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This page is a free sample showing what a hospital policy should look like. It can work at your place, you might need to modify it a little. The hospital here is HOSPITAL X. You might need to change that to your own institution name.
QUALITY MANAGEMENT MISSION
Achieve and maintain the integrity and continuous improvement of the quality system and risk management in a “patient-centered approach" and to satisfy patient’s needs and expectations according to the region's health laws and accreditation bodies requirements.
QUALITY MANAGEMENT VISION
"The Quality Management Department of HOSPITAL X seeks to ensure the disseminating of the quality, safety and customer services culture throughout the hospital, to promote, quality of care, ensure patient and staff safety and decrease potential risks as per national and international standards."
DEPARTMENTAL SCOPE OF SERVICE
TYPES OF CUSTOMERS SERVED
The Quality Management Department aims to establish a culture where the customer is always the focus of the operation and that quality is the responsibility and objective of all employees at all levels.
- 1Accrediting Bodies
- 2National Inspecting Bodies
- 3Big companies contracts and other companies.
- 4Quality Departments from sister hospitals
- 5Patient and their families
- 6Visiting organization (company, embassy representatives, etc.)
- 1Hospital Board of Owners and executive board members
- 2Hospital Administration and hospital directors
- 3Heads of the Departments (Medical and non-medical)
- 4Departmental Ql Officers (Medical and non-medical)
- 5Medical, nursing, non-medical, allied health employees
- 6Hospital committees’ chairmen, members
- 7Support Services like Infection Prevention & Control Department and Safety, Loss & Prevention Department [SLPD) among others
RANGE OF ACTIVITIES PERFORMED
- 1Patient Safety
- 2Document Management
- Policy and procedure development coordination.
- Ensures the consistencies of all written dated policies and procedures reflect the current professional knowledge and principles of each service area, department and function.
- Ensures that there is evidence of compliance with existing laws, regulations policies and procedures.
- 3Risk Management
- Identifies risk and adverse events through occurrence variance reporting, sentinel event, patient complaints and other data sources.
- Coordinates collection internal and external data on potential hospital risk and reports the analysis and investigated findings of the hospital's actual and potential risk to the Quality Management and Patient Safety Committee (QPS), medical staff, administration and the respective department.
- Accountability and corrective measures for incidents most often involve educational functions of all the hospital about Risk Management (Occurrence Variance Report, and Sentinel Event evaluation, Root Cause Analysis and performance improvement).
- 4Monitoring Patient Satisfaction
- 5Monitoring Staff Satisfaction
- 6Continuous Education Training
- 7Accreditation Coordination
- 8Monitoring Committees Performance
- Assigns a Quality Management staff representing the department in all hospital-wide regular monitoring committees as member (co-chairman, regular member, facilitator or secretary).
- Receives the minutes of all approved committee meetings and facilitates provisional & final scheduling, agenda and activities per committee and facilitates annual function review per committee. QM staff will be responsible of the meeting minutes if assigned as facilitator or secretary of a certain committee.
- 9Clinical Audit Program
- Develops and monitors clinical and managerial indicators, KPl’s, International Library of Measures to support the quality improvement efforts.
- Clinical Record Review
Some medical record of selected cases will be reviewed and find out the medical necessity for admissions, severity of illness and discharge criteria to assure the appropriate, cost-effective use of hospital resources, continued stays and services rendered. The Utilization Management addresses over utilization, underutilization, inefficient utilization of resources, in addition to some cases that can be referred to the focus review process.
- 10Credentialing and Privileging
- Ensures only qualified medical staff are hired by and is working in the hospital
- Facilitates the activities of Credentialing and Privileging Committee
- 11Construct a Communication Chart
- Reports all Ql activities to the hospital directors and heads of the departments and QMPS Committee.
- Summarizes all performance indicators and analysis graphs and sheets in a quarterly report to the hospital directors and QMPS Committee.
- Prepares clinical audit monthly and quarter reports for analyzing and follow up of improvement action based on results.
- Reviews Occurrence Variance Report (OVR) from all departments.
- Reviews hospital wide Sentinel Events.
- Facilitates the display of storyboards, performance indicators and analysis graphs to respective areas/ units per monthly/ quarterly/ annually.
- Validates reports from the departments including from Infection Prevention and Control and Safety.
- 12Departmental Committees and Meetings
- 13Supporting Services
TYPES OF STAFF CARRYING OUT THESE ACTIVITIES
for: Risk Management, Clinical Audit, Credentialing & Privileging, Committee & Training, and Manual & Indexing.
QM Department coordinates with the Departmental QI Officers including Nursing QI Coordinators with Nursing QI Unit Officers to convey the message to all departments.