Purpose
To have all quality improvement activities under a standardize umbrella and structure described by the total quality management system (tqm).
Plan
Rms will implement the total quality management system (tqm) and quality methodology (focus-pdca).
Approval
The chairman of central quality improvement committee
Reference
Jordan health care accreditation commission (jhac) standards for hospitals (phrplus),
Quality improvement and patient safety cluster.
Our vision
Presidency in providing complete excellent medical service copes with the global medical advancement
Our mission
Provide excellent and safe medical service which is characterized by high quality and acceptable cost, with commitment toward development, continuous improvement, and best utility of available resources through qualified and competent medical caliber and modern technological tools and equipment aim at ensuring an effective contribution in increasing the level of medical care in jordan.
Our values
Our values stem from the focus and commitments that we have outlined in the mission and vision for rms. As such, developing an agreed upon set of organizational values is a vital step in the continued evolution of our organization. These values will guide our activity- across all facets of the organization. In addition, they serve as the core components of the performance management system against which all rms employees will be regularly evaluated.
The set of values that follows will need to be tested and refined with the input of an interdisciplinary group of employees. Work will also need to be done to articulate what each value means to rms, what behaviors are required to be done to demonstrate proficiency and how each value will be incorporated into the ongoing performance management activities of the hospital.
Rms values
- Excellence: we depend on exceptional people to provide exceptional quality health care and services. We set high standards and we support each other as we strive to achieve them. Committed to building a reputation for leading the way as a health care provider through quality of care and service
Integrity: we conduct business with the highest standards of ethics, developing a mutual trust with each other, customers, shareholders, suppliers and the community. Integrity is the foundation of everything we do.
- Innovation: we embrace change, creativity, continuous learning and personal growth. We incorporate new ideas, technology and methods to improve the health care and services we provide. We anticipate future trends and we create strategic plans to insure future growth and continued vitality.
- Compassion: to serve, with dignity and respect, those who come to us
- Teamwork : we work as a team to achieve the strategic goals of the organization. Each staff member's contribution to creating a flexible, trusting, caring and supportive team environment is valued. We build constructive relationships to achieve positive outcomes for all. It is our responsibility to recognize the value of others and contribute to the success of the team and that of the hospital.
- Respect: we respect and respond to all individuals with honesty and integrity.
- Quality: our goal is to be the recognized leader in our marketplace; recognized for innovation, quality, responsiveness and value. We continuously strive to be the standard by which performance is measured.
- Continuous improvement: excellence in customer satisfaction entails continually searching for and identifying ways in which the organization can achieve higher standards of customer service by improving efficiency, effectiveness, and timeliness.
Performance improvement
In keeping with this mission and vision of rms, performance improvement means involving patients, families, employees and the community in determining ways to improve the quality of clients' health care services and related processes, it means measuring our performance by comparing ourselves to other equivalent hospitals and to our own progress over time. It means interdisciplinary problem-solving and using a systematic approach to improvement across the hospital. The result will improve patient health care services, patients satisfaction and cost reduction.
Performance improvement
- Is the science of managing processes. Two principles are central. They are eliminating inappropriate variation (usually in care process steps) and documenting continuous improvement (usually in outcomes).
- Creates a positive atmosphere within which to measure, study and improve health care processes and helps to redirect energy from finding fault to finding solutions.
Performance improvement monitoring quality indicators
Performance improvement monitoring involves observing, measuring, and recording the way activities are being implemented.
Monitoring should be:
- Planned, systematic and ongoing.
- Comprehensive
- Use indicators accepted to the staff and the hospital.
- Result in appropriate action
- Compare periodically with pre-set. Goals or standards
Performance improvement methodology
Focus: plan -do -check -act (pdca)
The rms method of performance improvement is called focus- pdca (plan-do check-act). The following explains briefly how this approach works.
F = find an opportunity for improvement.
- Select the process of interest
- Define preliminary process boundaries
- Decide if the selected process is the best one to improve.
O = organize a team
- Identify the team leader/ process owner.
- Assign a facilitator/ coach who will guide the team.
- Select team members from appropriate levels of the organization.
C = clarify the current process
- Flow chart the process.
- Make simple improvements to define the current best process.
- Identify suppliers and customers.
U = understand the sources of the problem and the process variation
- Investigate special causes and seek to stabilize the process.
S = select the improvement (a change)
- Identify improvement alternatives that will contribute the most to improving the process.
- Reduce common cause variation.
P = plan the improvement
- Plan how the improvement identified in the "s" phase can be made.
- An action plan is used to describe proposed improvement efforts.
D = do the improvement
- Implement the plan.
- Describe what was used to implement the plan.
- Collect data.
C = check the results (is the change an improvement?)
- Analyze data to evaluate the improvement.
- Compare data with process capability and baseline data.
A = act to hold the gain
- What steps will be taken next?
- The pdca cycle can repeat again and again, attempting to refine the improvement with each pass.
All performance improvement attempts are learning experiences. The pdca process is a cycle that enables systematic improvement to be continuously built upon. This assists in meeting the ever changing needs and expectations of our patients and employees
Rms plan for performance improvement
Continuous quality improvement in a health care organization is a bold aim and a challenging objective, success requires commitment from all in the organization.
A commitment learn new skills, a willingness to measure performance, an attitude that encourages collaboration with colleagues and a determination to learn how to deal with change. All change is not improvement but all improvement involves change.
