relevant to the service provided by KFHU to the patients.

The key initiatives in 2015 are:     

Developed a new template for KFHU annual report Prepared statistics for MOH in weekly and Monthly Basis Provided database for more than 40 research projects Continuous quality improvement for Utilization management Provided database for more than 20 research conferences forum as per the physician request Figure 41: Hospital In-Patients (IP) 1400 1200

1094 977

# of patients

1000

1030

1053

1110 991

946

1067

1091

1100

Oct

Nov

Dec

928

834

800 600

Total Pts. seen 400 200 0 Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

2015

A total of 12,221 patients were admitted at Inpatient clinics by various departments in 2015. The number of patients seen at Inpatient service during 2015 was an increase of 12,221 (8.7%) on the number seen during the previous year (11240).

82

Figure 42: Hospital Out-patients (OPD) 25000 18652 19131

20000

# of patients

15353

19498 20000

17993

16337

17599

16851 15041

15000

10000

11764

5000

Total OPD seen 195,201

6982

0 Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

2015

A total of 195,201patients were reviewed at out-patients clinics in 2014.which consisted of 76645 (41%) new patients and 110069 (59%) return. The number of patients seen at Out-patient clinics during 2014 was an increase of 195,201(4.5%) on the number seen during the previous year (186,714).

Figure 43: Hospital Emergency Patients 25000 19674 20164

# of patients

20000 15000

14761

15795 15959 16070 13632

15758

22000

16993

13337 13595

10000

Total Pts. seen

5000 0 Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

2015

A total of 197,738 patients were seen at Emergency service in 2015. The number of patients seen at ER service during 2014 was an increase of 197,738(5.9%) on the number seen during the previous year (186,690).

83

Figure 44: Top 10 Surgical Procedures 233

Repair of other current obstetric laceration

218

Other and unspecified coronary arteriography

211

Low cervical cesarean section

208

Episiotomy

120

Insertion of drug-eluting coronary artery stent(s)

97

Dilation and curettage following delivery or abortion

91

Laparoscopic cholecystectomy

70

Laparoscopy

53

Other partial gastrectomy

43

Repair of current obstetric laceration of bladder and…

0

50

100

150

200

250

# of procedures

A total of 1248 top 10 surgical procedures were performed in 2015. The number of Top 10 surgical procedures during 2015 was an increase of 1248 (8.1 %) on the number seen during the previous year (1154).

Figure 45: Top 10 Diagnosis 931

Mother with single liveborn

823

Single liveborn, born in hospital, delivered…

656

Unspecified essential hypertension

484

Diabetes mellitus without mention of…

344

Other and unspecified hyperlipidemia

252

Other sickle-cell disease with crisis

217

Asthma, unspecified, unspecified Surgical or other procedure not carried out…

198

First-degree perineal laceration, with delivery

194

Normal delivery

192 0

200

400

600

800

1000

# of Diagnosis

A total of 4291 patients were listed in the top 10 diagnosis

84

Figure 46: Average Length of Stay 16 13.4

Average length of stay in days

14 12

12.42 11.25

10.72

12.3 10.6

9.6

10

9

8.3

8.1

Sep

Oct

9.3

9.2

Nov

Dec

8 6 4 2 0 Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

An average length of stay (ALOS) for the entire service was 10 days, The ALOS increased from a rate of 9.0 days in 2014 to a rate of 10.0 days in 2015.

Figure 47: Bed Occupancy Rate 80 70

Percentage

60

64.9 65.8 64.6

68.5 68.7

65.5

71

68

59.93 56.01 54.42

61

50 40 30 20 10 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2015

An average percentage of Bed occupancy during the year 2015 was 64.0%

85

Figure 48: Birth Statistics 160 133

140 120

106

108

Mar

Apr

118

116

Jul

Aug

129

130

Nov

Dec

103

96

100 # of babies

118

113

141

80 60 40 20 0 Jan

Feb

May

Jun

Sep

Oct

2015

A total of 1411 new births were registered at Delivery room in 2015.

86

Documents Control Unit

87

Executive Summary 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.

Policy & Procedures King Fahd Hospital of the University (KFHU) started to develop 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. Almost all of the departments have completed their policies and procedures for the year 2015 as compared to the previous year 2014. However there is still one department who has not submitted the desired documents (see Table 1). There is also a considerable increase of policies and procedures in each department submitted as with the previous year. The Documents Control Unit 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 as compared to the previous year.

