SOP - CQI Policy and Plan

HANIF MEDICAL COMPLEX (PVT.) LTD.
STANDARD OPERATING PROCEDURE
SOP Title: Quality Improvement and Continuous Monitoring Programme

15 – 46 –
Department: OPD PHC STAND.: IND.:
17 58
Applies To: EMERGENCY ROOM AND OPD
Approved By: SOP No.: SOP/ADM/CQI/018/01
Issuance Date: 24 MARCH 2022
Prof. Dr. Jamal Revision Date: 30 SEPTEMBER 2023
Zafar: Superseded
Chief Executive Officer THIS IS THE FIRST VERSION
No.:
18 months issue
Valid Up To:
date
Muneeb Zafar: Prepared By: SALEEM KHAN
DIRECTOR OPERATIONS Total Page: 13
Saleem Khan Dr. M. Javad

Director Admin. & HR Q. A. Manager
Copy # Distribution Location Receive Date Signature
1. Chief Executive Office
2. Director Operations Office
3. Q. A Manager Office
4. Director Admin. & HR
5. Medical Officer
6. Nursing Counter Office
7. Emergency Room
8. Operation Theatre Room
9. Lab & Radiology Office
10. Document Control Office
General Information:
1. Guidelines can be processed, procedures, flowchart, steps to follow, instructions, patient education.
2. Guideline are applicable to HMC.
3. Guidelines needs to be revised at least every eighteen months and/or if anything changes. If a
Guideline is reviewed, but have no changes, it is indicated on the original cover page as "revised
guideline without changes (thus it has to re-signed again)”
4. Attachments (e.g. documents, flowcharts etc. can be added as is (i.e. not necessary to be on a
page with a header)
5. Indicate the total number of pages.
6. SOP Number: Obtain from Director Administration & HR
SOP | QI protocols and Procedure? Page 1 | 13

HANIF MEDICAL COMPLEX (PVT.) LTD. STANDARD OPERATING PROCEDURE

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Archive: Director Administration retains original signed copy. A “Copy for Information” could be
issued upon request as per distribution list in case of authorized copy damaged or lost.


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1. PURPOSE:
1.1. Purpose of this SOP to monitor and maintain patient safety and high-quality care at
affordable cost to deprived/middle class population.
2. SCOPE:
2.1. This SOP will be applicable in all functions and operational Departments of Hanif
Medical Complex (Pvt.) Ltd.
3. HEALTH, SAFETY AND ENVIRONMENTAL PROTECTION:

3.1. There are special risks or instructions, which need to be highlighted.
4. RESPONSIBILITY:
4.1. To develop agenda for all meetings
4.2. To assign responsibilities for committee members.
4.3. Present reports and recommendations to Board of Directors.
4.4. Coordinate meeting dates with
4.5. Oversee the development and approval of minutes.
4.6. To identify the problems in patient safety.
4.7. To create training opportunities for staff.
4.8. To measure and assess the performance of hospital services through collection and
analysis of data.
4.9. To conduct quality improvement initiatives by taking action where it indicated including:
4.9.1. Design of new services.
4.9.2. Improvement of existing services
5. TERMS AND DEFINITIONS:

5.1. MO Medical Officer
5.2. DFID Department for International Development
5.3. FGD Focus Group Discussion
5.4. IND Indicator
5.5. JCI Joint Commission International
5.6. MSDS Minimum Service Delivery Standards
5.7. PHC Punjab Healthcare Commission
5.8. PBTA Punjab Blood Transfusion Authority


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6. EQUIPMENT:
6.1. There is no equipment or tool involve for maintain and assess before using.
7. GENERAL INSTRUCTIONS & GUIDELINES:

