Healthcare Quality Digest -...
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Healthcare Q-Digest From the Chairman’s Desk Issue # 2 Autumn 2010 In this issue • From Chairman‟s Desk • Success Story of POLQM • Q- Digest Article • Quality for Beginners • Excellence Track • Customer Voice • Q- Tool • Q-Quotes • Coming Q-Events • Q-Link • 2 nd Q-Digest Team • Q-Digest Supporters Made by Professionals to Professionals Types & Number of Accreditations in KSA Compared to the Middle East 54 22 13 11 2 23 17 12 8 1 0 10 20 30 40 50 60 JCI Accreditations CAP Accreditations AABB Accreditations CCHS Accreditations Australian Accreditations ME KSA journey of excellence in health care services has been started by recognizing the importance of accreditations as tools in health care to reduce health care errors and not just medical errors. Accreditations are structured around systematic approaches rather than individual practices and therefore errors should be predicated or forecasted before they occur. However, more work and efforts are needed over the next two decades to make quality as culture in health care services due to shortage of skilled workers. Quality professionals need to show how their skill sets are perfectly aligned to work in addressing errors in the health care processes for any clinical pathway and not pigeonholed themselves into using their tools in very specific areas such as auditing, and management. They need not to forget that gained skills are transferable. The piece of advice I wish to provide to quality processional starting their career in a health care institution is to focus on sustainable performance of all provided services offered by their facility and not just focusing on passing an accreditation. Today‟s more sophisticated public, with awareness enhanced by the Internet, is more familiar to how organizations conduct and sustain their business practices. In addition if a healthcare institution decided to proceed and apply for excellence awards in the near future, the selection criteria are more stringent than accreditation requirements especially the focus on key performance results, benchmarking and social responsibility will be robust. As quality professional, you have probably been reading about the demand on reducing medical errors in the media and perhaps asking this question: are errors only medical as most individuals think or extend to encompass the entire health care services as a matrix, and more importantly, what is my role in making the picture clearer. The graph below shows the number of accredited health care facilities including hospitals in the Kingdom of Saudi Arabia compared to the Middle East. There are 102 health care institutions recognized by international accrediting bodies compared to 61 in the Middle East which indicates that the healthcare market in the kingdom is the largest in the region. Recently, the ministry of health launched a national quality program, Central Board for Accrediting Healthcare Institution (CBAHI), to improve quality of services, spread quality culture and accredit government and private health care institutions. 21 governmental hospitals were just recently accredited by CBAHI. This is optimistic and one can say that the
Transcript of Healthcare Quality Digest -...
Healthcare Q-Digest
From the Chairman’s Desk
Issue # 2 Autumn 2010
In this issue• From Chairman‟s Desk
• Success Story of
POLQM
• Q- Digest Article
• Quality for Beginners
• Excellence Track
• Customer Voice
• Q- Tool
• Q-Quotes
• Coming Q-Events
• Q-Link
• 2nd Q-Digest Team
• Q-Digest Supporters
Made by Professionals to Professionals
Types & Number of Accreditations in KSA Compared to the Middle East
54
22
13 11
2
23
17
128
1
0
10
20
30
40
50
60
JCI Accreditations CAP Accreditations AABB Accreditations CCHS Accreditations Australian
Accreditations
ME
KSA
journey of excellence in health care services has been started by recognizing the importance ofaccreditations as tools in health care to reduce health care errors and not just medical errors. Accreditations are structured around systematic approaches rather than individual practices andtherefore errors should be predicated or forecasted before they occur. However, more work and effortsare needed over the next two decades to make quality as culture in health care services due to shortageof skilled workers. Quality professionals need to show how their skill sets are perfectly aligned to workin addressing errors in the health care processes for any clinical pathway and not pigeonholedthemselves into using their tools in very specific areas such as auditing, and management. They neednot to forget that gained skills are transferable. The piece of advice I wish to provide to qualityprocessional starting their career in a health care institution is to focus on sustainable performance ofall provided services offered by their facility and not just focusing on passing an accreditation. Today‟smore sophisticated public, with awareness enhanced by the Internet, is more familiar to howorganizations conduct and sustain their business practices. In addition if a healthcare institutiondecided to proceed and apply for excellence awards in the near future, the selection criteria are morestringent than accreditation requirements especially the focus on key performance results,benchmarking and social responsibility will be robust.