Table 6: List of Total Number of Policy and Procedures in each Department 2014

2015

Department Total

Signed

Total

Signed

Administration

189

189

129

129

Anesthesia

14

14

10

10

Biomedical

16

16

10

10

Dentistry

16

16

0

0

Dermatology

11

11

8

8

Dietary

49

49

48

48

Directorate of Academic Affairs & Training

8

8

4

4

Directorate of Quality & Safety

9

9

12

12

Emergency Room

28

28

26

26

Health Information System

85

85

82

82

Housekeeping

20

20

20

20

Infection Control

34

34

22

22

Information Technology

11

11

10

10

Internal Medicine

110

110

90

90

Laboratory

798

798

798

798

Medical Supply Store

10

10

Neurology

8

8

10 0

10 0

Neurosurgery

7

7

7

7

Nursing

34

34

14

14

Obstetrics & Gynecology

52

52

47

47

88

Operations and Maintenance

48

48

37

37

OPD

29

29

29

29

Ophthalmology

0

0

0

0

Orthopedics

1

1

0

0

Otorhinolaryngology

7

7

7

7

Pediatrics

51

51

42

42

Pharmacy

16

16

1

1

Physiotherapy

22

22

22

22

Psychiatry

15

15

14

14

Radiology

15

15

11

11

Respiratory Therapy

40

40

38

38

Safety and Occupational Health

8

8

6

6

Security

3

3

2

2

Surgery

9

9

7

7

Urology

6

6

6

6

TOTAL

1779

1569

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. Some departments must have a job description which is specifically pertinent and appropriate to their line of work and to the department in which they are assigned. Addendums are used to the general job description for these specified jobs.

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.

Table 7: Job Descriptions submitted by each Department Department Departments with signed Job Descriptions

No Job Description Submitted

Administration

Patient Relations

Anesthesia

Security

Academic Affairs

Transportation

Biomedical

Telecom

Dentistry

Housing

Dermatology Dietary Directorate of Quality & Safety Emergency Room EHS Health Information System Housekeeping

89

ICU Internal Medicine Infection Control Information Technology General Store (Medical Supply Store) Laboratory Laundry Neurology Neurosurgery Nursing Obstetrics & Gynecology Ophthalmology Orthopedics Otorhinolaryngology Pediatrics Pathology Pharmacy Physiotherapy Psychiatry Radiology Respiratory Therapy Safety and Occupational Health Surgery Urology

Percentage of Departments with Job Description 12%

Submitted 88%

Non Submission

Figure 49: Percentage of Departments with Job Descriptions

90

Forms With the process of having all forms to be electronic, convenience and easy access will be available to most of the hospital forms. The IT department is collaborating to all hospital departments and having training of those concerned to access to some of these forms. However, since it is still in its experimental stage, forms are still used and available in the Stationery Store. Revisions and reprinting were made several times. 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.

Table 8: Number of Forms Available, Printed and Uploaded in the Intranet

No. of Forms

Printed Priority Forms

Uploaded in INTRANET

Administration

154

89

89

Anesthesia

12

9

9

Clinics

28

21

21

Dermatology

2

0

0

ER

11

6

6

Internal Medicine

40

32

32

Neurology

8

4

4

Obstetrics & Gynecology

13

11

11

Ophthalmology

1

0

0

Otorhinolaryngology

3

2

2

Pediatrics

8

2

2

Psychiatry

8

7

7

Surgery

6

5

5

Urology

2

2

2

Dietary

4

3

3

Laboratory

34

32

32

Pharmacy

49

45

45

Physiotherapy

15

8

8

Radiology

9

9

9

Respiratory Care

11

11

11

Dental

7

7

7

DQS

13

13

13

Socio-medical Services

5

5

5

Security

21

0

0

Infection Control

18

18

18

Nursing

92

89

89

TOTAL

574

430

430

Form Proponent

91

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 and it increased in the years from when it was developed.

The table and graph below shows the number of clinical pathways available.

Table 9: No. of Clinical Pathways Available

Form Proponent

No. of Clinical Pathways

Anesthesia

4

Dental

5

ER

8

Internal Medicine

11

Neurology

2

Neurosurgery

5

Obstetrics & Gynecology

5

Orthopedics

3

Pediatrics

4

Physiotherapy

2

Surgery

16

Number of Clinical Pathways

16 25%

4 6%

Anesthesia 5 8%

Dental 8 12%

2 3% 4 6%

3 4%

5 8%

11 17% 5 8%

2 3%

ER Internal Medicine Neurology Neurosurgery Obstetrics & Gynecology Orthopedics

Figure 50: Number of Clinical Pathways

92

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.

Almost all of the departments of KFHU have submitted their scope of service. Unfortunately, there’s still one department who lacked this document.

The table and graph below shows the departments who submitted their scope of service and those who did not.

Table 10: Signed Scope of Service of Each Department

Department Signed SOS Administration

No SOS Ophthalmology

Anesthesia Dentistry Dermatology Dietary Directorate of Academic Affairs & Training Directorate of Quality & Safety Emergency Medicine FAMCO Health Information and Medical Records Infection Control Information Technology Internal Medicine Laboratory Neurology Neurosurgery Nursing Obstetrics and Gynecology Operations & Maintenance Orthopedics Otorhinolaryngology Pediatrics Pharmacy Physiotherapy Psychiatry Radiology 93

Respiratory Therapy Security Surgery Urology

Percentage of Signed Scope of Service 1 3% Submitted Non-submission 33 97%

Figure 51: 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 and graph below shows the departments that have signed strategic plans and those who did not.

