Healthcare professionals are very keen on the patient's best interests
The Levant hospital is keen on providing patients with the best quality and security. It established to this end a problems and grievances department where unity, loyalty, team work and transparency coexist in a sanction free environment.
- Our professional team is convinced that medicine is first and foremost a quality service available to all
- "We listen to our patients"
The Quality Bureau Charter
n Assessing patient satisfaction by thoroughly analyzing the answers provided in the satisfaction questionnaire
n Generalizing risk management by examining and centralizing the incident description
n Examining, coordinating and promoting quality related endeavors
n Providing guidelines to the training policy and providing methodological support
n Helping physicians attain the accreditation objectives.
The risk management activities are as follows:
· Focusing on the identification of risks
· Using accidents reports, client complaints and the frequency of accidents to identify the risks
· Protecting the institution and the elements affiliated therewith
Listening to patients' complaints and/or accidents and investigating the responsibility thereof.
The Clinic is constantly concerned with improving quality and security. In the 2008-2013 strategic plan, a Chapter was devoted to improving the quality enhancement policy and hospital risk management.
The major axes are as follows:
· Coordination and implementation of the risks prevention and management policy (vigilance)
· Fighting nosocomial infections
· Fighting pain (organizing and fighting)
· Constant improvement of quality (self assessment and accreditation)
VIGILANCE
Our main goal is to examine and identify the risks that patients, guests, employees or hospital assets might encounter.
SELF-ASSESSMENT
Our clinic works constantly on improving its performance. Hence, it relies mainly on performance indicators such as assessing patient satisfaction on a daily basis and improving the performance indicators that are necessary to improving the quality and assessing the medical and health care professional practices.
Patients receive:
· A satisfaction questionnaire upon check-out
· A satisfaction assessment form during his stay
· A welcome booklet.
Health professionals assess their performance in order to improve the quality of their services and make sure that quality is attainted. Performance indicators are established to manage the patient file and the pain follow-up.
Strategic Actions relevant to the Quality Department
The quality department undertook many strategic actions that translated into a QIP:
- Patient satisfaction: "Feed-Back" and "Feed-Forward" QS/QIP/1.2009
- Document management QS/QIP/1.2009
- A booklet on the rights and obligations of the patient QS/QIP/1.2010
The Audit Commission
It aims at auditing all departments in a harmonized and objective manner.
Its objectives :
w Understanding the importance of audits feasibility
w Auditing the different departments
w Making sure that auditors are objective in conducting the audits and providing the necessary follow-up
w Following up on audits and undertaking the applicable improvement actions
The team project: it is professional and multidisciplinary and constitutes a coherent, involved, dynamic and unified group.
Training :
The head of the Quality Bureau holds a training session on audits (auditors and auditees) twice a year.
· Data Collection
Data collections aims at seeking, verifying and taking the necessary information and figures from one source or more from all departments in order to compute one or more indicators such as activities, resources and results.
A data collection form is compiled for every department and shall contain the information relevant thereto. The chosen indicators contain the figures and study the same in order to seek improvement.
A table is incepted for every department. Graphs are drawn at the end of every year. Comparison graphs are drawn in order to examine the periodic evolution.
Indicator cards help identify the "rationale" behind the indicators as well as the indicator, the nominator, the denominator, the exclusion, inclusion and data to be collected.
The data and indicators are interpreted on a quarterly or annual basis in the light of follow up reports, in order to examine data progression and evolution.
· Among the top quality indicators the following:
1. Complain/ stay ratio
2. Patient satisfaction ratio
3. Employee satisfaction ratio
4. Number of correction measures
5. Booklet distribution ration
· Among the risk management complied indicators, we identified the following:
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- Rate of patients suffering from an extravasation of cytotoxic products
- Rate of hospital readmissions 24 hours after checkout
- Rate of incidents occurring in the use of medical equipment
- Rate of patients checking out against medical advice
- Rate of contamination due to foreign bodies accidentally left following a surgical intervention
- Rate of medicinal error
- Rate of bloc readmission within 48 days
- Rate of hospital readmission within 28 days for the same reason
- Rate of surgical errors (operating from the wrong side)
- Rate of transfusion related accidents
- Rate of cases whereby a patient's file is found missing
- Rate of post-surgery infections
- Rate of persons suffering from a flu, pneumococcal or BMR infection
- Rate of mistakes in patients IDs (labels, diagnosis, name)
- Maternal mortality rate
- In uterus mortality rate after 26 weeks of life
- Rate of patients relapse
- Rate of bedsores
Annual training
Following the annual performance review of all members, the quality department assesses the specific needs for training and holds the relevant training programs.
