Continuous Quality Improvement Program

Hanif Medical Complex (Pvt.) Ltd.

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CQI PLAN- MSDS Implementation in HMC

1.1 Responsibility of Management (ROM) *Implementation of the indicators;

Issues Functional area wise Activities Duration Responsibilities

1. Regarding hospital identity,
easily accessibility & staff identity
2. Defining Responsibility of
Management
3. Hospital premises support the
scope of services and its adequate *Provision of different items for One week Admin Manager
maintenance hospital & staff
*Preparation of JDs for hospital staff
One week Admin Manager/ HR
* documentation for monitoring of
MS/Administrator
hospital performance
One week
*Need assessment to health
requirements of the community MS/Administrator
*Minimum Hospital space One week
requirements, civic amenities &
adequate arrangement for the privacy MS/Administrator/Admin
of the patients manager
Two weeks

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 1.2 Facility Management and Safety (FMS)

Issues Activities Duration Responsibilities

1. Awareness and Compliance with
the Relevant Rules and Regulations,
Laws and By –Laws and Facility
Inspection Requirements Under the Provision of copies of Relevant Rules Two weeks MS/Administrator/Admin
Relevant Building and Associated and Regulations and regular updating of manager
Codes Applicable to Hospitals licenses/registration
2. Program for Management of /certifications
Clinical and Support Service
Equipment

Preparation of Inventory of all medical

MS/Administrator/Admin
equipment, installation/testing report,
manager
planed preventive maintenance, log
books, formal write off process training Two weeks
of the saff for operation and
maintenance of equipment with
maintenance plan
3. Plans for fire and Non-Fire
Emergencies within The Facilities Development of documented SOPs and
Polices for early detection, containment
and abatement of fire and Non-Fire
Emergencies, training of the staff and
simulation exercise

MS/Administrator/Admin
manager

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 Two weeks

1.3 Human resource Management (HRM)

Issues Activities Duration Responsibilities

1.Orientation of the hospital
employees to their respective
section, their individual jobs and
performance appraisal system Written Orientation guides/manual to Two weeks Admin/HR Manager
cover overall scope of services of the
hospital, fire and general safety,
infection control and quality assurance,

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 information about the assigned
department, employee ‘s right and
responsibility and patient’s rights and
responsibility, JDs for the employees
and their documented performance
appraisal system

Personnel file for each employee

2.Personnel record for each containing all information and a
employee and process for collecting, documented process to verify the
verifying and evaluating the validity and accuracy of the
credentials of medical professionals credentials of medical professionals
including doctors and nurses including doctors and nurses

Two weeks Admin/HR Manager

1.4 Information Management System (IMS)

Issues Activities Duration Responsibilities

1.Complete and accurate medical
record for each patient

Use of unique identifier for the MS/Head of

medical record (indoor as well out department/Mo/Nursing
door) In charge
Development of SOPs for staff

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 authorization to make entries in Two weeks
medical record
Training of the staff that entries are
dated, timed and signed and
documentation of information
regarding provisional diagnosis,
treatment plan, informed consent,
care provided and copy discharge/
referral slip
Development of process review of
2.Review of Medical records medical record.
Notification of the professionals to
conduct review.
Preparation of minutes documenting
findings of the review, including
deficiencies and corrective
action/preventive measures

Two weeks Review committee/MS

1.5 Continuous quality improvement (CQI)

Issues Activities Duration Responsibilities

1. Structured Quality Improvement
and Continuous Monitoring
Programme in the hospital

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 Development of written CQI plan
Notification of the Committee
comprising from the relevant sections
TORs of the Committee CQI Committee/
4 weeks Coordinator
Responsibilities and authorities of the CQI
Committee
CQI methodology according to CQI Plan
Structure for reporting CQI Results
Recording of the minutes of the
Committee Meetings
Awareness/Training of all appropriate
staff with documented evidence

Development of key indicators

regarding; 1.Appropriate patient
assessment
2. Identification of Key Indicators to
Monitor the Clinical Structures, 2.Safety and quality control plans of the
Processes and Outcomes Which are diagnostic services
used as tool for Continual 3.Adverse occurrences in all invasive
Improvement procedures
4.Adverse drug events CQI Committee/
4 weeks Coordinator
5. Adverse occurrences and adequate CQI
follow up from the anesthetic services.
6. Adverse occurrences and adequate
follow up from the blood services.

