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Leadership & Quality chapters

ملتقى الجودة وسلامة المرضى
موضوع مغلق
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قديم 04-07-2011, 01:50 AM
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تحسين الآداء will become famous soon enough


Øمجلس الجودة بالمنطقة الشرقيه
ØOur Mission
رسالتنا هي تثقيف ومساعدة المستشفيات على فهم معايير الجودة وتطبيقها
ØStandards Are:
􀂾 Optimal and achievable
􀂾 Designed to encourage continuous improvement efforts within accredited organizations
ØLeadership and TQM Team
Ø

Øدور القيادة في تحسين جودة الرعاية الصحية في المستشفيات
Ø أدوار القيادة في التمهيد لتطبيق المعايير
هي عملية التخطيط
والتنظيم
والتوجيه
والمراقبة
والتنسيق
لجهود الآخرين المشتركة من أجل تحقيق
أهداف معينة.
Øخطوات إستراتيجية التغيير
Øكيف نبدأ؟
Øit is sometimes appropriate to start at " check-act-plan-do" cycle . the Quality system documentation process would then follow the following sequence
Ø الوضع الراهن
ARE PROCESSES Well DOCUMENTED ?
هل توجد هيكلة تنظيمية للمستشفى
هل توجد سياسات وإجراءات موثقة
هل توجد ايضاحات وظيفية لكل موظف
هل توجد خطة خاصة بالطوارئ
هل توجد خطة استراتيجية للمستشفى
Ø
ØStrategic planning is an organization wide/systemwide, ongoing look into the future ( usually 2-3 years ) , based on objective analysis of the current environment and trends , but it can incorporate both short-term and long-term goals , particularly in redesign mode .
Ø
Øخطوات التخطيط الاستراتيجي
Øالتخطيط الاستراتيجي للجودة
ØStrategies of …..hospital
ØEstablish Total Quality Management program through obtaining (CBAHI) accreditation which will enhance:
Ø Establishment of functional requirements Establishment of documentation requirements
Ø Creating a culture of continuous process improvement
Ø Conduct continuous utilization reviews and studies in clinical and non clinical operations in order to optimize utilization of resources and reduce abuse and or under utilization.
ØConduct more staff development activities
ØWork with higher authorities towards further cooperation and collaboration with various public and private facilities.
ØConduct marketing activities for the business center (Saudi Medical Consultant Center-SMCC).
Ø
ØOrganizational Mission Statement
ØMeasurable, definable, actionable
ØConsistent with values
ØDifferentiates organization
ØCompatible with strategic idea
ØNot too restrictive
ØNot contain untested ideas (become an IDS?)
ØReflect positive history
ØCall individuals to action
Ø
ØHGH Mission Statement
ØTo support the Ministry of Health mission by providing outstanding secondary healthcare services for the community of Makkah and the pilgrims [and visitors] of the Holy Mosque with full utilization of available resources in the highest standards of care services.
Ø To support the academic and postgraduate programs in different health care aspects.
Ø
ØVision Answers
ØWhy & for what should the organization exist?
ØIn what ways should it be different?
ØWhat should it become?
ØHow should it stay the same?
ØWhat must it do to meet the needs of key stake holders?
ØWho should it serve? Avoid?
Ø
ØHGHVisionStatement
ØTo be an outstanding and model facility among the Ministry of Health hospitals in the Kingdom in terms of achieving international standards through a skillful workforce and to excel in the provision of healthcare services.
Ø
رؤية
Ø
Øنعمل لأن نكون المستشفى الرائد في مجال علاج امراض الاورام والسرطان على مستوى الشرق الاوسط
مستشفى
Øقيم المؤسسة : Values
Ø"أساسيات, اعتقادات, أو عبارات فلسفية, والتي تقود السلوك, والتي قد تتضمن اعتبارات اجتماعية أو أخلاقية.”
Ø“…any organization, in order to survive and achieve success, must have a sound set of beliefs on which it premises all of its policies and actions.” T. Watson, IBM
Ø
ØHGHValues'
ØPoliteness
ØTeamwork
ØCreativity
ØDo as you would others do to you
ØSelf-evaluation and development
Ø
Ø
Ø
Ø
DO WHAT
YOU SAY
ترجم الخطة الاستراتيجيةالى خطة تنفيذية
