23.

Quality Management Plan

1. Purpose / Rational:
1.1 To ensure that the Governing Body, medical staff and professional service staff
demonstrate a consistent endeavor to deliver safe, effective, optimal patient care and
services in an environment of minimal risk.
1.2 In keeping with PHCC's mission; to foster, nurture and perpetuate the concept of a
community and family centered, quality conscious and cost-effective medical center of
excellence, the TQM Plan allows for systematic, coordinated, continuous data driven
approach to improve performance focusing upon the processes and mechanisms that
address these values.
1.3 As patient care is coordinated and collaborative effort, the approach to improving
performance involves multiple departments and disciplines in establishing plans,
processes and mechanisms that comprise the performance improvement activities at
PHCC.
2. Applicable to / Scope:
2.1 Public Health Administration.
2.2 Primary healthcare center (PHC)staff.
2.3 The scope of the TQM program includes an overall assessment of the efficacy of
performance improvement activities with a focus on continually improving care
provided throughout the PHCC, in addition to quality control activities that consist of
collaborative and specific indicators of both processes and outcomes of care. These
indicators are objective, measurable, based on current knowledge and experience.
The indicators produce statistically valid data over time.
3. Related standards/Laws:
3.1 MOH rules and regulations.
3.2 CBAHI standards for PHC.
3.3 JCI standards for PHC.
4. Definitions
4.1 Quality: is the degree to which health services for individuals and populations increase
the likelihood of desired health outcomes and consistent with current professional
knowledge (institute of Medicine)

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5. Objectives
The primary goal of the TQM Plan is continually and systematically plan, design, measure,
assess and improve performance of critical focus areas with reduction or prevention of
medical/health care errors. This is done by achieving the following:
5.1 Annual evaluation and revise — as necessary the TQM plan.
5.2 Identification of treatment and services affecting the health and safety of patients.
5.3 Tracking of the status of identified problems and action plans in order to assure
improvement or problem resolution.
5.4 Communication of the necessary information among department/services when
problems or opportunities to improve patient care and patient safety practices involve
more than one department/service.
5.5 Using information from departments/services and the findings of discrete
improvement activities and adverse patient events to detect trends, patterns of
performance or potential problems that affect more than one (1) department/service.
5.6 The improvement process is PHCC-wide and includes monitoring, assessing and
evaluating the quality and appropriateness of patient care and clinical performance to
resolve identified problems & improve performance.
5.7 Appropriate reporting to the Governing Body and to provide the leaders with the
information that help them to fulfill their responsibility for the quality of patient care
and safety.
6. Components of TQM Plan:
6.1 Organization: To achieve fulfillment of the objectives, goals and scope of the TQM
Plan, the organizational structure of the program is designed to facilitate an effective
system of monitoring, assessment and evaluation of the care and services provided
throughout the PHCC:
 The Governing Body is responsible for the quality of patient care provided
 With authority delegated by the Governing Body, the Public Health Administration
establishes TQM committee that strives to improve and assure the provision of
quality patient care through the monitoring, assessment and evaluation of
performance and outcome at PHCCs.

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  With designated responsibility from Public Health Administration through TQM
committee, the Continuous Quality Improvement (CQI) team will operate as a
functional grouping of individuals in the PHCC who meet to evaluate and improve a
specific process or system within the center. The CQI team is comprised of
departmental leaders, PHCC staff on an as needed basis and those individuals
designated from each department, as appropriate, who may have the highest degree
of knowledge regarding a given CQI topic.
6.2 Methodology: The Plan, Do, Check, Act (PDCA) methodology is utilized to plan,
design, measure, assess and improve functions and processes related to patient care
and safety throughout the PHCC
6.2.1 Plan:
 Objectively statistically valid performance measures are identified for
monitoring & assessing processes and outcomes of care including those
affecting a large percentage of patients, and/or place patients at serious risk
if not performed well, or performed when not indicated, or not performed
when indicated; and/or have been or likely to be problem prone.
 Performance measures are based on current knowledge & clinical
experience and are structured to represent interdisciplinary processes, as
appropriate.
 Data will be collected from internal sources (staff) & external sources
(patients, referral sources, etc.). The following data sources will be reviewed
for use in performance measures development:
 Staff opinions and needs.
 Staff perceptions of risks to patients and suggestions for improving
patient safety.
 Staff willingness to report health care errors.
 Performance measures from approved internal and external databases
 Infection control surveillance and reporting.
 Patient and family perceptions of care, treatment and services
(satisfaction surveys)