Table 11: Signed Strategic Plans of Each Department

Department Signed Strategic Plan

Not Signed Strategic Plan

Anesthesia

Neurology

Allied Medical Services

Support Services

Dentistry Dermatology Dietary Directorate of Academic Affairs & Training Directorate of Quality & Safety Emergency Room Family and Community Medicine Health Information System and Medical Records Housekeeping

94

Human Resources Infection Control Information Technology Internal Medicine KFHU Laboratory Medicine Medical Supplies Neurosurgery Nursing Obstetrics & Gynecology Ophthalmology Orthopedics Otorhinolaryngology Outpatient Department Patient Relations Pediatrics Pharmacy Physiotherapy Psychiatry Radiology Respiratory Therapy Socio-medical Services Surgery Urology

2 5%

Percentage of Signed Strategic Plan

Signed Not signed 35 95%

Figure 52: Percentage of Signed Strategic Plan

95

The ACTION PLAN for the Documents Control Unit: 1.

2.

3.

4.

5.

Updated Job Descriptions with addendum to specific department assigned.

Ensure that all staff had filled up the right job description for the position.

Revision of Policies and Procedures.

Assisting in of Forms.

Complete the required documents such as Scope of Service and Strategic Plans from the departments who have not submitted yet.

6. Continue to update the Intranet of the hospital.

7. Ensure up-to-date documents in the stationery.

96

Credentialing & Privileging Unit

97

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.

SQE required measurement standard 1. Recruitment process – There is Recruitment Plan.

2. Job description for employee: 81% of the total Departments in KFHU which compliance comparing with 19% are not.

3. 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 56% of Allied Clinical Departments in KFHU which are using competency evaluation to monitor their staffs. The clinical and non-clinical Departments used MCS appraisal template for their staff.

4. Staff orientation: New clinical staff, new non-clinical staff, contractor workers, medical Interns, medical student, volunteers – there are 79% of new clinical staff members are oriented to hospital. And 21% are not orient to hospital and Department.

5. BLS/ ACLS/ATLS – percentage certification are 49% of the new staff (January 2015-December 2015) compliance and 51% did not respond.

6. OPPE – Ongoing Professional Practice Evaluation is an evidence-based privilege process that continually monitors physician’s competency and is part of a decision-making process.

7. Primary source verification (Medical – Nursing – Allied) – there are 83% documents verified in human resource (HR) files. While 17% of HR files are not have primary source verification.

8. Staffing Plan – Making an inventory of present manpower resources, assessing the extent to which these resources are employed optimally and forecasting future manpower requirements in different Hospital Departments initiated on November, 2014. There are 97% of the total Departments in KFHU which compliance.

9. Personal file content for new staff as following:

98

CURRICULUM VITAE SECTION 1.

2.

3.

4.

Curriculum vitae Degree/ professional certificate Letter Of Appointment (for leadership positions) Job Description (signed)

LICENSE IN LINE WITH JOB 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. Hospital Wide Orientation 2. Department Orientation 3. Continuing Education 4. Confidentiality statement ( signed)

Available 89% 100%

Not Available 11%

Not Applicable

100% 81% Available 56% 67% 54% 83% 49% 97% Available 57% 19% 56% Available 79% 79% 70% 89%

19% Not Available 6% 33% 46% 17% 51%

Not Applicable 38%

3% Not Available 13% 81% 29% Not Available 21% 21% 30% 11%

Not Applicable 30% 16% Not Applicable

10. Continues education-70% of new staffs that provided continues education to HR while 30% 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 97% of the privileges granted to physicians in 2014 and 2015.

13. Confidentiality statement - There are 89% of confidentiality statement in HR files, while11% did not response.

II. Status of each required evidence Graphs: - Graph for personal file content of the Physicians Staff on 2015.

99

Curriculum Vitae Section 2015 70 60 50 40

Available

30

Not Available

20

Not Applicable

10 0 Curriculum vitae

Professional Letter of Job Certificate Appointment Description Figure 53: Curriculum Vitae Section 2015

Figure 54: License in Line with Job

100

Orientation & Contiuing Education 2015 60 50 40 30 20 10 0

Available Not Available Not Applicable

Figure 55: Orientation & Continuing Education 2015

Performance Evaluation 2015 60 50 40 Available

30

Not Available

20

Not Applicable

10 0 Probationary Annual/Yearly Competency Evaluation Evaluatin Assessment Figure 56: Performance Evaluation 2015

101

Empolyment Documentation 2015 70 60 50 40

Available

30

Not Available Not Applicable

20 10 0 Contract

Copy of Iqama

Personal ID

Copy of Passort

Figure 57: Employment Documentation 2015

Figure 58: Comparative Graph for 2014 and 2015

Analysis: An average there is increasing trend in all the areas related with Curriculum Vitae Section. With respect to curriculum vitae and Job Description, the percentage of compliance is high in 2015 as compared to 2014. Professional Certificate, the percentage of compliance is slightly increased for 2015 as compared to 2014. There is no data for Letter appointment for 2014 & 2015.