7.1. A Hanif Medical Complex will extend two additional units with most respected
healthcare facility in Rawalpindi District by the end of year 2022.
7.2. The following Quality Improvement Plan serves as the foundation of the commitment
of HMC – Hanif Medical Complex to continuously improve the quality of the treatment
and services it provides.
7.3. QUALITY:
7.3.1. Quality services are services that are provided in a safe, effective, recipient-
cantered, timely and equitable manner.
7.3.2. HMC – Hanif Medical Complex is committed to the ongoing improvement of
the quality of care its Patients receive, as evidenced by the outcomes of that
care. The Hospital continuously strives to ensure that:
a. The treatment provided incorporates evidence based, effective practices;
b. The treatment and services are appropriate to each Patient’s needs, and
available when needed;
c. Risk to Patients, providers and others is minimized, and errors in the delivery of
services are prevented;
d. Patients’ individual needs and expectations are respected.
e. Patients have the opportunity to participate in decisions regarding their
treatment; and services are provided with sensitivity and caring;
f. Procedures, treatments and services are provided in a timely and efficient
manner, with appropriate coordination and continuity across all phases of care
and all providers of care.
7.4. QUALITY IMPROVEMENT PRINCIPLES
7.4.1. Quality improvement is a systematic approach to assessing services and
improving them on a priority basis. The Hospital approach to quality
improvement is based on the following principles:
a. Customer Focus. The Hospital focuses on its patients and on meeting or
exceeding needs and expectations.


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b. Recovery-oriented. Services are characterized by a commitment to promoting

and preserving wellness and to expanding choice. This approach promotes
maximum flexibility and choice to meet individually defined goals and to
permit Patient-centred services.
c. Employee Empowerment. Effective programs involve people at all levels in
the Hospital in improving quality.
d. Leadership Involvement. Strong leadership, direction and support of quality
improvement activities by the governing body/MD is key to performance
improvement. This involvement of organizational leadership assures that
quality improvement initiatives are consistent with provider mission and/or
strategic plan.
e. Data Informed Practice. Successful QI processes create feedback loops, using
data to inform practice and measure results. Fact-based decisions are likely to
be correct decisions.
f. Statistical Tools. For continuous improvement of care, tools and methods are
needed that foster knowledge and understanding. CQI organizations use a
defined set of analytic tools to turn data into information.
g. Prevention Over Correction. Continuous Quality Improvement entities seek to
design good processes to achieve excellent outcomes rather than fix processes
after the fact.
h. Continuous Improvement. Processes must be continually reviewed and
improved. Small incremental changes do make an impact, and providers can
almost always find an opportunity to make things better.
7.5. CONTINUOUS QUALITY IMPROVEMENT ACTIVITIES.
7.5.1. Quality improvement activities emerge from a systematic and organized framework
for improvement. This framework, adopted by the hospital leadership, is
understood, accepted and utilized throughout the organization, as a result of
continuous education and involvement of staff at all levels in performance
improvement. Quality Improvement involves two primary activities:
a. Measuring and assessing the performance of hospital services through the
collection and analysis of data.
b. Conducting quality improvement initiatives and taking action where indicated,
including the
i. design of new services, and/or
ii. Improvement of existing services.


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7.6. LEADERSHIP AND ORGANIZATION

7.6.1. The key to the success of the Continuous Quality Improvement process is
leadership. The following describes how the Management of HMC Hospital
provides support to quality improvement activities.
7.6.2. The Quality Improvement Committee provides ongoing operational leadership

of continuous quality improvement activities at the Hospital. It meets at least
twice monthly (1st and 3rd Tuesday) and consists of the following individuals:
1. Prof. Dr. Jamal Zafar CEO & Chairman
2. Dr. Saeed Alam Lab. Director
3. Dr. M. Javad Quality Assurance Manager
4. Mr. Muneeb Zafar Director Operations
5. Mr. Saleem Khan Director Administration & HR
6. Dr. Anam Shahid Pharmacy Head
7. Mrs. Attia Paul CQI Coordinator – Clinical/Technical
8. Mr. Talha Bin Talib Lab. Manager
9. Mr. Kamran Ahmed Admin. Officer
10. Mr. Afreen Sahib OTA
11. Mr. Zia ul Islam CQI Coordinator – System
7.7. Term of Reference
7.7.1. To improve quality of patient care and allied services.
7.7.2. To monitor the preparation of SOPs/SMPs (MSDS)
7.7.3. To implement the SOPs/SMPs (MSDS) in the hospital.
7.7.4. To prioritize overall the issues presented in the QIC meeting.
7.7.5. To monitor overall quality of services (patient safety indicators).
7.7.6. To review and discuss complaints received from the patients and suggest
corrective action.
7.7.7. To improve the accuracy of patient’s identification.
7.7.8. To improve the effectiveness of communication among doctors/staff and
patients.
7.7.9. To improve safety of medical devices.
7.7.10. To train staff.
7.7.11. To reduce the risk of hospital incidents.


