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Quality Improvement Model

The Quality Improvement Model used in KSCKD is FOCUS-PDCA, (Find, Organize, Clarify, Understand, Select, Plan, Do, Check, Act). This model was selected for continuous improvement of identified projects because it is simple and can be understood by the multicultural staff that will be using it. It is effective and incorporates the continuous cycle of improvement to which the center is committed.

The following steps are utilized to plan, design, and measure, assess and improve functions and processes related to patient care and service throughout the organization:

  • Assign responsibility for monitoring, assessing and evaluating performance improvement activities.
  • Delineate the scope of care and services provided.
  • Identify the key aspects of care focusing on those aspects that relate to the health and safety of the patients served.
  • Identify objective and statistically valid performance measures (indicators) for monitoring and assessing the key aspects of care. These performance measures include processes performance measures and outcome performance measures that affect a large percentage of patients; and/or place patients at serious risk if not performed well, or performed when not indicate, or not performed when indicated; and/or have been or are likely to be problem prone.

Performance measures are structured to follow the CBAHI standards Dimensions of performance are based on current knowledge and clinical experience and are structured to reflect cross-departmental, interdisciplinary processes, as appropriate. The following represent data sources for the development of performance measures and related outcomes:

  • Risk Management
  • Utilization management
  • Quality Control
  • Staff opinions and needs
  • Outcomes of processes or services
  • Performance measures from organization approved internal and external databases
  • Customer demographics and diagnoses
  • Infection control surveillance and reporting
  • Research data
  • Performance measures related to accreditation and other requirements
  • Expectations and satisfaction of individuals served.

  • Performance measures for processes that are known to jeopardize the safety of the individuals served or associated with sentinel events will be routinely monitored. At a minimum performance measures related to the following processes, as appropriate to the care and services provided are monitored with the approval, and at the suggested frequency of the Quality management Committee:
  • Performance data identified in various chapters of the CBAHI manual
  • Medication Use
  • Seclusion when it is part of the care or services provided
  • Care or services provided to high risk patients

  • Outcomes related to resuscitation
  • Establish benchmarks of thresholds that trigger intensive assessment and evaluation of the function, process and /or care provided
  • Monitor, assess and evaluate the key aspects of care by assessment of data collected in order to determine:

  • Whether design specifications for new processes were met
  • The level of performance and stability of important existing processes
  • Priorities for possible improvement of existing processes
  • Actions to improve the performance of processes and functions
  • Whether changes in the processes and/or functions resulted in improvement.

  • Assess the care related to the key aspects and key processes under monitoring when benchmarks or thresholds are reached in order to identify opportunities to improve performance or resolve problem areas
  • Take actions to correct identified problem areas or improve performance
  • Evaluate the effectiveness of the actions taken and document the improvement in care
  • Performance improvement activities throughout the center are dependent upon the Management of Information function. This function is performed in an interdisciplinary collaborative approach throughout the center. As the management of information is a function that is comprehensive, impacting all services within the center, the review of this function is performed as a collaborative process when medical staff and departmental performance improvement activities are conducted. Outcomes are reflected in the specific departments through Quality management Committee’s review and analysis of performance improvement data.
  • This function is performed to obtain, manage and use information to enhance and improve individual and organizational performance in patient care, management and support processes. The quality of the medical record is reviewed for accuracy, timeliness, completeness, clinical pertinence and legibility.

FOCUS

F Find an Opportunity for  Improvement:

Improvement efforts should be focused on improving patient care reducing costs and fulfilling PSCKD mission, and goals. Review applicable standards and guidelines.

Analyze collected data to evaluate customers’ needs.

Outline the basic problem and the desired outcome

O Organize a Team:

Improvement may span several departments. Identify and involve stakeholders i.e. physicians, administration, finance, human resources, etc.

Select Team Members who do or know the process/problem.  “Ownership” of the solution helps ensure future compliance.

C Clarify the Current Process:

Improvement cannot take place until the current process is fully understood by all team members. Draw a flow chart of the problem.

