Staff should not feel that the Quality Management staff are policing them. These thoughts
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1 Chapter IV and Patient
2 Introduction This chapter is the responsibility of the Director/leader and everyone in the hospital, especially the senior leaders whose role is essential to implement the program. The senior leaders are expected to lead, support, and participate in the implementation of the MOH standards. The Director/leader is expected to work with all staff to educate them in the new language of quality and assist them in implementing the MOH standards. Staff should not feel that the staff are policing them. These thoughts should be avoided because this was part of the old Assurance method that involved inspection and blaming individuals. We know now that the old method of Assurance does not work. The new method emphasizes education and positive encouragement instead of punishment. By using the new method, we can build a safer environment in which patient care is delivered by reducing the number of medical errors. Only when everyone understands the new quality concepts and implements the MOH standards will staff truly feel that quality is the job of everyone in the hospital. Page 58
3 Scoring: Standard QM.1. QM.2. QM.3. QM.4. QM.5. QM.6. There is a qualified and experienced Director or leader who can apply quality concepts and principles and includes the following: QM.1.1 The Director has a degree in Healthcare Administration, or Related healthcare field and/or certification in and/or Risk. QM.1.2 The Director or leader has at least three years experience in Healthcare or Improvement. The QM Director or leader reports to the Hospital Director. The QM department has the following resources (and others as needed) to carry out its scope of service. QM.3.1 The QM department has sufficient working and meeting space to carry out its scope of service. QM.3.2 The QM department has sufficient computers, photocopier, printers, phones, faxes as needed to carry out its scope of service. QM.3.3 The QM department has Internet access. The QM department has an operating budget recommended by the QM Director/leader addressing manpower, consumables, capital assets and educational needs. The QM department has sufficient staff to carry out its scope of service. The Director or the Risk Manager is expected to identify and monitor high risk, problem prone and high cost areas: QM.6.1 Invasive procedures. QM.6.2 High risk procedures. QM.6.3 Unusually expensive medications. Page 59
4 QM.7. QM.6.4 All high-risk medications. There is a comprehensive hospital wide plan which includes but is not limited to: QM.7.1 QM.7.2 The and Patient initiative mission, vision, goals and objectives. Definitions of important, Risk safety concepts. QM.7.3 QM.7.4 QM.7.5 QM.7.6 QM.7.7 QM.7.8 QM.7.9 Defining the scope of activities and methodologies to be used for, Continuous and Performance improvement, Risk. Identifying all levels of staff roles and responsibilities. Outlining the educational activities about quality concepts and Risk that should be provided to hospital staff. Describing how the standards will be implemented and maintained. Describing how problem identification, information gathering, implementing actions, and evaluation of actions taken will occur (models like FOCUS PDCA) Describing the method for the use of data (measurements), analyzing the data, and implementation and evaluation of improvements. Outlining how quality improvement projects are identified and prioritized by the leadership. QM.7.10 Outlining that all Improvement teams report to the Improvement committee. QM.7.11 Describing how quality improvement activities will be communicated to everyone in the organization. (Flow of information) Page 60
5 QM.8. QM.9. QM.7.12 Describing how the plan is approved by the committee and the Hospital Director. QM.7.13 Reviewing the plan on an annual basis and making revisions as necessary. There is a committee consisting of the leadership group that implements the QM plan and the hospital standards and this includes at least the following: QM.8.1 All of the hospital leaders (the Hospital Director, Medical Director, Nursing Director, Director/leader, Medical Records Director/leader, departmental heads). QM.8.2 The committee approves all initiatives and provides oversight for the program. QM.8.3 The committee receives reports from all teams, heads of departments, and other members assigned quality improvement projects. QM.8.4 The committee approves all hospital wide teams that are formed to solve a particular issue. QM.8.5 The committee provides feedback to their staff on quality improvement projects. The hospital leaders are actively involved in the quality campaign efforts and participate in: QM.9.1 QM.9.2, Risk educational activities. FOCUS PDCA based quality improvement teams. QM.10. The hospital leaders encourage all hospital staff to participate in: Page 61
6 QM.11. QM.12. QM.13. QM.14. QM.10.1, Risk educational activities. QM.10.2 FOCUS-PDCA based quality improvement teams. The hospital has an incident reporting system (occurrence /variance /accident) Policy and form (OVA) that staff follow and use when reporting adverse events. Sentinel events are identified in a policy that includes but is not limited to: QM.12.1 Unexpected deaths. QM.12.2 Suicide of a patient. QM.12.3 Infant abduction or discharge to a wrong family. QM.12.4 Hemolytic transfusion reaction. QM.12.5 Surgery on the wrong patient or the wrong body part. QM.12.6 Serious injury with loss of limb or function. The hospital has a process to handle Sentinel events and it includes: QM.13.1 Formation of a team for studying the causes of the event (root cause analysis) QM.13.2 Root cause analysis is to be performed within 10 working days QM.13.3 Developing an action plan and review systems for improvement. The hospital supports Patient by: QM.14.1 Defining and adopting selected International Patient Goals in the Plan. QM.14.2 Establishing a Patient Committee/Team with representation from medical, nursing, and pharmacy and safety departments. Page 62