102

Figure 59: License in Line with Job

Analysis: The graph shows there is increasing trend in Credential Documentation, Saudi Commission Registration, Document Verification, CPR/BLS, and Privileging for 2015 as compared to 2014. While Country of Origin, the percentage of compliance for 2015 is slightly low as compared to 2014.

Figure 60: Performance Evaluation

Analysis: The graph indicate that there is high increasing trend in all the areas related with Performance Evaluation with respect to probationary evaluation (57% for 2015, it was 11% in 2014), Annual/yearly evaluation (19% for 2015, it was 2% in 2014) and competency assessment (56% for 2015, it was 5% in 2014).

103

Orientation and Continuing Education 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

2014 2015

Hospital Orientation

Department Orientation

Continuing Education

Confindentiality statement

Figure 61: Orientation and Continuing Education

Analysis: The graph indicates significant increase in all areas related with Orientation and Continuing Education with respect to hospital orientation, department orientation, continuing education and confidentiality statement, the percentage of compliance is high in 2015as compared to 2014.

104

Table 12: Strength and Opportunities for improvement

# 1 2

4

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, Housekeeping, Security Services, Biomedical Services, Laundry Service, General Store and Administrative Communication.

Staff orientation: most of clinical medical staffs, medical Interns, medical student and volunteers are oriented to hospital.

There is department orientation.

5 6

8 10 11 12

There is objective and subjective OPPE applied for most of clinical physicians (Consultants, Specialists, and Residents).

Staffing Plan: 95% of all departments’ compliance are compliance.

70% Continues education are compliance.

Privileging

Opportunities for improvement To follow –up with Security Service, Patient Relation & Right Administration, Telecommunication, Purchasing, Housing Department, and Finance to ensure their compliance to submit Their specific Job description.

Staff orientation: non-clinical staffs and contract workers did not all orient to hospital.

21% of department orientation and hospital orientation are not compliance for new non-clinical staff, contractor workers, medical Interns, medical student, volunteers.

BLS/ ACLS/ATLS –51% of certification are not available in new personal file.

63% compliance of physicians had an objective OPPE that was extremely benchmarked.

Follow –up with Anesthesia and Telecommunication department to ensure their compliance.

There is no Occupational health safety policy procedure for staff.

Re-Privileging not yet started as it’s within three years.

105

Table 13: Improvement action plan

# 1

Issue Process of staff evaluation (probationary and annual period )

1.

2.

2

Staff orientation

1.

2.

3.

4.

3

OPPE

4

BLS/ACLS/ATLS

5

Primary source verification (Medical –Nursing – Allied)

Action plan Send letter to all clinical specific Department & non-clinical departments to submit probationary and annual period.

Follow up with consider Department every two weeks.

Requesting from Purchasing Department to submit the update list of contract workers from different companies and to send the contract workers to Academic Affairs to assign them in Hospital orientation schedule.

Implementation & review Hospital orientation of non-clinical staffs.

Mentoring and review Hospital orientation for all clinical & nonclinical staff by Human Resource Department.

Coordinate with Department heads and supervisors to provide department orientation of new non-clinical staff, contractor workers, medical Interns and medical student.

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.

1. Coordinate with Department heads and supervisors to provide BLS/ACLS/ATLS certification of new staffs.

2. Require all health care providers to update BLS/ACLS/ATLS. 1. Established primary source verification unit in HR Department.

2. Authenticate the primary source verification done by Saudi Council

Responsible - Human Resource Department.

-

Time frame Five-six month

Purchasing Department.

Administration Hospital departments.

Human Resource Department.

Five-six months

C&P unit Data analyst (Satiation) Clinical Department.

Three-Six months

- HR Department - Academic Affairs

Six months

-

-

-

HR Department

Fourth months

106

6

Staffing Plan

7

There is no Occupational health safety policy procedure for staff

3. Review and Revise the primary source verification policy and procedure 4. Define the Performance Indicator.

5. Integrate the new primary source verification process to the recruitment 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 policy procedure of staff Occupational health safety.

-

C&P unit All Hospital Departments Employee Health Clinic (EHS)

Four – six months Six months

Challenges to achieve 100% compliance: To accomplish the short term plans of the C&P unit within established time frames, it is essential to increase staffing. Prompt response of, HR, Medical Departments Allied Health Services, and Administrative Department.

Recommendation: Keep monitoring the improvement.

107

Risk Management Unit

108

Executive Summary 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 patientcentered 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 2015. 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 2016

109

Introduction A total number of eight thousand nine hundred thirty-eight (8938) Occurrence Variance Reports (OVRs) were received by the Risk Management Unit (RMU) for the year 2015. As compared to year 2014, a decrease of 181 (1%) had been noted.

