1- Goals / Objectives:

1.1 Establishment of Quality Improvement culture throughout the center & promote an organization wide commitment to maintain high Quality of Patient care and services and leadership involvement in improving quality.

Objectives :

· Conducting regular quality awareness lectures about the basic concepts of quality for all staff.

· Conducting a quality rounds to all departments in which the quality personnel try to disseminate the culture of quality.

· Communicating all quality activities to the leaders for revision and approval during the Quality Committee and approving all cross functional teams and committee’s term of reference from the leadership.

1.2 Ensures continuous monitoring and improvement of clinical and non-clinical services, by increasing the probability of desired patient outcomes, including patient and staff satisfaction.

Objectives :

· Establish and prioritize performance indicators in collaboration with all clinical, managerial, and support areas.

· Involving all departments in the performance improvement projects.

· Ensure the coordination and integration of all performance improvement activities.

1.3 Meeting the International Patient Safety goals:

Objectives :

· Improving the accuracy of patient identification

· Improving the effectiveness of communication among care givers

· Improving safety in using medication

· Eliminating wrong-site, wrong-patient, wrong procedure surgery

· Reducing the risk of health care-associated infections

· Reducing the risk of patients harm resulting from falls

2 Scope:

The Quality Improvement Program includes the following activities:

All direct patient care services and indirect services affecting patient health and safety

Medication therapy (includes medication errors)

Utilization management

Healthcare associated infections

Patient/staff satisfaction surveys

Health record

Risk management activities

Morbidity/Mortality Review

Patient Safety Goals

3.1 The Governance responsibilities :

· Approve and maintain the QMPS Plan

· Review & approve the annual report of achievements reported by the Quality Committee.

· Allocate the proper budget for QI/PI activities.

3.2 Quality Committee are responsible to:

· Approve the QMPS Plan.

· Approve high-level policies and procedures.

· Disseminate patient-related risk management information to the appropriate heads of departments.

· Ensure compliance with the applicable accreditation standards

3.3 Quality Designees (QID) are responsible for:

· Act as a liaison between the department and the TQM department.

· Facilitate adherence of department to the mission, vision, value statement and the (QMPS) Plan.

· Provides functional guidance and coordinates the QI/PI activities with the assigned department, sections, or units.

· Identifies problems that may impact on delivery of quality of service/ patient care.

· Provides educational and technical assistance using QI/PI Tools to his/her departmental staff.

· Identify quality indicators in their respective area, collect and analyze data, develop and implement changes to improve service

3.4 All Staff are responsible to:

· Report unusual and /or undesirable patient-related incidents.

· Implement/ comply with the recommended modifications in policies, procedures and practices.

3.5 Multidisciplinary Teams are responsible to:

· Address quality improvement opportunities that require multidisciplinary input identified by leaders and/or other organization’s units, committees, or individuals.

4.1 The quality coordinator conduct coordinated, comprehensive, and continuous educational activities on quality concepts and tools include:

· Concepts of quality management.

· How to work in teams.

· Use of data, display of data.

· Quality improvement tools.

· Quality improvement cycle model FOCUS – PDCA .

· Decision-making tools.

4.2 Education regarding QI/PI methods and activities will be provided to PHC leaders on an ongoing basis.

4.3 Education of the medical staff and of nursing including the basic concepts of quality improvement, statistical tools, and team dynamics.

5. Leadership prioritization criteria :

5.1 PHC Quality Committee will select, prioritize, and monitor a set of center-wide indicators.

5.2 Organizational QI/PI priorities are assessed on a yearly basis.

5.3 Establishing priorities for the PHC QI/PI efforts as a whole are set by the Quality Committee based on the following factors:

· High risk to patients,

· High volume (e.g. the number of patients involved),

· Problem-prone in the provision of care,

· High Cost

· Requirements of government law and regulation.

· Effects on patient and family satisfaction

· Effects on staff satisfaction

6.1 PHC leaders develop and implement a set of indicators that are collected and aggregated on a regular basis and are used for quality improvement, as well as strategic and operational planning.

6.2 The indicators represent service structures, processes, and outcomes.

6.3 The indicators focus on important managerial and clinical areas.

6.4 The clinical indicators are referenced to current evidence based practice.

6.5 Data are coordinated with other performance monitoring activities such as patient safety and risk management.

6.6 Each indicator has an operational definition, sample size, data collection method, frequency, analysis, and expression.

6.7 Structure indicators based on the mission and scope of services that include:

· Availability of essential supplies and equipment

· Availability of health records.

· Availability of emergency medications.

· Vacancy rates in all departments.

6.8 process indicators based on the mission and scope of services that include:

· The timing and use of antibiotics.

· Documentation in the health records

· Delays of physician answering calls.

6.9 outcome indicators based on the mission and scope of services that include:

· Staff satisfaction.

· Patient satisfaction.

· Unplanned returns to the PHC.

· Resuscitation of patients

· Adverse events

· Sentinel events.

· Patient complaints.

· Medication errors.

· Common procedures.

7.1 PHC select FOCUS – PDCA methodology to be used in all its process improvement activities or /and when monitoring detects that a process may need a redesign, or when new processes are designed, such as the provision of new patient services.

7.2 The criteria used for QI /PI prioritization ( mentioned in leadership prioritization criteria )

8 QI/PI COMMUNICATION (FLOW OF INFORMATION) :

8.1 The QI/PI Program includes communicating and liaising the QI/PI efforts with other departments and committees through TQM coordinator.

8.2 Medical Interdisciplinary QI/PI activities are also reported through the medical staff structure.

8.3 Cross functional QI/PI activities are reported through the Team Facilitator to the TQM coordinator and Departments involved in this activity

9 REVIEW AND APPROVAL

9.1 The QM Plan will be approved by the PHC governance, quality committee and PHC Director for three years.

9.2 The effectiveness of the QM plan will be evaluated and revised on an annual basis by the quality committee and could be revised when necessary.

1.10NA

11.1CBAHI standards for PHCs