- Strong organizational focuses on performance improvement which means center-wide understanding of the principles and methodology of performance improvement. This is accomplished through the establishment of the central quality improvement committee and ongoing educational programs.
- A consistent methodology for performance improvement
Focus-pdca (plan, do, check, act) is the methodology used at rms.
- Systems for measuring performance improvement:
- Outcome tracking measure. They can be clinical or management.
- Internal and external benchmarking. These are ways to identify best practices, compare our selves to other similar centers and measure our own performance over time.
- Teaching programs for employees at all levels which may include the following contents:
- A performance improvement methodology (focus-pdca)
- Communication skills
- Supportive management
- Team effectiveness & conflict management
- Data management in pi
- Leadership and management
- Setting and communicating standards
- Customer service.
- Managing change.
- Accreditation and surveying.
- The training of skilled team facilitators.
- Employee evaluation and reward systems that encourage performance improvement.
Strategic plan
Refer to the rms strategic plan which consists of major change opportunities that will be faced. Strategic objectives are generally external in nature, relating to significant community need, significant market need, or technological opportunities and challenges.Broadly stated, they are what rms must change or improve, and what guides resource allocations and redistributions.
Strategic plan objectives
Strategic plan objectives are attained by a process of setting strategic directions and determining key action plan, and for translating plans, which translate into an effective organizational performance management system. The process leads to the establishment of general goals and objectives, including outcome related goals and objectives, for the major functions and operations, and for the establishment of annual performance goals linked to the general overall goals and objectives.
Rms strategic goal
The following have been selected and approved by the rms as the strategic goals:
- Provide high quality care services
- Obtain maximum customer satisfaction
- Attain safe and healthy environment
- Participate with other health care organizations to create healthy communities
- Be governed and managed effectively
- Maintain continuous quality improvement
- Provide safe & efficient training programs
Objectives
- Educate the leaders and selected staff members on quality management concepts.
- Implement the quality and risk management activities.
- Communicate the results of all organizational improvement efforts to all staff.
- Standardize reporting methods to assist with analysis of performance data
- Increase data based decision-making.
- Use team methods to improve care related processes.
- Use performance improvement methods as a strategy to manage cost
Quality improvement department
The quality improvement department is is responsible for leading all activities related to defining, measuring and continuously improvement the quality and hospital -wide performance.
The quality improvement department reported directly to the ceo.
Definitions
Rms adopts and approve the following definitions.
- Quality
Is the process through which we measure actual performance, compare it with standards, and act on deference to meet client's needs and expectations in a safe environment .
- Accreditation:
A process in which an entity, separate from the hospital assess the hospital to determine if it meet a set of standards.
- Performance improvement:
Performance refers to outcome results obtained form processes, and services that permit evaluation and comparison relative to goals, past results or other organizations. Performance improvement: measures are based on functions, processes, and outcomes. These measurements provide a statistical basis for monitoring performance improvement".
- Outcome indicator:
Measure patient outcomes such as:
- Mortality rate.
- Infection rate.
- Customers' satisfaction.
- Process indicators:
Measure the system in place for doing certain things such as:
- Waiting time
- Length of stay
- Turn around times
- Medication errors.
- Sentinel event indicators:
Are the events which require an immediate response from the hospital with root cause analysis and recommendations to prevent future occurrences.
Dimensions of performance improvement
The degrees to which the care and services provide are relevant to the patient's clinical needs, given the current state of knowledge.
Continuity of care
The coordination of needed healthcare services for a patient or specified population among all practitioners and across all involved or organizations over time.
Safety
The degree to which the risk of an intervention and risk in the care environment are reduced for patient and others includes healthcare providers.
Timeliness
The degree to which needed care and services are provided to the patient at the most beneficial or necessary time.
Effectiveness
The degree to which a desired outcome is reached, the positive results of care delivery.
Efficiency
The relationship between outcomes and resources used to deliver patient care and services.
Patient-focus
The degree to which those providing care and services do, so with sensitivity and respect for patient's needs, expectations and individual differences.
Quality management structure and information flow
Appendix (3) show a schematic representation of the flow of information and functional structures that support performance improvement at rms. This is not an organizational structure but depicts how information flows between the central quality improvement committee, hospital's directors, quality improvement teams, and the quality improvement division.
Central quality improvement committee (cqic)
The rms chief executive officer (ceo) assigns responsibility for implementation of performance improvement and central quality improvement committee (cqic)to determine methods, measurements, project's priorities, goals and reporting guideline to ensure compliance with quality improvement objectives, the (cqic) will be comprised of representatives from administration, medical staff, nursing, quality improvement division, and other departments. The ceo shall serve as a chair person for
(cqic).
The roles and responsibilities for (cqic) are:
- To determine the hospitals definition of quality and insure that all staff and customers are aware of the definition.
- To adopt a quality approach at rms
- To approve the hospital strategic plan
- To discuss all quality improvement issues at rms
- To prioritize work at the beginning of the year and determine what the committee will focus on in its annual work plan
- To approve an annual work plan (action plan) that address quality improvement needs
- To assign responsibility to individuals to make the needed changes.
- To approve standards that adopted from accreditation committee
- To conduct, review results, and take action in response to patient, medical and other
- To conduct, review results, and take action in hospital satisfaction surveys,
- To promote/create a climate of quality in the hospitals through different means.
- Reporting information both upward to leaders and downward to staff members.