Figure 118: OVR received

OVRs Received from Year 2013-2015 9114

9200 9000 8800 8600 8400 8200 8000 7800 7600 7400

8933

7986

Y 2013

Y 2014

Y 2015

As shown in Figure 118, the month with the lowest number of OVRs received was September. The top three months wherein the highest amount of OVRs received where during the months of February, November and December.

Figure 119: Monthly OVR for 2015

OVRs Received Monthly for 2015 1400

1230

1200

986

1000 800 600

812 537

648

712

633

684

795 624

769 503

400 200 0

The Risk Management Unit considers occurrences or variances that happened inside the hospital premises as areas for improvement.

110

Out of the 8933 OVRs submitted, 121 (1%) 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 120: OVR vs Non-OVR

OVRs and Non-OVRs Received 121

OVR Non-OVR 8812

For the third consecutive year, the most active reporter of areas for improvement was the Department of Nursing Services with a total number of 8646 (97%) of the total OVRs received.

Other reporting department, with 196 (2%) reported OVRs, included the Directorate of Quality and Safety, Infection Control, Respiratory Therapy, Physiotherapy, Medical Store, Dietary, Laboratory Medicine, Medical Records, Pharmacy, and Radiology.

Figure 121: OVR by Reporter

Reporting Departments 91

196 Nursing Medical Others 8646

In-patient variances were the top most reported OVR followed by the Emergency Room and Ambulatory or Out-patients. The “others� category pertains to reported clinical, non-clinical, building or structure, materials or consumables variances or Near Misses.

111

Figure 122: Status Involvement in OVR

Status Involvement in OVR Reports 4000

3384

3180

3000 2000

1151

1000 0

In-patient ER Patient

Out Patient

739

Others

307

99

51

Employee Contractor Visitor

21

1

Student Reasearch Patient

TOP REPORTED OVRS Figure 123: 2015 Top Reported

Top Reported OVRs 1800 1600

1674

1607

1400 1200 1000 800 600 400 200

881 704

586 347

310

297

216

192

0

112

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.

For the year 2015, LAMA was the top most identified occurrence in King Fahd Hospital of the University (KFHU). Out of the total OVRs received last 2015, 1674 (19%) were about LAMA. Figure 124: Reasons for LAMA

Reasons for LAMA 629

refused treatment or management

417

refused admision

155 122 88 78 59 50 43 18 9 6

Absconded refused to wait - results refused to continue treatment refused further observation transfer hospital Personal Out on pass refused to wait - bed availability refused to wait - physician refused examination - male physician

0

100

200

300

400

500

600

700

In figure 124, it is further shown other contributing factors for patient leaving against medical advice.

The top three most contributing factor was refused treatment or management, refused admission or patient absconded.

113

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. As shown in figure 125, an increase of 17 (1%) was noted in the reported number of overstaying cases in ER as compared to 2014.

Figure 125: Overstaying from 2013-2015

Overstaying in ER Reported from 2013-2015 1620 1615 1610 1605 1600 1595 1590 1585 1580 1575

1617

1607

1590

Y 2013

Y 2014

Y 2015

As shown in Figure 126, it was noted that the top three reasons for patient’s overstaying in ER were due to medical re-evaluation (53%), bed in the ward was unavailable (33%) and patient not eligible (3%).

Figure 126: Reasons for Overstaying in ER

Factors related to Overstaying of Patients in ER 854

medical re-evaluation

536

bed unavailable

54 47 44 30 19 9 9 7

not eligible awaiting family or sponsor ICU bed unavailable isolation bed unavailable for blood transfusion refused to leave awaiting admission orders transfer hospital

0

100

200

300

400

500

600

700

800

900

114

Procedure Cancellation A total of 881 (10%) of the OVRs relates to this category. It was very evident in figure 126 that there was an increased cancellation on the last quarter of 2015. This can be related due to the expansion of the Endoscopy Unit with 10 additional beds, wherein more patients were scheduled.

Figure 127: Procedure Cancellation Statistics

Procedure Cancellation Statistics for 2015 140 120 100 80 60 40 20 0

105

115 111 107

104 66

68

73 52

49

17

14

Jan Feb Mar Apr May Jun

Jul Aug Sep Oct Nov Dec

As shown in figure 127, the top most contributing factor for Procedure Cancellation is “patient didn’t come” 301 (68%), which was unavoidable as they were Out-patients. Followed by “Others” 127 (14%) which included poor preparation of patient, patient needs admission and no bed was available to accommodate the patient, patient was out on pass or discharged already, and the third reported was due to patient’s condition (7%).

Figure 128: Reasons for Procedure Cancellation

Contributing Factors of Procedure Cancellation 700 600

601

500 400 300 200

127

100 0

Patient did not come

Others

61 Patient's condiiton

29

21

18

13

11

Needs Physician Patient Poor Procedure further unavailable refsued preparation no longer evaluation indicated

115

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.