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 Written definition of sentinel events and
documented process of monitoring
reviewing, responding to and mitigate
with analysis including corrective action
to prevent or reduce the likelihood of
reoccurrences.

3. Defining of sentinel events and

intensive analysis when they occur

4 weeks
CQI Committee/
Coordinator
CQI

1.6 Access, Assessment and continuity of care (AAC)

Issues Activities Duration Responsibilities

1.Services are provided as
portrayed and well established
patient management system
1.Board displaying the menu of services
MS/MO/Admin manager

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 2. Written SOPs on well- established Two weeks
registration, guidance process and well-
established patient assessment processs
2.Provision of Laboratory services
as per patient requirements
1.Development of documented SOPs
and Policies lab services
3. Provision of Imaging Services as
2. Training of the staff on these SOPs HOD pathology/ lab
per the clinical requirements of the
patients 1.Development of documented SOPs Two weeks services in charge
and Policies imaging services
2. Training of the staff on these SOPs

HOD radiology

Two weeks

1.7 Care of Patients (COP)

Issues Activities Duration Responsibilities

1.Emergency Services Polices,
Procedures and Applicable Laws/
Regulations.
Development of documented
2.Policies/Procedures for rational

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 Use of Blood and Blood Products SOPs/Polices and Training of the staff
3. Polices and Procedures for Care of Development of documented 3 weeks HOD/MO
High Risk Obstetrical Patients SOPs/Polices and Training of the staff
4. Polices and Procedures for The Development of documented
Administration of Anesthesia SOPs/Polices and Training of the staff
3 weeks BTO/ MO
5. Polices and Procedures for Care of Development of documented
Patients Undergoing Surgical SOPs/Polices/formats and Training of
Procedures the staff
Development of documented
SOPs/Polices/formats and Training of 3 weeks Gynecologist/ Lady MO
the staff

Anesthetist / MO trained in
3 weeks Anesthesia

3 weeks HOD/Surgeon

1.8 Management of Medication (MOM)

Issues Activities Duration Responsibilities

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 1.Polices and Procedures for the
Prescription of Medications
Development of documented SOPs/ 3 weeks
HOD/Pharmacist/MO
2. Polices and Procedures for the Polices /formats and Training of the
safe storage and dispensing of staff
Medication
3. Defined Procedures for Medication
Development of documented SOPs/
Administration
Polices /formats and Training of the 3 weeks Pharmacist/MO
staff
Development of documented SOPs/
Polices /formats and Training of the
staff MS/ Nursing In charge
3 weeks

1.9 Patient Right and Education (PRE)

Issues Activities Duration Responsibilities

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 1. Documented Process for Obtaining
Patient and/or Family Consent for
Informed Decision making about their
Care. Development of documented SOPs/ 3 weeks
MS/MO/ Nursing In
Polices /formats and Training of the
2. Patient and Families have a Right charge
staff
to Information on Expected Costs

Development of documented SOPs/

3. Patient Rights for Appeals and
Polices /formats/Charges list and
Complaints
Training of the staff MS/ finance manager/
3 weeks
Development of documented SOPs/
Nursing In charge
Polices /formats and Training of the
staff

MS/ Admin & HR

3 weeks managers

1.10 Hospital Infection Control (HIC)

Issues Activities Duration Responsibilities

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 1.Comprehensive and Coordinated
Infection Control Programme Aimed
at Reducing/Eliminating Risks to
Patients Visitors and Providers of *Notification of the Infection Control
Care Committee, Team and Nurse
3 weeks
*development of infection control plan
Infection Control
* provision of consumables, waste Committee, Team and
management system and facilities for Nurse/MS
control of infection
* Training of staff