Obtain input from all affected areas.

Collect or obtain data relevant to the process and desired outcomes.

U Understand the Sources of the Problem and the Process Variation

Improving the process means identifying all possible causes and variations developing solutions to achieve the desired outcome. Obtain additional information that is required:  collect data benchmarking best practice, etc.

Identify the tools required to describe and analyze the process and desired outcome.

S

Select the Improvement:

Analyze alternative solutions and process improvement. Choose the best solution that will achieve the desired outcome. Develop approval with a summary of required information, expected outcomes, resources, time frames, team membership, etc.

STEPS FOR IMPLEMENTATION OF QUALTIY IMPROVEMENT OPPORTUNITIES

P

Plan the Improvement:

An improvement project will be well planned with goals and target according to the established ongoing objectives. The plans will be communicated to all departments of concerns. Tasks will be assigned to the Team, a checklist and realistic time frames will be set for its realization.

Each Team Leader will be responsible for obtaining necessary data, monitoring the project, and keeping track of it.  The overall outcome is the responsibility of department head concerns and the T.Q.M. Department

All departments that will be affected by the projects will be notified of the implementation by the Action Team Leaders.

D Do the Improvement:

After the project planning, the implementation strategies will be identified to be implemented systematically. All the people involved in the process will be trained.

In the process data will be collected including negative and positive outcomes and the required checklist will be updated as per outcome.

The improved process will be kept and maintain and defects will be rectified.  It will be kept on track by monitoring.

C Check  the Results:

The result of the implemented strategies will be analyzed to measure the outcome.  This question is necessary to rise at this time to see the results:  “Did the change lead to the expected improvement?”  Compare the data collected with that collected during and after implementation to ascertain, if the project goals were met. Check for any adverse consequences whether the change is acceptable to all involved.

Continue to collect data to determine the effectiveness and compliance with the strategic solutions.

A Act to Hold the Gain:

If the project goals, change, and the desired outcome were met, the improved process shall be standardized throughout PSCKD, where applicable. Necessary adjustments will be made to the policies and procedures to update and adopt the improved processes.

These changes will be communicated to employees who will be involved in its performance by orienting or including it in the continuing education or career development.

Changes will be monitored and documented to identify any additional opportunities for improvement. The success of any improvement project shall be owned by the Team and the Departments involved in the process.

 

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Quality Department Acts as an organizational resource, consultant, facilitator and change agent to add value to all areas of the King Salman Center for Kidney Diseases in support of the mission, vision and values of the Center.

 

Vision of Quality Department :

The Quality Department at KSCKD will make quality improvement part of everything we do.

The VALUES of the Quality Department are:

  • Safe – reduce risks to ensure the safety of our patients and staff .
  • Effective – provide the correct care in the correct manner consistent with current state of knowledge, relative to the patient.
  • Patient Centered – provide care, treatment and services sensitive to and respectful of the patient’s needs, expectations and preferences. We are here to serve our patients.
  • Timely – provide a service, treatment, test or procedure at the necessary or most beneficial time
  • Equitable – closing the gaps so all patients who need services, receive them.
  • Efficient – provide care that balances patient outcomes with resources needed.

SCOPE OF ACTIVITIES:

All departments are responsible for establishing and maintaining a management style that fosters quality standards of service and care. The QM 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.

The scope of the Center’s Quality Improvement program includes an overall assessment of the efficacy of performance improvement activities and evaluation of the dimensions of performance of patient care and the clinical performance of all individuals with clinical privileges with a focus on continually improving care provided throughout the center. The program consists of: performance improvement and quality activities. Collaborative and specific indicators of both key processes and outcomes of care are designed, measured and assessed by all appropriate departments/services and disciplines in an effort to improve the Center’s performance. These indicators are objective, measurable, based in current knowledge and experience and are structured to produce statistically valid performance measures of care provided. This mechanism also provides for evaluation of improvements and the stability of the improvement over time.