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7.8. THE RESPONSIBILITIES OF THE COMMITTEE INCLUDE :

7.8.1. Developing and approving the Quality Improvement Plan.
7.8.2. As part of the Plan, establishing measurable objectives based upon priorities
identified through the use of established criteria for improving the quality and
safety of Hospital services.
7.8.3. Developing indicators of quality on a priority basis.
7.8.4. Periodically assessing information based on the indicators, taking action as
evidenced through quality improvement initiatives to solve problems and
pursue opportunities to improve quality.
7.8.5. Establishing and supporting specific quality improvement initiatives.
7.8.6. Formally adopting a specific approach to Continuous Quality
Improvement (such as Plan-Do-Check-Act: PDCA).
7.8.7. The Management of HMC also provides leadership for the Quality
Improvement process as follows:
a. Supporting and guiding implementation of quality improvement activities at
the Hospital
b. Reviewing, evaluating and approving the Quality Improvement Plan annually.
7.9. GOALS AND OBJECTIVES :
a. The Quality Improvement Committee identifies and defines goals and specific
objectives to be accomplished each year. These goals include training of clinical
and administrative staff regarding both continuous quality improvement
principles and specific quality improvement initiative(s). Progress in meeting
these goals and objectives is an important part of the annual evaluation of
quality improvement activities.
7.10.THE FOLLOWING ARE THE ONGOING LONG TERM GOALS FOR THE QI PROGRAM:
a. To implement quantitative measurement to assess key processes or outcomes
b. To bring managers, doctors, and staff together to review quantitative data and
major clinical adverse occurrences to identify problems;
c. To carefully prioritize identified problems and set goals for their resolution;
d. To achieve measurable improvement in the highest priority areas
e. To provide education and training to managers, doctors, and staff
f. To develop or adopt necessary tools, such as patient surveys and quality
indicators.
7.11.PERFORMANCE MEASUREMENT
a. Performance Measurement is the process of regularly assessing the results
produced by the program. It involves identifying processes, systems and
outcomes that are integral to the performance of the service delivery system,
selecting indicators of these processes, systems and outcomes, and analyzing


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information related to these indicators on a regular basis. Continuous Quality

Improvement involves taking action as needed based on the results of the data
analysis and the opportunities for performance they identify.
7.12.THE PURPOSE OF MEASUREMENT AND ASSESSMENT IS TO:
a. Assess the stability of processes or outcomes to determine whether there is an
undesirable degree of variation or a failure to perform at an expected level.
b. Identify problems and opportunities to improve the performance of processes.
c. Assess the outcome of the care provided.
d. Assess whether a new or improved process meets performance expectations.
7.13.MEASUREMENT AND ASSESSMENT INVOLVES:
a. Selection of a process or outcome to be measured, on a priority basis.
b. Identification and/or development of performance indicators for the selected
process or outcome to be measured.
c. Aggregating data so that it is summarized and quantified to measure a process
or outcome.
d. Assessment of performance with regard to these indicators at planned and
regular intervals.
e. Taking action to address performance discrepancies when indicators indicate
that a process is not stable is not performing at an expected level or represents
an opportunity for quality improvement.
f. Reporting within the organization on findings, conclusions and actions taken as
a result of performance assessment.
7.14.SELECTION OF A PERFORMANCE INDICATOR
7.14.1. Performance indicator is a quantitative tool that provides information
about the performance of Hospital’s process, services, functions or
outcomes. Selection of a Performance Indicator is based on the
following considerations:
a. Relevance to mission - whether the indicator addresses the
population served
b. Clinical importance - whether it addresses a clinically important
process that is:
i. High volume
ii. Problem prone or
iii. High risk


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7.14.2. The Performance Indicator Selected for HMC Hospital Quality

Improvement Plan
7.14.3. For purposes of this plan, an indicator(s) comprises five key elements:
name, definition, data to be collected, the frequency of analysis or
assessment, and preliminary ideas for improvement.
7.14.4. Quality Improvement Initiative
7.14.5. Once the performance of a selected process has been measured,
assessed and analysed, the information gathered by the above
performance indicator(s) is used to identify a continuous quality
improvement initiative to be undertaken. The decision to undertake the
initiative is based upon clinic priorities. The purpose of an initiative is to
improve the performance of existing services or to design new ones. The
model utilized at HMC Hospital is called Plan-Do-Check-Act (PDCA).