*Adequate space for Sterilization

2. Documented Procedures for Activities, defining process/procedure
Sterilization Activities in the Hospital to validate for complete
Sterilization/formats
* Sop/ procedure for recall in case break
down in Sterilization system
Infection Control
Committee/MS/ OT IN
3 weeks Charge

CQI Committee:

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An apical committee is notified having representation from all the departments of the hospital which shall be responsible for
developing and implementing the CQI program for the hospital.
Following are the members of the CQI Committee:
1. …………………..member of the Board of Management ABC Hospital XYZ
2. …………………..MS ABC Hospital XYZ
3. …………………..AMS ABC Hospital XYZ (also the CQI coordinator)
4. …………………..DMS(Admin) ABC Hospital XYZ
5. …………………..DMS(Clinical) ABC Hospital XYZ
6. ………………….. Head of the Surgery department ABC Hospital XYZ
7. ………………….. Head of the ER & OPD ABC Hospital XYZ
8. ………………….. Head of the Lab & Imaging department & Blood Transfusion ABC Hospital XYZ
9. ………………….. Head of the Anesthesia department ABC Hospital XYZ
10. ………………….. Head of the Medicine department ABC Hospital XYZ
11. ………………….. Hospital Pharmacist ABC Hospital XYZ
12. ………………….. Hospital Infection Control Nurse
13. ………………………………………

Terms of Reference of the CQI Committee:

 The CQI Committee will implement comprehensive CQI program with in the stipulated time.
 Developing an understanding of the hospital staff regarding CQI and its methodology
 The CQI Committee shall meet once in the month and also when required to discuss the progress of the CQI program,
monitor the performance various departments against the Key Performance Indicators and suggest necessary actions.
 Reporting to HCE Management/ Medical staff monthly, or as appropriate.
 Coordinating activities with PHC as and when required.

Responsibilities of the CQI Committee

 Prioritizing issues referred to CQI Committee.
 Assuring that the review functions out lined in the plan are completed.
 Assuring that data out obtained through QI activities are analyzed, recommendations made and problem resolution is
appropriately followed.

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  Reporting the ongoing findings, studies, recommendations and trends, quarterly and annually to the Board of
Management/Directors
 Identifying continued professional development /educational needs and assuring that staff education for quality
improvement takes place.
 Periodic review and modification of the CQI program.
 ……………………………………………………………………..
 …………………………………………………………………….

Authorities of the CQI Committee:

Apart from the authorities of the CQI members by virtue of their respective positions as Heads of various departments and
sections, the Committee shall have following authorities:

 Appointment of sub committees or teams to work on specific issues, as necessary

 Assuring that the necessary resources are available
 Making recommendations to the Board of Management for necessary actions for the implementation of CQI
 Calling meetings of the committee or Hospital Management as and when required
 Introducing new systems and formats in various departments for the QA and QI
 Taking necessary steps to assure patient safety and the security of the hospital staff.
 Assuring that necessary resources are available.
Job Description of the CQI Coordinator:

 He will work collaboratively with CEO/MS committee members and departments to coordinate and facilitate the activities
of the CQI program throughout the Hospital.
 Recording the minutes of meetings and circulation of these minutes.
 Responsible for identifying quality indicators, collecting and analyzing data developing and implementing changes to
improve service delivery, and monitoring to assure that improvement is made and sustained.
 Ensuring an active communication between the hospital staff and the CQI Committee and the committee and the
management
 Liaison with external regulatory bodies like PHC.