Ø
ØInternal policies & procedures (IPPs)
Defines activities at the departmental level and written by department supervisors.
Typical outline of a quality procedure
ØPurpose/objectives : aim of the procedure
ØScope: what the procedure does and does not cover
ØResponsibilities : who ( by job function) has responsibilities for specific tasks or actions
ØReference : to all documents covered under the procedure
ØDefinition : of key terms or acronyms
ØProcedures : de******ion of the actions or tasks to be carried out , by whom , and in what sequence
ØDocumentation : what documentation and records are needed
ØLeadership and TQM Team
Ø مفهوم الجودة ؟
Ø
ØStructure Indicator relates to the integrity of the facility, the condition of the equipment, and the quality of the supplies e.g. : preventive maintenance checks shall be completed on all of the hospital equipment at 6 monthly intervals.
Ø
ØProcess Indicator relates to how care is delivered and includes such variables as
staffing, patterns, implementation of policies and procedures, and medical
techniques. e.g. : there should be no patient complaints concerning any patient waiting in excess of 1 hour in any outpatient clinic.
Ø
ØOutcome Indicator relates to the condition of the patient following some type of hospital intervention. e.g. : there shall be no unscheduled re-admissions to the hospital within 30 days of discharge.
ØLeadership and TQM Team
Ø
ØThe hospital demonstrates respect for the following patient needs:
ØConfidentiality
ØSecurity
ØResolution of complaint
ØCommunication
Ø
Ø
ØEach patient receives a statement of his her rights and responsibility
ØAcknowledgement recommended
ØPosters
ØAttached to the general or admission consent
Ø
ØLeadership and TQM Team
ØASSESMENT & EVALUATION
Øthe patient psychosocial needs.
Øsocial needs of the patient
Øthe patients home situation
Øthe patients emotional and psychological factors
Ødischarge planning process
Ø
ØLeadership and TQM Team
ØMOIs
Øidentify the necessary data that will be used for decision-making
Ødetermines the roles and responsibilities for data entry (completion of forms), data collection, data analysis, and report generation
Øuses the information to make decisions, strategic plan, and identify and prioritize quality improvement projects.
Øconfidentiality of data and information
ØLeadership and TQM Team
ØMedical Records (MR)
ØMEDICAL RECORDS CONTENT ( THE PATIENT INFORMATION , HISTORY , DIAGNOSTIC AND THERAPUTIC ORDERS…….ETC)
ØAUTHORIZED STAFF MEMBERS
ØSTORAGE
ØHOW RECORDS ARE PROTECTED FROM LOSS
ØVERBAL TELEPHONE ORDERS
ØAVAILIAILITY ( TIME TURNOVER)
ØGap analysis
Ø
ØCBAHI requires that every applicable requirement of the standard be met and all procedure be adequately documented . this calls for a system –wide structure that links all activities effectively , ensuring a smooth flow of information throughout the hospital.
Ø(The process of Identifying missing process elements or undocumented procedures is called gap analysis).
ØCorrective Action
ØDevelops any necessary changes to existing process to close the gap and obtains approval from management
Ø Develops new documents or changes existing documents as necessary and obtains approval from management
ØAssist management in training of personnel and implementation of changes
ØVerifies effectiveness of any changes over time
ØWorking with a consultant
ØAsk for help in understanding how to implement CBAHI standard , don’t ask the consultant to do your job.
ØAsk questions to help clarify any misunderstanding you may have on any of the CBAHI standards that apply to you.
ØAsk for pointers on writing your job de******ion or documenting your processes
ØAsk for advice on how to conduct yourself during an audit.

شارك
مشاركة في فيسبوك مشاركة في تويترمشاركة في قوقل بلص


من مواضيعي : تحسين الآداء
موضوع مغلق

مواقع النشر (المفضلة)


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