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7.14.6. Plan - The first step involves identifying preliminary opportunities for
improvement. At this point the focus is to analyse data to identify
concerns and to determine anticipated outcomes. Ideas for improving
processes are identified. This step requires the most time and effort.
Affected staff or people served are identified, data compiled, and
solutions proposed.
7.14.7. Do - This step involves using the proposed solution, and if it proves
successful, as determined through measuring and assessing,
implementing the solution usually on a trial basis as a new part of the
process.
7.14.8. Check - At this stage, data is again collected to compare the results of
the new process with those of the previous one.
7.14.9. Act - This stage involves making the changes a routine part of the
targeted activity. It also means “Acting” to involve staff who will be
affected by the changes, those whose cooperation is needed to
implement the changes on a larger scale, and those who may benefit
from what has been learned. Finally, it means documenting and
reporting findings and follows up.
a. Summarize the progress towards meeting the Annual
Goals/Objectives.
b. For each of the goals, include a brief summary of progress including
progress in relation to training goal(s).
c. Provide a brief summary of the findings for each of the indicators
used during the year. These summaries should include both the
outcomes of the measurement process and the conclusions and
actions taken in response to these outcomes. Summarize progress in
relation to Quality Initiative(s). For each initiative, provide a brief
description of what activities took place including the results on
indicator. Describe any implications of the quality improvement
process for actions to be taken regarding outcomes, systems or
outcomes at Hospital program in the coming year.
d. Recommendations: Based upon the evaluation, state the actions
necessary to improve the effectiveness of the QI Plan.
7.15.EVALUATION
7.15.1. An evaluation is completed at the end of each calendar year. The annual
evaluation is conducted by the Hospital and kept on file in the Hospital


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along with the Quality Improvement Plan. These documents will be

reviewed by the Management as part of the Hospital certification
process.
7.15.2. The evaluation summarizes the goals and objectives of the Hospital’s
Quality Improvement Plan, the quality improvement activities conducted
during the past year, including the targeted process, systems and
outcomes, the performance indicators utilized, the findings of the
measurement, data aggregation, assessment and analysis processes, and
the quality improvement initiatives taken in response to the findings.
7.16.CQI PLAN
7.16.1. The treatment provided incorporates evidence based effective
practices.
7.16.2. The treatment & services are appropriate to each need and are
available when needed.
7.16.3. Risk to patients, providers and others is minimized and errors in the
delivery of services are prevented.
7.16.4. Patients’ needs and expectations are respected.
7.16.5. Patients or those, whom they designate, have the opportunity to
participate in taking decisions regarding their treatment and services
provided with sensitivity and care.
7.16.6. Procedures, treatments and services are provided in a timely ad
efficient manner, with appropriate coordination and continuity across
all phases of care.
7.17.TOR
7.17.1. Committee members
7.17.2. CQI committee consists of the following members:
7.17.3. To improve quality of patient care and allied services.
7.17.4. To prioritize overall the issues presented in the QIC meeting.
7.17.5. To monitor overall quality of services (patient safety indicators).
7.17.6. To review and discuss complaints received from the patients and
suggest corrective action.
7.17.7. To improve the accuracy of patient’s identification.
7.17.8. To improve the effectiveness of communication among doctors/staff
and patients.
7.17.9. To improve safety of medical devices.
7.17.10. To train staff.
7.17.11. To reduce the risk of hospital incidents.