As quality professional, you have probably been reading about the demandon reducing medical errors in the media and perhaps asking this question:are errors only medical as most individuals think or extend to encompassthe entire health care services as a matrix, and more importantly, what is myrole in making the picture clearer. The graph below shows the number ofaccredited health care facilities including hospitals in the Kingdom of SaudiArabia compared to the Middle East. There are 102 health care institutionsrecognized by international accrediting bodies compared to 61 in the MiddleEast which indicates that the healthcare market in the kingdom is the largestin the region. Recently, the ministry of health launched a national qualityprogram, Central Board for Accrediting Healthcare Institution (CBAHI), toimprove quality of services, spread quality culture and accredit governmentand private health care institutions. 21 governmental hospitals were justrecently accredited by CBAHI. This is optimistic and one can say that the
Dr. Michael A Noble, Professor at UBC and Chair of the POLQM , enlighten Q-Digest team about thesuccess story of the Program Office of Laboratory Quality Management, Department of Pathology andLaboratory Medicine, University of British Columbia. He said the POLQM has been existed since2004. When we started, we were aware that the new ISO standard (ISO15189 = Medical laboratories -particular requirements for quality and competence) was going to expect there to be Quality Managersfor medical laboratories, and at the time there were few (if any) in Canada. While CAP accreditationand CLIA has created certain quality expectations, they were certainly not on the same scale as ISO, andhad never fostered the new position.
As Canada is a large country with 5 time zones, it was unrealistic to provide a course of any substancethat was going to have national reach without being on-line, and so our course was developed. AcrossCanada it was an immediate success, but along the way, the on-line nature of the course was seen tosatisfy other countries including in the Middle East, China, Central and South America.
Today the course is very international in its reach. Anyone can set up a course, and anyone can takeone, but it there are not stringent requirements for admission and assessment of performance, then thecourse has limited value. From the very beginning, our certification process was seen to provideemployers with some confidence in the quality and knowledge and competence of our graduates. It isrecognized by organizations in the US and Canada as accepted for continuing education credits,including the Royal College of Physicians and Surgeons of Canada.
To date we have limited the course enrollment in order to ensure best opportunities for discussion andcommunication not only with faculty, but equally important between course participants. This has leadto the creation of a quality community that has remained active year over year. We have had about 150people through the course, with a certification rate of about 90%. Each year there are folks who decideto enroll in the course, without realizing that the course can be demanding of time andparticipation. Some of the folks who have joined and dropped out have come back the next year andtaking a more serious approach and been successful. I think we have had 5 successful certificates fromthe Middle East.
Last year we started the regional ambassador program to promote participation outside Canada. Wehave one successful person in place and two others under consideration.