Figure 129: Types of Break in Skin Integrity

Types of Break in Skin Integrity 321

Hematoma

146

Redness Pressure ulcer

76

Skin peeling

75 50

Blister Others

15

Abrasion

14 7

Cutwound

0

50

100

150

200

250

300

350

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 129, OR cancellation peaked up once again in the last quarter of year 2015.

.

Figure 130: OR Cancellation Statistics

Monthly Statistics of OR Cancellation 80 60 60 40

54

51

53

62

55

71 60

42 24

30

24

20 0

Jan

Feb Mar Apr May Jun

Jul

Aug Sep

Oct Nov Dec

116

As shown in figure 130, the top reasons for OR cancellation were lack of time (26%), patient’s condition (21%) and patient didn’t come (19%). Lack of time could either mean prolonged previous case or the case was overbooking while patient’s condition meant that on the day of the operation the patient developed sickness, unstable or unfit for the procedure.

Figure 131: Causes OR Cancellation

Contributing Factors of OR Cancellation 200 150

153 124

110

100

76

74 44

50 0

5 Lack of time Patient's Patient Physician condition didn’t come unavailable

Needs ICU/bed Procedure further unavailable no longer evaluation post op indicated

Documentation or Records This category refers to the variances related to documentations pertaining to patient’s medical record.

As shown in figure 131, 209 (60%) reported were categorized as others which pertains to unavailability of forms used in the patient’s file, and the problems experienced after having the Physician’s Order electronic. The second most reported OVR pertains to poor documentation wherein the hospital staff didn’t complete the form or file of the patient. It also included the overriding of error in documentation.

Figure 132: Documentation or Records Variances

Types of Documentation or Records Variances 209

Others

76

Poor documentation

25 16 12 6 2 1

Missing or unreturned files Use of non- approved abbreviations Multiple file Delayed files Unreturned Files Filed in wrong medical record

0

50

100

150

200

250

117

Line, tube, drain or catheter 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.

Figure 133: Type of Line, tube, drain or catheter

Type of Line, Tube, drain or Catheter Variance 200

171

150 100 37

50 0

21

Central line

ETT

IV infiltration

23

16

12

9

8

wound drain

Foley catheter

NGT

Others

IV line

IV infiltrations, dislodged lines, accidental removal and removal of line by patient were the 8th most reported OVR for the year 2015. 297 (3%) of the reported incidence via OVR were about Line, tube, drain or catheter.

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. Figure 134: Types of Admission Related Issues

Chart Title 95

100 80

66

60 40

26

20 0

5 Others

ICU/isolation bed unavailable

without MDRO screening result

Unplanned admission

118

International Patient Safety Goals ( I P S G s ) The International Patient Safety Goals (IPSG) promotes specific improvements in patient safety. The goals highlight the most common problems in health care and provide support with simple, effective solutions.

Goal 1: IDENTIFY PATIENTS CORRECTLY This goal focuses on the importance of the right patient receiving the right care. This ensures the correct identification of patients at all times thereby minimizing risks and incidents caused by patient misidentification. It is imperative that healthcare professionals use at least two ways to identify a patient when giving medicines, blood or blood products; taking blood samples and other specimens for clinical testing, transporting or transferring of patient or providing any other treatments or procedures.

As per policy ADM-Gen 01-035: PATIENT IDENTIFICATION, patients should be identified by verbal and visual means to confirm the identity of the patient using the two identifiers (Name and Medical Record Number).

All In-Patients should wear Identification (ID) Band throughout their hospital stay.

Total Numbers of OVRs Received Related to IPSG 1 80 70 60 50 40 30 20 10 0

70

16

First Quarter

24

22 8

Second Quarter

Third Quarter

Fourth Quarter

Total

Figure 135: Total Numbers of OVRs Received Related to IPSG 1

119

IPSG 1 RELATED OVRS IN 2015 80 70 60 50 40 30 20 10 0

70

30

24

Others

10

4

2

Missing ID Band

Incorrect ID Band

Incorrect Name or Medical Record Number

Incorrect Demographics

Total

Figure 136: IPSG 1 Related OVRs in 2015

CONTRIBUTING FACTORS TO "OTHERS" 30 25 20 15 24

10 5 0

10

6

4

Multiple File Poor Patient Incorrect Identification Labeling

2

1

1

Cut ID Band No ID Band Refused to Presented wear ID Band

Total

Figure 137: Contributing Factors to “Others”

A total of 70 OVRs related to IPSG 1 reported in 2015. The reported variances were incorrect name or MRN which is the highest reported occurrence, then followed by the contributing factors to “Others” like patient has multiple files, incorrect labeling of specimen, patient refused wearing of ID Band, poor patient identification, cut ID Band and No ID presented.