Methodology:

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There are several definitions of Quality around the world and still several methods in use to maintain and improve it continuously.
A simple approach is to watch for one’s mistakes and deficiencies, learn from them and improve upon them. The CQI methodology
of ABC Hospital XYZ focuses on measuring the performance of various departments, reporting the quality issues and errors, and
analyzing them in order to come up with a strategy for preventive measures. It reflects the universal cycle for quality
improvement in terms of planning, doing, learning and re-planning.
The committee for CQI having representation from all the departments of the hospital and more than that the Heads of the
departments, and also from the top management shall ensure data collection from all the departments and sections of the
hospital as they deem necessary against the key performance indicators they would have agreed upon. These data and thence the
analyses will be presented to the committee in the monthly meeting. The committee will compare this data in their first
monitoring meeting against the baseline prepared prior to the regular data collection and then with the report of the previous
month. Any sentinel event or any other issue relating to the safety and well-being of the patients and staff of the hospital will
also be reported to the committee in these meetings or even before meetings according to the nature of the issue or incidence.
The committee will discuss the reports and will take decisions required to minimize the deficiencies and improve the quality. The
committee will appoint individuals or sub committees to be responsible for execution of these decisions and set time frames for
the action. The committee may also notify any such support that may be required for the purpose. The committee will follow up
these decisions in the subsequent meeting or prior to this if necessary.

Reporting Structure:
Any staff member who comes to know a quality issue or any such matter that relates with the quality of the healthcare provision
or safety of the patients or staff will immediately report it to the CQI Coordinator. The CQI coordinator may report it to the
relevant department Head or can call CQI meeting depending upon the nature of the issue.
The sub committees and the teams appointed by the CQI committee for specific assignments will report to the committee
according to the nature of the assignment.
Report of each department will be presented to the committee in regular meetings to be discussed and decided upon.
The CQI committee member who is also the representative of the Board of Management will keep the Board abreast of the
committee performance and decisions.

MINUTES of CQI COMMITTEE FOR QUARTER/MONTH– MEETING HELD ON 30 January 2017

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Attendance
MR XYX - Chair
All Committee members
CQI Coordinator will inform the decisions as recorded and put up the implement status in the next meeting on ------------
2017.

Monitoring of Appropriate Patient Assessment

Sr # Issues Activities outcome Remarks of the CQI Committee
1.
a. Time of initial
assessment of indoor
patients
(Time of initial assessment A sample of medical e.g 85 % of the This percentage is not
of indoor patients is 30 record was taken and sample taken for acceptable. All the HOD’s are
minutes) time for initial indoor patients were directed to look into the matter
assessment by ward assessed within the and find out the reasons why all
mo was take from prescribed time for the patients were not seen by
the record. assessment the MO within the prescribed
time. CQI Coordinator to get the
feed back and put up in the next
the CQI
Committee Meeting

b.Time of initial
assessment of emergency

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 patients
c. Percentage of patient
care plan is documented
and signed by clinician
d. Percentage of cases
where in the nursing care
plan is documented.

2 Monitoring of safety and

quality plans of Diagnostic
services
a. Implementation of
SOPs regarding quality
and safety plan of i. Activities regarding
adherence to safety
diagnostic services precautions by
Percentage of adherence
employees working in to safety precautions by
diagnostics. employees working in
ii.Total no of re-dos diagnostics.
iii.Documented
Percentage of re-dos.
occupational health and
safety protocols
iii.Reports on calibration
of diagnostic equipment
Data from the
respective
department
3 Monitoring includes all invasive Total no invasive Reporting of all adverse
procedures procedures occurrences such as
return to operating room
within 24 hours and

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 readmission within 24
hours if related invasive
procedures
5 Monitoring includes Adverse Total no of adverse Briefly description
Drug Events
drug reactions of Management of
No of allergic these events
reactions
No events of wrong
dose, wrong drug
and wrong patient

6 Monitoring includes use of Total no patients Adequate follow up

anesthesia from anesthetic services
having all types
anesthesia. Percentage
of modification of
anesthesia plan
Percentage of unplanned
ventilation following
anesthesia
Percentage of adverse
anesthesia events
Anesthesia-related
mortality rate.

7 Monitoring includes use of Percentage of Adequate follow up from

blood and blood products transfusion reactions. blood services
Percentage of wastage

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 of blood and blood
products.
Percentage of blood
component usage.
Turnaround time for
issue of blood and blood
components.

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