The purpose of our course remains the same today, as it was when we started; to create a community ofquality managers who can work within the medical laboratory community to promote and grow qualitymanagement principles that will enhance laboratory performance. Some will decide to gofor accreditation, some will not, but all of them will have better laboratories.
People interested in the course can go to www.POLQM.caFor regional queries, contact Dr. Nashat Nafouri, KSA regional ambassador at [email protected], for those interested in being part of another ongoing Quality Discussion, join or visit my blog at www.medicallaboratoryquality.com
The Success Story of the Program Office of Laboratory Quality Management (POLQM) at UBC by Dr. Michael A. Noble
Q-Digest Article by Zaki Qawas
إجراءات اجلودة يف إدارة امرػاة امطحة
وما ، كبل ذي من أكرث اامتم من امطحة ابخلدمات امؼالكة ذات اجلات مؤخرا أظرث ما ذكل وؼزز .املاضة امس يوات خالل كبريا زخام امطحة واملشآت املسدشفات يف امطحة اخلدمات يف اجلودة اكدسبت
، مس مترة بطفة وحتسهنا اجلودة ملخابؼة املثىل واألسامب ابمعرق اامتهما إىل إضافة ومؤةل، ػامةل وكوى ، جد بشلك موهجة دورات خالل من وذكل ، اخلدمات ذ معاميب ػامة جودة ثلدمي من ب ثلوم أن بغي
:احلرص ال املثال سبل ػىل .هبا ثيفرد اميت وامسامت اخلطائص من دلهيا ملا امرحب جس هتدف ال ثلدم اميت اخلدمة أن خاضة
. امؼامة مس ئومهتا•
. وأسايس جوري يشء مألفراد همية وجود•
. وامة رئس ة مخغريات اخلضوع إماكهة•
. متاما نولاس كابال مس اخلدمة من اهمنط ذا يف امؼمل أداء•
.اخلاص املعاع يف اجلودة إدارة هظم من ضؼوبة أكرث امؼام ابملعاع اجلودة إدارة هظم مضامني جنؼل اخلدمات من اميوع ذا ويف
بة امثلافة واميوايح اجلودة حتسني بأهظمة خؼوق فامي وذكل خمخوفة ومبؼدالت كثريا اخلدمات ثخلدم سوف اجلودة ثعبق غيد : وجشمل ، املس مترة وامخدر
. وامثلايف اإلداري الامزتام•
ق املوظفني إدراك و وغي مدى• . اخلدمات ذ بخلدمي املؼيني امؼمل وفر
. املين امخدفق وخمععات امشاط حتسني•
ب• . اجلودة حتسني ػىل امخدر
وثدرب امطحة، املية امخخططات منو إىل ابإلضافة امطحة اخلدمة هظام ػىل نولامئني امواحضة امرؤة حزاد مع .مهنا املس خفدن رغبات ثومس و امسائد الاجتا فإن امطحة، اخلدمات جودة مبس خوى الارثلاء أجل من
د وابمخايل اخلدمة ملديم وغي وحزاد ف اجلودة إدارة ثعبق مؼدل رسػة حزاد إىل ذكل فس ؤدي املوظفني، فئات خمخوف من امؼدد واظالػا وزوكا أكرث وطبح امللدمة اخلدمات من املس خفدن ورسور رضا من حز
املراجؼة سواء املخخططخني امؼموخني لكخا ثغعي حبر جودهتا من وامخثبت ػامة بطفة امطحة امرػاة ثلدمي إدارة إحاكم ظرق حتسني املؼية اجلات ػىل وجب ذلا .اجلودة ػامة حصة خدمة ػىل نوحطول ثأكدا وأكرث
ة وأن مروهة أكرث إداري وأسووب امطحة اخلدمة ميظام اجلدد امخيظمي إكرار و امطحة اخلدمات هظام يف اجلودة إدارة همنط أوىل ومبراجؼة ، امللدمة اخلدمات من واملس خفدن املرىض اامتمات اس خكشاف أو امرسر
ة اخلدمات ػىل امرتكزي ورضورة اجلودة من نوخثبت وابمس بة. اخلدمة ملديم بني امود من جو سود ة غري و امرسر احلاالت ذ غن دراسة وبوضع اجلودة، مخلمي مخظمة مهنجة أسس وفق هجود وبذل امللدمة امرسر
: امخايل إمتام حاةل يف ثغري ميكن
. اجلودة مخحسني أكرب أوموة إغعاء•
. اجلودة غن أفضل باانت ثوفر•
. امؼامةل نوكوادر امثلافة اميوايح يف ثغري إحداث•
. فني وغري فني امؼاموني واكفة األظباء بني امؼالكات حتسني•
د مما ة امرػاة جودة من امخثبت موضوع إغعاء يف ز : امخايل ثخضمن املرىض حللوق الحئة ووضع مس مترة بطفة امطحة امرػاة ميظام امفؼوة الاحذاجات وحتدد ، وس خخدهما اميت امؼياة امرسر
.امعبة احذاجاث أساس ػىل امطحة امرػاة املرظ خولى أن•
. وكت أي يف امعوارئ حاالت يف امعبة امرػاة خولى أن•
. ممكن وكت بأرسع الاسدشاري اس خدػاء أو املرظ حيال اسدشاري رأي أخذ إىل امعوارئ ظبب كبل من امعوارئ بلسم ػو امكشف بؼد املرظ احذاج إذا•
امللرتح امؼالج من ثلرر ما غن وذكل امطحة حامخ ثياسب اميت امبدةل امخدابري إػالم وكذكل ما، خؼرض كد أخعار أي ثوضح مع ملرتحة ثدابري أو مؼاجلة أي حول واحضا ثفسريا أهل و املرظ إغعاء•
ق أفراد أو امعبب كبل من . املؼاجل امعيب امفر
ظ خاح أن جيب• . امرضورة غيد امطحة نوخعورات اسدشارات أي ػىل حطوهل نومر