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7.18.METHHODOLOGY
7.18.1. Determine the current performance.
7.18.2. Establish a need to improve.
7.18.3. Obtain commitment and define the improvement objective.
7.18.4. Organize the diagnostic resources.
7.18.5. Carry out research and analysis to discover the cause of current
performance.
7.18.6. Define and test solutions that will accomplish the improvement
objective.
7.18.7. Produce improvement plans which specify how and by whom the
changes will be implemented.
7.18.8. Identify and overcome any resistance to change.
7.18.9. Implement the change.
7.18.10. Put in place controls to hold new levels of performance and repeat
the step 1.
7.18.11. PLAN
7.18.12. Analyse the process, determine what changes would most improve
the process and establish a plan for working the improvement.
7.18.13. DO
7.18.14. Put the change into motion on trial basis.
7.18.15. STUDY / CHECK
7.18.16. Check to see whether change is working.
7.18.17. ACT
7.18.18. If the change is working, implement it on a large scale if not than
refuse it or reject it ad begin the cycle again.
7.18.19. Analyse measure and improve the way, care is administered. All areas
of hospital services are assessed. When a problem or opportunity for
improvement is identified a team of employees clearly defines the
issue, collect data and information, identifies possible solutions,
implements a change and continues to measure to see if this change
made improvement.
8. INTERPRETATION:
There is no interpretation in this SOP.
9. REFERENCE:
9.1.Punjab Healthcare Commission IIA – Standard No. 15-17 and Indicator No.46-58


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Muneeb Zafar:
Prepared By: SALEEM KHAN
9.2.PHC MEMO: PHC/L&A/2022/16686

https://www.phc.org.pk/download_CCL.aspx#policies
10. ANNEXURES:
10.1. Annexure – 1 KPIs of operational areas
DOCUMENT CHANGE RECORD:
REVIEW DATE IDENTIFICATION OF

REVIEW No.: DESCRIPTION OF CHANGE
(DD–MM–YYYY) CHANGE
00 00 Nov. 2022 There is no change of history in 1st ver. of the SOPs.

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HANIF MEDICAL COMPLEX (PVT.) LTD.

STANDARD OPERATING PROCEDURE

SOP Title: Quality Improvement and Continuous Monitoring Programme

Saleem Khan Dr. M. Javad

Copy # Distribution Location Receive Date Signature

1. Chief Executive Office

2. Director Operations Office

4. Director Admin. & HR

6. Nursing Counter Office

8. Operation Theatre Room

9. Lab & Radiology Office

10. Document Control Office

SOP | QI protocols and Procedure? Page 1 | 13

SOP Title: Quality Improvement and Continuous Monitoring Programme

SOP | QI protocols and Procedure? Page 2 | 13

SOP Title: Quality Improvement and Continuous Monitoring Programme

3. HEALTH, SAFETY AND ENVIRONMENTAL PROTECTION:

5. TERMS AND DEFINITIONS:

SOP | QI protocols and Procedure? Page 3 | 13

SOP Title: Quality Improvement and Continuous Monitoring Programme

7. GENERAL INSTRUCTIONS & GUIDELINES:

SOP | QI protocols and Procedure? Page 4 | 13

SOP Title: Quality Improvement and Continuous Monitoring Programme

b. Recovery-oriented. Services are characterized by a commitment to promoting

SOP | QI protocols and Procedure? Page 5 | 13

SOP Title: Quality Improvement and Continuous Monitoring Programme

7.6. LEADERSHIP AND ORGANIZATION

7.6.2. The Quality Improvement Committee provides ongoing operational leadership

SOP | QI protocols and Procedure? Page 6 | 13

SOP Title: Quality Improvement and Continuous Monitoring Programme

7.8. THE RESPONSIBILITIES OF THE COMMITTEE INCLUDE :

SOP | QI protocols and Procedure? Page 7 | 13

SOP Title: Quality Improvement and Continuous Monitoring Programme

information related to these indicators on a regular basis. Continuous Quality

SOP | QI protocols and Procedure? Page 8 | 13

SOP Title: Quality Improvement and Continuous Monitoring Programme

7.14.2. The Performance Indicator Selected for HMC Hospital Quality

SOP | QI protocols and Procedure? Page 9 | 13

SOP Title: Quality Improvement and Continuous Monitoring Programme

SOP | QI protocols and Procedure? Page 10 | 13

SOP Title: Quality Improvement and Continuous Monitoring Programme

along with the Quality Improvement Plan. These documents will be

SOP | QI protocols and Procedure? Page 11 | 13

SOP Title: Quality Improvement and Continuous Monitoring Programme

SOP | QI protocols and Procedure? Page 12 | 13

SOP Title: Quality Improvement and Continuous Monitoring Programme

9.2.PHC MEMO: PHC/L&A/2022/16686

DOCUMENT CHANGE RECORD:

REVIEW DATE IDENTIFICATION OF

SOP | QI protocols and Procedure? Page 13 | 13

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