Development Policies and Procedures Manual

1. Development Policies and Procedures Manual Examples of table of contents: Example 1: demonstrates a organization numbering system Example 2: demonstrates a service-specific numbering system

2. Patient Safety Dr. Hussein Saad Assistant Professor and Consultant Family &Community Medicine College of Medicine King Saud University

3. Quality of Care ■The degree to which patient care services increase the probability of desired patient outcomes and reduces the probability of undesired outcomes.

4. Accreditation Focus on Quality

5. What is the importance and benefits of Accreditation? • Improve the quality of patient care and outcome. • Improve the Patient Safety, Save Environment. • Competition for excellence. • Enhance the confidence of public. • Shows accountability.

6. What is Quality Improvement? ■An organization philosophy that seeks to meet clients’ needs and exceed their expectations by using a structured process that selectively identifies and improves all aspects of service.

7. Communication Positive Change Sharing Ideas How will be benefit?

8. Elements of Quality Safety Competence Continuity Acceptability Client Accessibility Effectiveness Appropriateness Efficiency

9. Policies and Procedures ■ Policies are guidelines or instructions on what “needs to be done” ■ Guides for organizational strategies objectives ■ Policies are statements about pre-determined courses of action

10. Patient Safety The Reduction of unsafe acts within the health care system. Patient safety is to Avoid, Manage and Treat unsafe acts within health care system.

11. Goal Areas: • Communication • Medication Use • Worklife • Infection Prevention and Control Patient Safety Areas

12. Goal: Improve effectiveness among care providers Goal: Safe administration of Drugs Communication Medication Use

13. Goal: Safe Physical Environment Goal: Reduce Risk of Organization-Acquired Infection Worklife Infection Prevention and Control

14. Steps to Insure Patient Safety • Develop and Support the principles of patient safety. • Identify key individuals to be involved- key stakeholders. • Identify activities/action steps to develop and implement your patient safety program. • Make ongoing improvements to patient safety.

15. ROP RequiredOrganizationPractice The practice that is expected to enhance Patient Safety and Minimize Risk.

16. ROP RequiredOrganizationPractice An essential practice that organizations must have in place to enhance Patient / Client Safety and Minimize Risk.

18. Patient Safety Area Communication: Client Verification: Implement a client verification protocol for all services and procedures.

19. Communication Patient Safety

20. Patient Safety Area Communication Medication Reconciliation: Reconcile the client’s medications upon admission to the organization (including the emergency department or patient units) Control of Concentrated Electrolytes: Remove concentrated electrolytes from client service areas

21. Patient Safety Area Communication Medication Reconciliation: Reconcile the client’s medications to preventAdverse Drug Reactions.

22. Patient Safety Area Communication Safe Surgical Practices: Develop a process and written protocol for preventing wrong-site, wrong –procedure and wrong-person strategy.

23. Patient Safety Area Worklife Training on Patient Safety: Deliver training and education on patient safety at least annually to senior leaders, staff, service providers and volunteers. e.g. Good system of Fire Drill.

24. Patient Safety Area Actions in case of Fire (RACE) • Rescue persons in immediate danger • Activate the alarm call • Contain the fire • Extinguish if safe and possible or • Evacuate the place

25. Patient Safety Area Hand Hygiene Provide easy access and resources for staff to comply with recommended hand hygiene guidelines.

26. Hand Hygiene: provide easy access and resources for staff to comply with recommended hand hygiene guidelines. Patient Safety Area

27. Patient Safety Area Infection Control Injection Safety: develop safe injection protocols and practices in order to prevent harm to clients, health care workers and community. Antibiotic Prophylaxis during surgery: Administer prophylactic antibiotics to prevent surgical site infections.

28. The Accreditation Canada Qmentum Program ROPs

29. Some reasons Why Errors Occur • System Factors • Complexity of health care processes. • Complexity of health care work environments. • Lack of consistent administration practices. • Deferred maintenance. • Clumsy technology. • Human factors • Limited knowledge. • Poor application of knowledge. • Fatigue • Sub-optimal teamwork. • Attention distraction. • Inadequate training. • Reliance on memory. • Poor handwriting.

30. “Exercise” Patient Safety terms 1.Adverse Event 2.Medical Error 3.Sentinel Event 4.Near miss 5.Retrospective analysis 6. Prospective Analysis Identify risks and processes before they happen. Bad outcome from care. Major and enduring loss of function. An examination of past events. Deficient process of care. Could have resulted in loss, injury or illness but did not.

31. Quality Improvement Plan

32. The PDCA

33. O V R Occurrence Variance Report

34. OVR What is OVR? • It is a process for reporting errors, deviations and improper actions. When there is deviation from standards of care and safety. • Sentinel Events: death of the patient or loss of organ or function, • Near Miss: incident about to happen , but by chance it didn’t occur • Major incidents : revisable damage or risk for permanent loss

35. Reporting and Critical Test Notification: • The Lab will call the assigned person to notify certain critical tests • The nurse/Physician receiving the result must inform the attending physician /team leader immediately. • Patient call for action

36. Patient fall: what are you going to do? • Put the patient back on bed/chair • Check his vital signs and quick assessment • Inform the physician • Write an OVR

37. Patient suffering pain : What do you do: • Do Pain assessment • Use pain scale and document the grade • Inform the physician • Follow instruction and monitor pain intensity

38. CONCLUSION • The Reduction of unsafe acts within the health care system. • Good system of Communication • Quality Improvement Plan • Occurrence Variance Report “OVR”

39. THANK YOU