. امعبة املرافق بؼظ يف ثمت واميت ظبة أحباث إجراء يف املرضة حبامخ املشاركة ػدم أو املشاركة رغبخ غن امخلرر يف اخلار نومرظ كون أن•
. فهيا اهخظار ألوكات األكىص واحلد امللدمة امطحة اخلدمة غن مفطةل مبؼوومات املرظ ؼمل أن•
. ذكل حامخ جس خدغي ما غيد نوؼالج املسدشفى دخول ادن يف احلق نومرظ كون أن•
. املس ئول املدر من وشامةل مكذوبة حكون وأن حوما رسؼة إجابة خولى وأن امشكوى يف حتلق إجراء مت وأن ثلدم اميت اخلدمات جتا م شكوى وجود حاةل يف احلق نومرظ كون أن•
ظ كدشف بذكل ويف : امخايل غهنا ذج امالحئة وذ ، امللدمة نوخدمة امفائلة وامؼياة امعبة امرػاة جلودة املرثفع املس خوى املر
. امللدمة اخلدمة غن اجيابا اهعباػا ثودل اس خذاج•
. ابالظمئيان وشؼر ساػد مما املسدشفى يف امؼاموني األفراد كبل من ابملرىض امشخيص امرتحب•
.مذدرب أو مذخطص ممرض أو مدربة أو مذخططة ممرضة ذكل يف وساػد امعوارئ أخطايئ كبل من امعوارئ كسم إىل املرظ وضول غيد رسري ثلمي•
. ما حيخاجون كد اميت والاجامتغة امطحة امرػاة الس مترار هلم س خجرى اميت ابمرتثبات ظمأىهتم مت املرىض خروج غيد•
. (( مساػدك ساػدان )) شؼار ثبين ػىل املرىض شجع مما هبم والاامتم املرىض حلوق وضوابط مبؼوومات الاس خلبال كسم يف املرظ حزود•
Quality for Beginners by Dr. Nashat Nafouri
When a group of 23 health care services providers were asked about the % of time that should be spent on "Improving" and "Doing" work by Managers as follow:
90 for improving work and 10 for doing it
70 for improving work and 30 for doing it
30 for improving work and 70 for doing it
50 for improving work and 50 for doing it
Their answers can be demonstrated using the following pie graph:
4%
26%
30%
39%
The Awareness about the Manager Role in Improving and Doing the
Work (Sample Size n=23)
90 for improving work and 10 for doing it
70 for improving work and 30 for doing it
30 for improving work and 70 for doing it
50 for improving work and 50 for doing it
Interpretation: The majority 39% believes that Managers should spend 50% of their time for
improving work and 50% for doing it. While 30% thinks that Managers should spend 30% for
improving work and 70% for doing it. Only 4% thinks that Managers should spend 90% of their time
improving and 10 % for doing it. The correct answer as per international benchmark is that Managers
should spend 70% of their time for improving work, work environment, processes and resolving bottle
necks and spend 30% for doing it to ensure effectiveness.
Excellence Track by Adel Osama Sayed
Customer Voice by Dr. Hani Fetyani
Keep it Simple …A quality management system is described as a set of key quality elements that must be in place for anorganization‟s work operations to function in a manner as to meet the organization„s quality objectivesand goals. Unfortunately, most of healthcare organizations have yet to understand that quality must bebuilt into, not inspected into. Many healthcare organizations are focusing on their destination (i.e.passing an accreditation inspection) instead of more carefully mapping out their journey (i.e. buildquality culture within their organizations to ensure the highest level of quality and patient safety). Thejourney toward total quality management must begin with an understanding of the fundamentalrelationship between healthcare quality management and technical activities. The Clinical andLaboratory Standard Institute (CLSI) has developed quality management standards (QMS) modelwhich provides a means for aggregating all like requirements from different regulatory, accreditation,and standards. This helpful framework allows healthcare organizations to develop quality and technicalpolicies, processes, and procedures that meet all current regulatory requirements. The figure belowrepresents a QMS model and illustrates the important relationship between technical and managerialactivities.
