Académique Documents
Professionnel Documents
Culture Documents
for
Improvement
Nazzar Butt
CQI&PS Director
Quality and
Patient Safety
Program
PURPOSE
The purpose of Armed Forces Hospital, Southern
Region Quality Improvement and Patient Safety
Program is to identify the hospital systematic
approach to improving and sustaining its
performance through the prioritization, design,
implementation, monitoring, and analysis of quality
improvement and patient safety improvement
initiatives.
SCOPE
The AFHSR CQI & PS program includes all
departments and services in the organization and
all related quality activities such as clinical,
laboratory, quality improvement, patient safety and
risk management activities.
How quality and safety information flows through the
hospital/committee structure.
Hospital Director
Variation demonstrated
Ease of Data Availability
Impact on Customer
Linkage to Startegic
Time to Complete
Regulatory Need
Environment
Satisfaction
Priorities
Project Selection Criteria
3 4 4 2 3 2 5 5 Priority Score
Domain Project Name
Hospital Wide Patient identification compliance 7 5 2 6 9 8 9 9 194
Hospital Wide Telephonic/verbal order compliance 7 4 2 8 7 8 9 7 178
Hospital Wide Implementation of ISBAR Handover 7 4 2 8 9 8 9 9 194
Hospital Wide High Alert Medication Inspection Compliance 7 4 5 8 7 8 9 9 200
Hospital Wide Safe Surgery Marking Compliance 7 3 2 6 9 8 9 9 186
Hospital Wide 5 Moments Hand Hygiene Compliance 7 5 2 8 8 8 9 9 195
Hospital Wide Reduce number of Falls 7 7 3 8 9 8 9 9 210
Hospital Wide Implement patient safety culture 8 3 6 9 8 8 8 7 193
Hospital Wide Implement electronic incident reporting system 8 4 7 8 9 8 7 9 207
Hospital Wide Implement JCI International Library of Measures 8 5 5 6 8 8 9 8 201
Hospital Wide Selection for 5 Clinical Practice Guidelines/pathways/protocols 8 6 4 6 7 8 9 6 188
Hospital Wide Reduce Discharge Against Medical Advice 5 8 8 2 7 8 3 5 160
Hospital Wide Incomplete Discharge Summaries 4 5 3 3 5 7 3 6 124
Hospital Wide Impact Analysis on Clinical Waste Disposal 5 5 9 4 8 8 9 7 199
Hospital Wide Reduce readmission rates 4 7 8 4 6 7 5 7 172
Hospital Wide Improve quality of medical record documentation 5 6 5 5 4 6 6 6 153
Hospital Wide Improve compliance to pain assessment and management 5 6 4 4 5 6 5 7 150
Hospital Wide Reduce the number of prescribing errors 4 6 5 4 3 6 5 6 140
Hospital Wide Ensure avaialability of essential medications 6 7 5 6 5 5 5 8 168
Hospital Wide FMEA Infant Abduction 5 7 6 9 9 6 9 8 209
Hospital Wide FMEA Concentrated Electrolytes 5 7 6 9 9 6 9 8 209
Hospital Wide Improve Patient Satisfaction 8 9 6 7 8 6 8 9 219
Hospital Wide Improve Staff Satisfaction 8 9 6 7 8 6 8 9 219
Hospital Wide Improve Patient Flow in ER 7 9 4 8 3 6 8 4 170
456 564 460 306 510 342 895 905 4438
Generic Hospital Wide Indicators
Hospital Wide Indicators
Patient Satisfaction
Staff Satisfaction
Culture of Safety
Nursing Department Core Measures
Dialysis Patients
High Risk Service Quality Indicator % of dialysis patients with hemoglobin of 11
Hemoglobin achievement 12
High Risk Service Quality Indicator - Dialysis % of patients with URR between 65% to 80%
adequacy
Guidelines/pathways/protocols
Diagnosis Process Owner Process/Outcome Measure
Departments Measures