Action: IPSG Team coordinated with the ER/OPD Reception, Admission Office and Health Information Management. Scanning of the patient’s Family Card or Iqama should be done during the registration process.

Staff should inform the registration to correct the patient information upon recognition of incorrect name or MRN 120

and wrong or incomplete demographics. The relatives of the patient must be informed by the health care staff of the wrong data entry or error and should present again the Family card or the Iqama in the registration office.

Recommendation: Compliance to the Policy & Procedure must be emphasized in the hospital. Patient identification is very important and must be given an emphasis to prevent near misses and sentinel events. OVR must be accomplished and submitted to DQS-RMU in recognition of patient misidentification.

Goal 2: IMPROVE EFFECTIVE COMMUNICATION Effective communication, which is timely, accurate, complete, unambiguous, and understood by the recipient, reduces errors and results in improved patient safety. The goal is to ensure that standardized critical content is communicated between healthcare providers during handovers of patient care. In addition, this goal aims to ensure the implementation of a process/procedure for taking verbal or telephone orders, or for the reporting of critical test results that requires a verification “read-back” of the complete test result by the person receiving the information.

IPSG 2 Related OVRs 2015

Total, 55

Poor Hand Over, 46

Critical Results, 9

Figure 138: IPSG 2 Related OVRs 2015

A total of 55 OVRs related to IPSG 2 were reported in 2015. There were 46 variances reported as poor handover and 9 variances related to critical result reporting. In this case, the use of effective communication among patients and healthcare professionals is critical for achieving a patient's optimal health outcome.

Reported variances of poor handover were during transfer of patients in the units, transport of patients in the diagnostic/procedure area, incomplete documentation such as no initial assessment and history taking and incomplete physician’s admitting orders. Reported variances related to critical result reporting were delayed acceptance of the doctors on the critical results and no management given to patients with critical results.

The use of SBAR form is very important because this is a structured system designed to help team members communicate about the patient in the most convenient form possible. Communication between healthcare professionals not only helps achieve the best results for the patient but also prevents any unseen incidents.

Action: Strict implementation on the use of the SBAR form during hand over process, from one shift to another shift, transfer of service or level of care or during patient’s transport to diagnostic or other treatment department.

121

Recommendation: A thorough implementation of a process to improve the effectiveness of verbal and/ or telephone communication among caregivers. Laboratory and Radiology departments should defined critical values for each type of diagnostic tests. Reporting staff must identify by whom and to whom critical results of diagnostic tests are reported. All received critical results should document in the multi-disciplinary notes of the patient and accurate information in the Quadramed.

Goal 3: Improve the Safety of High- Alert Medications When medications are part of the patient treatment plan, appropriate management is critical to ensuring patient safety. This standard aims to ensure that hospitals implement strategies to improve the safety of high-alert medications, which may include specific storage, prescribing, preparation, administration, or monitoring processes.

Medication is distributed through the hospitably unit dose system: (via Omni cell) High-alert meds were labeled with a red stickers. The hospital is using methods to reduce error include strategies such as improving access to information about these drugs limiting access to High-alert medications, using Tallman lettering, using auxiliary labels and automated alerts, standardizing the ordering, storage, preparation, and administration of these products, and employing redundancies such as automated or independent double checks when necessary.

IPSG 3 Fourth Quarter, 12

First Quarter, 16

Third Quarter, 8 Second

Quarter, 18

Figure 139: IPSG 3 Related OVRs 2015

122

IPSG 3 Related OVRs 2015 54 40

8

6

Broken Crash Cart Dispensed High Unsafe handling and Lock Alert Drugs without storage of High Alert Red Sticker Drugs

Total

Figure 140: IPSG 3 Related OVRs 2015

A total of 54 reported variances related to IPSG 3 in 2015. The reported variance for broken crash cart lock were 40 which was the highest reported variance, followed by 8 variances regarding unsafe handling of high alert drugs like incidence of an ampule breakage. Third, 6 variances received regarding High Alert drugs were dispensed without Red stickers.

Crash cart locks break easily due to easy access in time of emergency situation.

Goal 4: Ensure Correct-site, Correct patient, and Correct procedure surgery A total of 28 variances reported related to IPSG 4 in 2015. There were surgical site not marked, site marking paper not signed, non-legible OR consent, site marking done by junior doctor, surgical site marking was performed late, incorrect site marking, incomplete Time Out form, and wrong patient for OR.

30 25 20 15 10 5 0

IPSG 4 Related OVRs 2015

2

5

9 1

2

6 1

28

2

Figure 141: IPSG 4 Related OVRs 2015

123

A near miss is an unplanned event that did not result in injury, illness, or damage- but had a potential to do so.

Reporting of near misses by observers is an established error reduction technique in aviation.

Actions: Constant monitoring on the use of the "Time Out Form" in units performing invasive procedure. Strict compliance to the policy and procedure was emphasized to the involved departments.