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 o Data collected includes the specific need and expectations of the
patients.
o Patients’ perceptions on how well the PHCC meets these needs &
expectations.
o Patient suggestions for improvement of their safety.
 Risk management.
 Utilization management .
 Quality control.
 Customer demographics and diagnoses.
 Research, as applicable.
 Performance measures for processes that are known to jeopardize the
safety of patients or associated with sentinel events will be monitored.
 Benchmarks or thresholds that trigger intensive assessment and evaluation
are established
6.2.2 Do: Data is collected to determine:
 Whether design specifications for new processes were met
 The level of performance and stability of existing processes
 Priorities for possible improvement of existing processes
6.2.3 Check: Assess care when benchmarks or thresholds are reached in order to
identify opportunities to improve performance or resolve problem areas.
6.2.4 Act:
 Take actions to correct identified problem areas or improve performance.
 Evaluate the effectiveness of the actions taken and document the
improvement in care.
 Communicate the results of the monitoring, assessment & evaluation
process to relevant individuals, departments or services.
6.3 Reporting Formats: Recommendations, findings, actions taken to improve
performance and their results are documented and reported through established
channels:
 Results of the outcomes of performance improvement & patient safety activities
identified through data collection and analysis, performed by the PHCC staff and

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 CQI team activity will be reported to TQM Committee on monthly basis as
designated.
 TQM Committee will report, to the Public Health Administration on a monthly
basis, their analysis of the quality of patient care and services provided
throughout the PHCCs
 TQM Committee will provide the Governing Body with a report of the relevant
findings from all performance improvement activities performed throughout the
PHCCs at least on a quarterly basis.
6.4 Confidentiality
 All information related to performance improvement activities performed by the
PHCC personnel in accordance with this plan are confidential according to
information confidentiality policy.
 Some information may be disseminated on a "need to know basis" as required by
law or by Governing Body and Public Health Administration
6.5 Quality Education
Familiarizing TQM concepts & subsequently involved with specific quality
improvement efforts and team works, each PHCC staff will have the opportunity to
enroll in quality training that suits each staff needs:
6.5.1 New Staff:
 Objectives: part of general orientation
o PHCC mission, vision, core values & objectives.
o Quality management & patient goals.
o Quality role in their working area
o Quality function hierarchy in the PHCC.
 Topics to be covered:
o What is quality in brief?
o Quality is the science of implementation & improvement.
o Aim of the PHCC in patient & staff safety.
o Pillars of quality.
o Importance of events reporting.
o Quality department, Q. coordinator & Q. committee role

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  Remarks
o Orientation continues according to the orientation program.
o It should be at least in Arabic &in English
o Tutors are from quality department
6.5.2 Quality Coordinators
 Objectives: to be aware & know:
o Quality & patient safety concepts
o Quality role in their department
o Sharing in quality control and improvement.
 Topics to be covered
o Introduction to quality.
o Aim of the PHCC in patient & staff safety.
o Who is responsible for quality?
o How to deal with reporting of events &sentinel events
o Key performance indicators
o Team work building
o Quality improvement approaches e.g. FOCUS-PDCA & Lean Six Sigma
o Document management
 Remarks
o The topics covered in 120 Min. for 5 days.
o It should be in Arabic & in English.
o Tutors from Quality department.
6.5.3 Quality Department Staff
 Objectives: to understand & know
o Quality & patient safety concept
o Their roles in quality
o Leading improvement process
o Follow-up standards compliance
 Topics to be covered
o Introduction to quality
o 8 quality principles

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 o Dealing with events reporting& sentinel events
o Key performance indicators.
o Data management & analysis
o Team building
o Quality improvement approach such as FOCUS-PDCA & Lean Six Sigma.
o Document management
o Clinical audit.
o Risk assessment & analysis
o TQM plan
o CBAHI & other standards
o Job description.
 Remarks
o Topics covered over 6 hours in 5 days
o It should in Arabic & in English
o Tutors is quality department head & external consultant (if needed)
o Others specified topics about quality tools & advanced subjects as
needed
6.5.4 Top management (All Leaders):
 Objectives: to be aware & know:
o Quality concepts
o Commitment to quality activities
o Their role in quality
o Prioritize quality control & improvement issues
 Topics to be covered
o Introduction to quality
o Events reporting & sentinel events
o Key performance indicators
o Team support.
o PHCC TQM plan
o CBAHI standards related to the leaders.
 Remarks

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 o Topics covered in 60 min, for 10 days.
o Topics should be in Arabic & in English.
o Tutors from quality department.
6.6 Annual Evaluation & Approval
To assure that the appropriate approach to planning processes of improvement;
setting priorities for improvement; assessing performance systematically;
implementing improvement activities on the basis of assessment; and maintaining
achieved improvements, the TQM plan is evaluated for effectiveness at least annually,
including the identification of the number of distinct performance improvement
projects, and revised as necessary.
7. Form/s used — Resources needed N/A
8. Annexes N/A

24. Patient Safety Plan

Purpose / Rational
1.1 To provide a systematic, coordinated and continuous approach to the maintenance
and improvement of patient safety through the establishment of mechanisms that
support effective responses to potential or actual occurrences; ongoing proactive
reduction in medical/health care errors; and integration of patient safety priorities
into the new design and redesign of all relevant PHCC processes, functions and
services.
2. Applicable to / Scope:
2.1 Public Health Administration.
2.2 Primary health care center (PHC) staff.
2.3 The plan addresses maintenance and improvement in patient safety issues in every
department throughout the PHCC.
2.4 The patient safety is included within the scope of TQM committee's responsibilities.
3. Related standards/Laws:
3.1 MOH rules and regulations.
3.2 CBAHI standards for PHC.
3.3 JCI standards for PHC
4. Definitions:

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 4.1 Patient Safety:
Freedom from accidental injury by medical care (Institute of Medicine).
4.2 Safety Culture:
The product of individual & group values, attitudes, perceptions, competencies and
patterns of behavior that determine the commitment to and the style & proficiency
of an organization's health and safety management.
5. Objectives
5.1 The primary objectives of the patient safety Plan is to deploy safety culture within the
PHCC and to continually and systematically plan, design, measure, assess and improve
compliance with at least the International Patient Safety Goals:
5.1.1 IPSG1: Identify patient correctly.
5.1.2 IPSG2: Improve effective communication.
5.1.3 IPSG3: Improve the safety of high alert medication
5.1.4 IPSG4: Eliminate wrong site, wrong patient & wrong procedure.
5.1.5 IPSGS: Reduce the risk of health care acquired infections.
5.1.6 IPSG6: Reduce the risk of patient harm resulting from fall
6. Components of Patient Safety Plan
6.1 Organization
6.1.1 The Total Quality Management (TQM) Committee is responsible for the
oversight of the Patient Safety Plan. The TQM Committee Chairperson will
have administrative responsibility for the plan, or may assign this
responsibility to another member of the committee (such as Quality or Risk
Manager).
6.1.2 All departments within the PHCC (patient care and non-patient care
departments) are responsible to report patient safety occurrences and
potential occurrences to the Quality/Risk manager, who will aggregate
occurrence information and present a report to the TQM Committee on a
monthly basis. The report will contain aggregated information related to type
of occurrence, severity of occurrence, number/type of occurrences per
department, occurrence impact on the patient, remedial actions taken, and

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 patient outcome. The TQM Committee will analyze the report information
and determine further patient safety activities as appropriate.
6.1.3 Any individual in any department identifying a process/system failure and/or
potential patient safety issue will immediately notify his or her supervisor and
document the findings on an occurrence report. The occurrence report will be
submitted to the Quality Department per event reporting policy
6.2 Methodology:
6.2.1 Staff will receive education and training during their initial orientation period
and on an ongoing basis regarding job-related aspects of patient safety,
including the need & method to report medical/health care errors. Because
optimal provision of healthcare's interdisciplinary, staff will be educated and
trained on the provision of an interdisciplinary approach to patient
care.
6.2.2 The TQM Committee will select at least one high-risk safety process for
proactive risk assessment annually - as per risk management plan. This
selection is based on review of internal data reports (including, but not
limited to, monitoring of IPSGs compliance and events reported) and reports
from external sources (including, but not limited to, The Joint Commission
sentinel event report information, occurrence reporting information from
MOH or CBAHI sources and current literature).
6.2.3 Established event reporting system policy(such as the Sentinel Event Policy)
and/or the TQM Committee will determine the PHCC response to
process/system failures and/or medical/health care errors and occurrences.
All sentinel events and near miss occurrences will have a root cause analysis
conducted.
6.2.4 The Patient Safety Plan includes annually survey of patients, their families,
volunteers and staff opinions, needs and perceptions of risks to patients and
requests suggestions for improving patient safety.
6.2.5 Patients, and when appropriate, their families are informed about the
outcomes of care, including unanticipated outcomes, or when the outcomes
differ significantly from the anticipated outcomes. The TQM Committee will

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 request a report from the Information Management Committee on a
quarterly basis consisting of random record review verifying compliance with
informing the patient about outcomes of care.
6.2.6 Lessons learned from a root-cause analysis shall be communicated to staff
who provide services or are affected by a patient safety incident. Education
shall take place through the Education Department.
6.3 Reporting Formats:
6.3.1 The Patient Safety Plan includes consideration, at least annually, of data
obtained from the PHCC Information Management Needs Assessment, which
includes information regarding barriers to effective communication among
caregivers.
6.3.2 The TQM Committee will also request on a quarterly basis, a report from the
Information Management Committee identifying the effectiveness of the
PHCC to provide accurate, timely, and complete verbal and written
communication among caregivers and all other involved in the utilization of
data.
6.3.3 Patient safety reports from the TQM Committee will be submitted to the
Public Health Administration on monthly bases.
6.3.4 The TQM committee shall forward a Patient Safety Report to the Governing
Body, at a minimum, once per year. Information in the report shall include:
 All system or process failures.
 Number and type of sentinel events.
 If patients and families were informed of the adverse events.
 All actions taken to improve safety, both proactively and in response to
actual occurrences.
 All results of the analyses related to the adequacy of staffing and actions
taken to resolve the identified problem(s).
7. Forms/Resources Needed
N/A
8. Annexes
N/A

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