2014 Occurrences Monitoring

Transcription

1 Newsletter is released by Quality Improvement and Risk Management Department at least twice per year which tackles indicators, quality improvements education, events and a lot more. ABDUL LATIF JAMEEL HOSPITAL QUALITY IMPROVEMENT NEWS Quality is Everyone s Responsibility Volume 1 Issue # 3 Feb Occurrences Monitoring Prepared by: Evalyn Macalintal R.N. Clinical Reviewer Reviewed by: Engr. Eman Ali MuzaynI Quality Coordinator Approved by: Figure 1 Reporting is essential to the identification and evaluation of errors for the purpose of improving processes. All employees are encouraged to participate in the detection and reporting of any error, medication error, near miss, hazardous condition, occurrence, injuries involving patients, visitors, and staff, or sentinel or reportable event. As seen on Figure 1,it was noted an increase in OVR ( Occurrence Variance Reports) reporting trend from 2012 up to 2014 partly because of active campaign & encouragement imposed by Quality Department which also shows pro-active staff involvement. Dr. Youssef Abdelrahman Chief Executive Officer Inside this 2014 Occurrences Monitoring ( OVRs ) Significant Hospital Wide Indicators Rehab Services Quality Improvement Project Quality Week Celebration 2014 Children s Day Event World Aid s Day Celebration Fire Drill with Civil Defense 7 Education Corner & 2014 Best Employee Figure 2 Incident categorization is a challenge for any organizations. It is also important to track OVR according to its Category to facilitate and speeds up the process of corrective action and creates greater efficiency within the process flow. As presented in Figure 2, Medication Error in OPD has the highest occurrences and this has been the result of active participation of new pharmacist who showed interest in pharmacy related audits in 4rth quarter of It was observed that it was under reported on early part of 2014 wherein system & human factor were contributory factors. Disregarding Hospital Rules ranked as the second which got 10.1% of the total 288 OVRs that were managed accordingly through proper patient and carer education upon admission by different members of rehabilitation team.

2 Page Significant Hospital Wide Indicator Skin Injury Another significant occurrences in 2014 was an increase in skin injury which paved way for Nursing Department in collaboration with Rehab Services to conduct a project to minimize somehow the causes which are elaborated in their project which can be accessed in shared folder. Fire & Safety Training The goal of this Fire Safety Training is to provide a knowledge to All ALJH staff on how to deal with Fire if it occurs and we had a great improvement on this aspect. It was 84.4 % in 2013 and by 2014 it was increased to 98%. Most department participated well on the training scheduled by our Safety officer. Incomplete Files Upon patient discharge, Medical record are analyzed and those that have specific deficiencies that need be completed by a health care provider are considered incomplete. In 2013, we have only 5% incomplete files and it was increased in 2014 to 30%. The reason for such increase is due to wrong way it was previously audited and icorrected accordingly. Turn Around Time Turnaround time (TAT) is one of the most noticeable signs of laboratory service and is often used as a key performance indicator of laboratory performance. For this year our TAT average is 83 % not yet satisfactory but far better as compared to previous year which was 71%. Staff Turn-Over Staff turnover is important to any Institution of all sizes because it deals with increase finances, time and resources to recruit and train employees. A high turnover rate can be costly to a company because it requires the management to recruit and hire new workers constantly to fill open positions. New workers often are not as productive as experienced workers and require days, weeks or even months to learn how to perform their jobs efficiently. For 2014, we have a high staff turnover at the end of contract which was 12% and it or areas for im- is one of the focus provement in New Hire Orientation New hire orientation is not a single event but an entire process that could take weeks as you help new hires become acquainted to our workplace. Base on the report of EPD Coordinator, In 2014, only 75% among new hires received Hospital Wide Orientation Program. Since ALJH is small size institution, we were able to conduct twice for past year but it should be improved in the years to come and Department Head should ensure compliance on this aspect as it is mandatory for all the staff before they proceed to General and Unit Specific Orientation. Patient s Complaint Rehab Services got the topmost complaints in the first quarter of 2014 which allow us to have another FOCUS PDCA Project which turned into success. You may refer to story board of the said project on the next page and a more detailed contents on shared folder. intelligent effort. Quality is never an accident; it is always the result of

3 Page 3 REHAB SERVICES COMPLAINTS FOCUS PDCA FOCUS PDCA PROJECT TIME MEETINGS & BRAIN STORMING.. There was an increase complaint in Rehab Services in the first quarter of 2014 which signal Rehabilitation Department in Coordination with the Quality Team to start a project in order to mitigate patient complaints from them & was headed by Mr. Reynaldo Banting, Occupational Therapist. As seen on the graph from 48% on the first quarter which dramatically dropped down to 0 % after FOCUS PDCA 1ST 3RD Q PATIENT COMPALINTS IN 2014 FOCUS PDCA DONE