Recommendations: To give continuous IPSG education to all clinical departments and tracer activity should be done to monitor OR and give more education for the surgeons, and all the units using the Time Out Form during invasive procedures.

Goal 5: Reduce the Risk of Health-Care Associated Infections Infection prevention and control are challenging in most health care settings, and arising rates of health careassociated infections are a major concern for patients and health care practitioners. Infections common to all health care settings include catheter-associated urinary tract infections, bloodstream infections, and pneumonia (often associated with mechanical ventilation). Central to the elimination of these and other infections is proper hand hygiene, which is a central part of everything we do.

There were only 3 reported OVRs related to IPSG 5 in 2015. These are non-compliance to 5 Moments of Hand Hygiene such as poor hand hygiene before treatment, before aseptic procedure and after exposure to blood and body fluids risk.

Non Compliance to 5 Moments of Hand Hygiene 2015 1

1

1

Poor Hand Hygiene Before Providing Treatment

Poor Hand Hygiene Before OR Procedure

Poor Hand Hygiene after Exposure to Blood & Body Fluids

Figure 142: Non Compliance to 5 Moments of Hand Hygiene 2015

124

IPSG 5 OVRs Received in 2015 2

1

First Quarter

0 Second Quarter

Third Quarter

0 Fourth Quarter

Figure 143: IPSG 5 OVRs Received in 2015

Action: IPSG team is giving continues IPSG education and part of it is IPSG 5. And during the Safety Week Campaign, IPSG team was involved on the said awareness campaign.

Recommendation: To increase the attendance of healthcare providers to infection control mandatory and orientation lectures. Distribution of alcohol hand rub dispenser to all hospital area.

Goal 6: Reduce the Risk of Patient Harm Resulting from fall Patient falls are serious problems in hospitals and are used as a standard measure of quality. The unfamiliar environment, acute illness, surgery, bed rest, medications, treatments and the placement of various tubes and catheters are common challenges that place patients at risk for falls in hospitals.

Figure 144: IPSG Falls 2015

IPSG Falls 2015 14

with injury without injury

68

125

Falls 2015 82

28 16

27

11

First Quarter Second Quarter Third Quarter Fourth Quarter

Total

Figure 145: Falls 2015

A total of 82 variances related to IPSG 6 in 2015. There were 68 reported falls without injuries and 14 reported occurrence of falls with injury.

Action: NQI Nurses and IPSG Team emphasized to the nurses to comply with Falls policy and procedure. The use of the appropriate fall assessment tools was strengthened in the hospital by giving the staff a copy of educational pamphlets related to IPSG 6.

Recommendation: To reemphasized the universal fall precaution to minimize the incidence of falls.

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Sentinel Events Reported Sentinel Events  Death of a Patient – On March 24, 2015 patient underwent several attempts of Pericardiocentesis but still failed. Code blue was announced after patient assessed with bradycardia. CPR was unsuccessful, patient pronounced dead at 1630H.

1.

2.

Table 14: Sentinel Events (Death of a Patient-March 24, 2015) Findings: Action Taken Pericardiocentesis done without guidance of  A letter was written addressed to all Xray or Echocardiogram machine. department enforcing that all Pericardiocentesis should be done guided by echocardiogram.  This procedure has also been included in the policy and procedure No policy and procedure or clinical  A policy and procedure regarding pathways or guidelines for Pericardiocentesis was formulated. (SUR 30 Pericardiocentesis.

– 009: Pericardiocentesis)

3.

Physician was not privileged to do the procedure alone or solo.



4.

Procedure done at bedside.

 

The credentialing and privileging of the physician was evaluated and revised as necessary.

Pericardiocentesis is a high risk procedure and should be done at the OR, Cath Lab or ICU. This procedure has also been included in the policy and procedure

 Death of a Patient – Patient admitted from ER to 4D on 26th of November 2015 with complaints of left sided weakness and slurred speech. On December 1, 2015 at 400H, patient vomited blood tinged vomitus. Physicians were bleeped and overhead paged but no response. Patient coded at 0650H and was pronounced dead at 0903H.

1.

2.

3.

4.

Table 15: Sentinel Events (Death of a Patient-December 1, 2015) Findings: Action Taken Calls regarding condition of the patient  Increase awareness of staff regarding proper were not escalated to appropriate escalation of calls to appropriate personnel. personnel.

Lack of knowledge as to when to activate  Re-education of ADM-Gen 01-011: Rapid Code Black/Rapid Response Team.

Response Team should be initiated to strengthen the awareness and compliance of staff to the said policy.

Internal arrangement in change of duty rota for On-Call physicians..

A physician not on duty was bleeped by staff involved. The duty-rota list was hard copy and manually distributed



A memo was sent to all department heads that internal arrangement between physicians regarding change of duty rota is not allowed.



Any change should apply in the duty rota, must be approved, signed, and notified by the Chairman of the department.

Electronic duty-rota was established and linked to the KFHU server for accessibility.



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