7 QM.14.3 Charging the Patient Committee/Team with implementing and monitoring the patient safety goals and recommending actions for improvement. QM.15. The hospital adopts a process that requires patient identifiers (neither to be the patient s room number) whenever taking blood samples or administering medications or blood products or QM.16. There is a process for preventing wrong site, wrong procedure, and wrong person surgery that includes: QM.16.1 Documentation of the verification process pre-operatively of the correct person, procedure, and site. QM.16.2 A process to mark the operative site in a standardized method and symbol with permanent ink by the person performing the operation and/or procedure. [For organs, mark on the Body Diagram form in the appropriate area (left or right)] QM.16.3 A documented time out conducted in the location where the procedure will be done, just before starting the operation, and involves the entire operating room staff using speech to verify correct patient identity, correct site, agreement on the procedure to be done, correct patient position, and availability of any needed equipment. QM.17. QM.18. QM.19. There is a standardized list of abbreviations, acronyms, and symbols that are permitted for use in the hospital and it includes a list of abbreviations, acronyms, and symbols NOT to be used. Infusion pumps have free-flow protection. All alarm systems for patient care equipment (such as Infusion Pumps heart monitors, ventilators and pulse oximeters), have documented preventative maintenance, inspection and testing on a regular basis. Page 63
8 QM.20. QM.21. QM.22. QM.23. QM.24. All staff are trained in the safe use of alarm systems for patient care equipment and the use of appropriate settings for sound. There are coordinated, comprehensive, and continuous educational activities on quality, Patient and Risk concepts and tools taught by staff who are qualified in the field and educational activities include: QM.21.1 Concepts of, Patient and Risk QM.21.2 How to work in teams. QM.21.3 Use of data, display of data QM.21.4 Improvement tools. QM.21.5 Risk tools. QM.21.6 learning and improvement cycle (PDCA or other). QM.21.7 Decision-making tools. The leadership develops and implements a set of measurements and indicators that are collected and aggregated on a regular basis and is used for quality improvement and strategic planning There are structure measurements (indicators) based on the mission and scope of services that may include but is not limited to: QM.23.1 Availability of essential supplies and equipment. QM.23.2 Availability of medical records. QM.23.3 Availability of blood and blood products. QM.23.4 Availability of emergency medications. QM.23.5 Vacancy rates in all departments. There are process measurements (indicators) based on the mission and scope of services that may include but is not limited to: Page 64
9 QM.24.1 The timing and use of antibiotics prior to surgery. QM.24.2 Blood and blood products administration. QM.24.3 Documentation in the medical record. QM.24.4 Delays of physician answering nurses phone calls/beeps, and/or pages. QM.25. There are outcome measurements (indicators) based on the mission and scope of services that may include but is not limited to: QM.25.1 Mortality rates. QM.25.2 Nosocomial Infection rates. QM.25.3 Staff satisfaction. QM.25.4 Patient satisfaction. QM.25.5 Unplanned returns to operating room. QM.25.6 Unplanned transfer to critical care area. QM.25.7 Resuscitation of patients (Cardiac/respiratory arrest). QM.25.8 Readmission to the hospital within 3 days of discharge. QM.25.9 Adverse events (falls, injuries, pressure ulcers). QM Sentinel events. QM Patient complaints. QM Medication errors. QM Conscious sedation. QM All invasive and high-risk procedures. QM Increased length of stay. QM.26. There are quality control results from the laboratory and radiology. Page 65
10 QM.27. QM.28. QM.29. QM.30. Staff that analyze aggregated data for trends and variances on a regular basis are qualified and: QM.27.1 He/she is familiar with use of data display and data analysis techniques. Data is compared internally by historical trends and externally by benchmarks (when available). The Committee identifies and prioritizes recommendations for quality improvement projects based on the organization's prioritization criteria and the analysis of trends. teams are selected by the leadership and these teams use quality tools to improve processes. QM.30.1 Membership of the quality improvement teams is determined by the leadership (Hospital Director, Medical Director, Administrative Director, Nursing Director). QM.30.2 The teams include staff who have working knowledge of the process. QM.30.3 The teams include a facilitator. QM.30.4 The teams include a designated team leader who is an identified leader within the organization. QM.30.5 The teams use a learning cycle (PDCA or other) for process improvement. QM.30.6 The teams use CQI tools (Pareto charts, brainstorming, affinity diagrams, fishbone charts, multivote, etc). Page 66
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