2. WHAT IS QUALITY OF CARE?
‘DOING THE RIGHT THING(GETTING THE HEALTH CARE
SERVICES YOU NEED),AT THE SAME TIME(WHEN YOU
NEED IT),IN THE RIGHT WAY(USING THE APPROPRIATE
TEST OR PROCEDURE ), TO ACHIEVE THE BEST POSSIBLE
RESULTS.’
THE WHO DEFINITION OF QUALITY OF CARE IS “THE
EXTENT TO WHICH HEALTH CARE SERVICES PROVIDED
TO INDIVIDUALS AND PATIENT POPULATIONS IMPROVE
DESIRED HEALTH OUTCOMES. IN ORDER TO ACHIEVE
THIS, HEALTH CARE MUST BE SAFE, EFFECTIVE, TIMELY,
EFFICIENT, EQUITABLE AND PEOPLE- CENTERED.”
3. Safe: Delivering health care that minimizes risks and harm to
service users, including avoiding preventable injuries and
reducing medical errors.
Effective: Providing services based on scientific knowledge and
evidence-based guidelines.
Timely: Reducing delays in providing and receiving health care.
Efficient: Delivering health care in a manner that maximizes
resource use and avoids waste.
Equitable: Delivering health care that does not differ in quality
according to personal characteristics such as gender, race,
ethnicity, geographical location or socioeconomic status.
People-centered: Providing care that takes into account the
4. QUALITY IMPROVEMENT
IN HEALTH CARE, QUALITY IMPROVEMENT
(QI) IS THE FRAMEWORK WE USE TO
SYSTEMATICALLY IMPROVE THE WAYS CARE
IS DELIVERED TO PATIENTS. PROCESSES
HAVE CHARACTERISTICS THAT CAN BE
MEASURED, ANALYZED, IMPROVED, AND
CONTROLLED.
12. QUALITY IMPROVEMENT TOOLS
Quality improvement tools are standalone
strategies or processes that can help you better
understand, analyze, or communicate your QI
efforts.
Brainstorming is a group creativity
technique by which efforts are made
to find a conclusion for a specific
problem by gathering a list of ideas
spontaneously contributed by its
members
15. 4. FLOW CHARTS
A flowchart is a diagram that
shows the step-by-step flow of
operation to get a solution of a
problem or to figure out the
correct sequence of the process
16. 5.CAUSE & EFFECT DIAGRAM (FISH BONE
DIAGRAM
A cause and effect
diagram examines why
something happened or
might happen by
organizing
potential causes into
smaller categories.
17. 6. PARETO DIAGRAM
A Pareto diagram is a simple bar
chart that ranks related
measures in decreasing order of
occurrence
18. 7. HISTOGRAM
A histogram is a graphical tool
used to visualize data that can
be produced with histogram
,where the height of each bar
represents the number of
observations falling within a
range of rank-ordered data
values.
19. 8. CONTROL CHARTS
The control chart is a graph
used to study how a process
changes over time
20. 9. SCATTER DIAGRAM
Scatter Diagram or
correlation diagram is a tool to
describe changes in a
dependent variable in relation to
any change in the independent
variable
21. PROJECT TITLE: TO REDUCE VOLUNTARY NURSE TURNOVER RATE
IN UMLUJ GENERAL HOSPITAL
F- FIND A PROCESS TO IMPROVE:
DATA COLLECTION TOOL
Description of Indicator
Indicator Name: Voluntary Nurse Turnover Rate
Target: ˂2% Saudi, MOH
˂ 3% Saudi, HOP
˂5% Non-Saudi, MOH, HOP
Numerator: Number of voluntary leaving of nursing staff
(nurses & midwives) after finishing their
contract in the hospital during the month
Frequency: Monthly
Denominator: Number of nurses on the last day of the
month
Source of Data: Audit
Selection Criteria: Manual Responsible Party: Nursing Quality
Reporting Method: Excel Sheet
Reported to: Nursing Director/QM
Director/ HR Director
Type of Indicator: Structure Process Outcome
Criteria
Total
No.