4 ALJ Hospital Quality Week 2014 Page 4 Healthcare Quality Week is being celebrated all throughout the world every third week of October. For 2014, we celebrated it on October 19-26, 2014 This is an excellent time to recognize everyone who is dedicated to improving the safety and quality of healthcare. Everyone in our organization is a contributor to healthcare quality. Everyone in the organization plays a role in healthcare quality and it is important that everyone understands their role and how important they are in the process. The above awarding ceremony was held on the first Quality Week Celebration ever of the Hospital wherein Quality Department recommended to the CEO of the hospital to push through with the previously raised acknowledgement of those staff 5 years and above in service by giving them certificates and incentives for their dedicated service in our organization and was approved by Chairman of the Board. Quality is never an accident; it is always the result of intelligent effort.

5 Page 5 Q & A Portion of Quality Week PREPARATION OF QUALITY WEEK PREPARING STAFF RECOGNITION CERTIFICATE QUALITY WEEK RIBBON DAY 1: PHYSICIANS,PHARMACY, X-RAY AND ADMIN AREA Photo on the right with the CEO before initiating the Question and Answer portion of Quality Week with Quality Coordinator and Clinical Reviewer. DAY 2: WARD 6 AND PT AREA As seen on the photos : X-Ray Dept, Receptionist, Pharmacist, Nurses and even Physicians on Day 1 and Day The event was a long week Celebration wherein 3 days Q & A in all areas of the hospital both Clinical and Non Clinical staff enthusiastically participated and had fun. Those staff who answered correctly were given simple gifts as appreciation from Quality Department as supported by higher management. There were 3 Special Awards of Quality Week. Decision were made after group discussion by Infection Control Practitioner, Safety Officer and Quality Team. Selected staff had shown knowledge, confidence and promptness on the question asked. Winners all came from Nursing Department: Best In Infection Control goes to Ms. Christa Joy Guba, Best in Safety was Mr. Robert Rivera and Best in Quality was received by Ms. Wang Dekai. Three abovementioned staff received special gifts and were awarded on October 26, 2014 by CEO, Vice & Chairperson of the Board. DAY 4 : STAFF WITH BEST ANSWER IN Q & A BEST IN SAFETY. INFECTION CONTROL AND QUALITY WERE GIVEN SPECIAL AWARDS BEST IN SAFETY BEST IN INFECTION CONTROL BEST IN QUALITY A total of 98 staff were given service recognition : 63 of which stayed for more than 10 years and 35 staff have been with ALJH for more than 5 years. Sample of Service Award Certificate Quality is never an accident; it is always the result of intelligent effort.

6 Page 6 Children s Day 2014 Children's Day is recognized on various days in many places around the world to honor children globally and to protect and promote their rights to survive and thrive, to learn and grow, to make their voices be heard. November 24, 2014 was a very special day for our beloved especially able pediatric patients when their special gifts were handed to them after inspiring word as seen on the upper right photo of Dr. Mahmoud Khalifa, Pediatric Specialist by Dr. Youssef Abdelrahman, CEO, Madam Najia, Chairperson of the Board & the person behind above event, Ms. Asmaa El Debaa, W6-& W7 Patient Relation Officer. World Aids Day World Aids Day is being celebrated globally every first week of December to raise the awareness of everyone. For us, it was held on December 4, 2014 as part of our Yearly Educational Calendar wherein our Infection Control Nurse, Ms. Christian Lass Iballa conducted a presentation with theme ZERO New HIV Infections and also tackles on important aspect of HIV disease, its causes, prevention & a lot more. All attendees worn a special red ribbons that symbolizes everybody s awareness, support and remembrance of those affected by HIV.

7 Page 7 Fire Drill with the Ministry of Interior Head nurse prepares portable stretcher to evacuate bed ridden patient. Disaster triage procedure of Doctor observed by Policy reviewed by MOI representative & evacuation procedure is explained by Charge Nurse. Notes taken by Medical Director External assembly triage doctor attending first to red color cod- Evacuation initiated and observed by MOI representative. Fist patients to be evacuated are ambulatory Procedure adjustments discussed by MOI representatives to doctors ALJH Evacuation Procedure is accepted base on MOI Standard (Dec. 2014) C E R T I F I C A T E Education Corner Physician s Emergency Equipment Orientation is essential in all Healthcare Facility to promote patient safety. Events were taken on Dec 22, 2014 during the medical Staff Committee Meeting. Best Employee of the Year 2014 ALJ Hospital recognized outstanding employees who showed exemplary individual achievement, contribution, and performance in their jobs and other related duties for the year Ms. Judith Dimayuga from HR Department and Mr. Musthafa Kodiyatt from Finance Department were chosen by Staff Reward Committee headed by Hospital CEO, Dr. Youssef Abdelrahman.