A Customer Satisfaction Survey was made on a group of 63 people to know what Healthcare servicescustomers want. In each Q-Digest issue we will present a question asked and share with our readersparticipants‟ opinion. One of the questions was about the importance of Staff awareness about theimportance of receiving patient. Their answers are demonstrated in the following graph. The majorityagreed that this awareness is important to them and health care providers should have measurableelements to enhance performance.
Strongly Agree
1829%
Agree29
46%
Rather11
17%
Disagree1
2%
Disagree strongly
46%
Q- Tool by Ms. Daliah Taibah
Q-Quotes
“Inspired by the American Collage of Healthcare Executives, HIG believes it is incumbent on healthcare
professionals to strive to eliminate errors, continuously improve the quality of healthcare services, and
better serve the patients entrusted to their care.”
Nashat Nafouri
“If quality is to become the lifeblood of your healthcare organization, only a transfusion of new ideas
will get quality flowing.”
Healthcare Division, Films incorporated
The PDCA cycle
A Project Planning and Implementing ToolPDCA (plan-do-check-act) is an iterative four-step problem-solving process. It is also known as the Deming cycle, Shewhart cycle, and Deming wheel.
Plan - Recognize an opportunity and plan a change.Do - Test the change; Carry out a small study for new process or solutionCheck - Examine outcome, analyze the results and identify what you‟ve learned.Act - Take action based on what you learned: If the change did not work, go through the cycle againwith a different plan. If it worked, use what you learned to plan new improvements, begin the cycleagain.
PDCA applies to all sorts of projects and improvement activities; such as developing new process orservice, and planning data collection and analysis to verify and prioritize problems or root causes. Justas a circle has no end, the PDCA cycle should be repeated again and again for continuous improvement.
Plan-Do-Check-Act Example:In an attempt to control biohazardous waste costs, a committee was formed to address these issues:
Check: approximately90% of the waste found in red containers did not contain biohazardous waste.
Do: determine areas that generated the largest amounts of biohazardous waste.
Plan: reduce biohazardous waste
Act: educate and train employees on biohazardous waste reduction.
Mark your calendar for the coming events from September to December.
Event Date Time Organization Venue
Building Health, Safety And Environment Program On Actual Hospital Needs.
28 September 2010
8-10 PM KFH, Jeddah
3rd National Quality Conference3-6 October 2010
KAU Conference Hall, Jeddah
Patient Safety Practitioner Certificate Program
18-20October 2010
Baltimore, MD, USA
HER, PACS & Related Standards Training Seminar & workshop
OCT 24-27, 2010 DUBAI , UAE
Is Six-sigma A Solution For Health Care Services Stigma?
26 October 2010 8-10 PM KFH, Jeddah
3rd National Quality week6-11 November 2010
Kingdom Wide
HIMSS Middle East 108-10 November 2010
DUBAI , UAE
Balance Score Cards Shape The 21st Century Health Care Processes
30 November 2010
8-10 PM KFH, Jeddah
Middle East Quality Association International Conference
7-8 December 2010
Abu Dhabi , UAE
Middle East Healthcare Projects 201012 - 13 December 2010
The Westin
Hotel, Dubai,
UAE
Q-Events: HIG –KFH Quality Professional Development Program is the Grand Event of 2010
Abbreviations:HIG: Health Interest Group KAU: King Abdulaziz UniversityKFH: King Fahad Hospital
Middle East Healthcare News: www.blog.ictforhealth.com
This website provides the latest Healthcare news in the Middle East as well as case studies, articles
upcoming events, and research papers. Although it is not a primarily quality website but it provides
good quality articles, studies and news in healthcare. It is useful website for those who are seeking the
latest in healthcare updates and those who want to submit their own news through the White papers
page.
Q-Link
Meet the 2nd Q-Digest Team:
Dr. Nashat Nafouri Ms. Daliah Taibah Dr. Michael Nobel
HIG Chairman Healthcare Q-Digest Coordinator Professor and Chair
KAMC-WR POLQ, UBC
Dr. Hani Fetyani Mr. Adel Osama Sayed Zaki Qawas
Quality Advisor Quality Manager Hospital Management
Saudi Geological Survey Al Borg Laboratories Consultant
Ms. Sarfinaz Hanbazaza
Point Of Care Coordinator
IMC
Q-Digest Supporters:
For any comment, please send your feedback to [email protected]