Percentage Remarks
Total Number of nurses/midwife
Voluntary end their contract
× 100
Total Number of nurses/midwives at the
end of the month
22. O- Organize a team to work on improvement
NAME POSITION SIGNATURE
Team Leaders Ms. Bincy T Joy Quality Nurse
Coordinator
Ms. Mashael Sleem Al Johani Nursing Director
Team
Members
Ms. Amal Sulaiman Al Qureshi Asst Nursing
Director
Ms. Hanan Mohammed Al Johani Nursing Supervisor
Ms. Princy K S Nursing Supervisor
Ms. Hanadi Mohammed Al Johani ICU Head nurse
Ms. Aswathy S S FW Head Nurse
Ms. Agripina Capablanca DR Head Nurse
Ms. Weed Mansoor ER Head Nurse
Ms. Shalini Shasidaran ER Charge Nurse
Mr. Ahmed Abdel Hadi HR Head
23. C- Clarify current knowledge of the
process
Inform to head nurse and
nursing office
Resignation letter with survey form
submitted to nursing office through email
Counselling done with the staff to
explore the reason of exit
Letter forwarded to
hospital director and then
to HR department
YES NO
Immediate action taken
and cancel exit process
Prepare final paper
work
Staff
going exit
Check
whether the
problem is
solvable or not
Staff
decided to
go exit
25. P – Plan the
Improvement
No Plan Responsible
person
Time frame Status
1. Hold meeting Ms. Mashael Sleem
Al Johani
Ms. Bincy T Joy
Monthly Met
2 Provide transportation facility to
entertain staff nurse
Ms. Mashael Sleem
Al Johani
Monthly Met
3 For increment and allowances sent
request to HR through email
Ms. Mashael Sleem
Al Johani
1 week Met
4 Feedback for all issues Ms. Mashael Sleem
Al Johani
Ms. Bincy T Joy
1 week Met
5 Staffing plan request should be sent
to HR for hiring new staff
Ms. Bincy T Joy 1 week Met
6 Continuing education Ms. Annaliza R
Dreibach
Monthly Met
26. D – Do the Improvement
# Activities Time Frame Venue
1.
Meeting Done
Monthly
Nursing Office
2 Provide transportation facility to
entertain staff nurse
Monthly -
3 Request sent to HR for
increment
1 week -
4 Feedback for all issues 1 week Nursing Office
5 Staffing plan request sent to HR
for hiring new staff
1 week Nursing Office
6 Continuing education Monthly Lecture Hall and
Department
27. C – Check the results
Jan, 0, 0%
Feb, 0.006, 0%
March, 0.011, 0%
April, 1.1, 16%
May, 4, 58%
June, 1.8, 26%
VOLUNTARY NURSE TURNOVER RATE
July, 3.703,
100%
August, 0.006,
0%
VOLUNTARY NURSE TURN OVER RATE
28. A – Act to hold the gain
oOngoing education
oSupport system for staff to
share their feelings
oTransportation facility provided
monthly to entertain staffs.
oYearly job satisfaction survey
to explore the causes and
consequences of nurse
turnover
oHold meetings
oFeedback for all issues
29. PATIENT SAFETY
“PATIENT SAFETY IS THE AVOIDANCE OF UNINTENDED
OR UNEXPECTED HARM TO PEOPLE DURING THE
PROVISION OF HEALTH CARE”
S-SENSE THE ERROR
A-ACT TO PREVENT IT
F-FOLLOW SAFETY GUIDELINES
E-ENQUIRE INTO ACCIDENT/DEATH
T-TAKE APPROPRIATE REMEDIAL MEASURES
Y-YOUR RESPONSIBILITY
30.
31. MEDICAL SAFETY
*MEDICATION ORDER SHOULD BE WRITTEN LEGIBLY WITH ALL
MEDICATION &PATIENT DETAILS
*ANY ABBREVIATIONS USED IN ORDER SHOULD BE
STANDARDIZED
*DISCOURAGE TELEPHONE ORDER, DO NOT ACCEPT VERBAL
ORDERS EXCEPT EMERGENCY
*FOLLOW 10 RIGHTS OF MEDICATION
*PATIENT IDENTIFICATION WITH 2 IDENTIFIER BEFORE ANY
PROCEDURE
32.
33. SURGICAL SAFETY
* WRITTEN SURGICAL CONSENT
* CORRECT IDENTIFICATION OF PATIENT
* SITE MARKING
* PRE ANESTHETIC CHECK UP
* USE OF SURGICAL SAFETY CHECKLIST
* PREVENTION OF SURGICAL WOUND INFECTIONS
34. ELECTRICAL SAFETY
*SAFETY FUSES WITH EACH EQUIPMENT
*NO LOOSE WIRES/CONNECTION
*PROPERLY PLUGGED & FIXED
*ELECTRICITY BACK UP BATTERY & GENERATOR
35. INFECTION CONTROL & SANITATION
*PROPER SEGREGATION & TRANSPORTATION OF BIOMEDICAL
WASTE
*USE OF STERILE PROCEDURE
*FORMATION OF INFECTION CONTROL COMMITTEE
*INVESTIGATION OF ALL HOSPITAL INFECTION
*EDUCATION & ORIENTATION OF HOSPITAL STAFFS
*SANITATION & HYGIENE OF HOSPITAL AREA TO AVOID
INFECTION
36. FIRE SAFETY
*USE FIRE PROOF MATERIAL
*HAVE FIRE EXIT IN ALL BUILDING
*SMOKE DETECTORS & WATER SPRINKLERS ON THE
ROOF OF ALL
FLOOR
*FIRE EXTINGUISHERS IN ALL AREA
*TRAINING IN FIRE MANAGEMENT
37. BLOOD SAFETY
*PROPER GROUPING & CROSS MATCHING
*PROPER LABELLING OF GROUP &NAME OF PATIENT
*SCREENING AGAINST HIV, HEPATITIS, VDRL
*CONTROL OF MISMATCH REACTION
*INFORM ADVERSE REACTION TO BLOOD BANK
