CQI Activities

7/31/2019 CQI Activities

1/20

Quality

AssuranceRadiology Laboratory

Nursing

Pharmacy

Medical

Dietary

Administrative

Maintenance

Sayre Highway, Valencia City, Bukidnon


2/20

Hospital Vision and Mission

Re-iterate the hospital vision and mission toall employees during regular meeting

VISION:

To become one of the best healthcareinstitutions that provide quality healthservices to humanity.

MISSION:To promote preventive health medicine andprovide quality health care services to allpeople at all times.


3/20

4 Elements of CQI

Assessmentand

Monitoring Action

Evaluation Feedback

PDCA is arepetitive

cycle

PLAN

DO

ACT

CHECK


4/20

Self-Assessment Survey using the

PhilHealth Regulatory Standards

The hospitals benchbook team with the top

management conducts a self-assessment

survey of each hospital section.

A report was made and proper action was

carried out to address the deficiencies noted

during the survey.


5/20

Monthly Patient Satisfaction Surveys

In-Patient Satisfaction Survey

OPD Patient Satisfaction Survey

Billing Patient Satisfaction Survey

These surveys are conducted and analyzed

each month by the QA Committee.Specific issues are noted based on the result

of the survey analysis and proper action is

then carried out.


6/20

3 Research Studies conducted

Patient Satisfaction with Quality Nursing Care,

Valencia Medical Hospital

Caring Behaviors of Staff Nurses

Effectivity of Waiting time at the OPD and

Emergency Room Departments as perceived

by the patients and SOs


7/20


8/20

Quality Improvement Plan

Areas of

Concern

Specific

Objectives

Strategies Resources Time

Frame

Expected

Outcome

Patients

suggestions on

quality nursing

care

improvement

are the

following:

1. Nurses musteducate

patients on

their drugs

To re-orient andmotivate nurses to

fulfill their

responsibilities on

drug administration

specifically in

educating patients

and their families ontheir medication

regimen.

Conduct lecture

on the nurses

responsibilities

on drug

administration

-Utilize Trainingmaterials from

ANSAP on drug

administration

-Formulate

PowerPoint

Presentation on

nursesresponsibilities on

drug

administration

from valid and

reputable

pharmacology/

nursing books.

1-2 daysin-house

lecture

The nurses will

be able to fulfill

their

responsibilities

on drug

administration

particularly in

educatingpatients and

their families on

their prescribed

medications.


9/20

Areas of

Concern

Specific

Objectives


Frame

Expected

Outcome

2. Long

waiting time

of patients for

nurses to

respond to

their call.

To re-orient the

nursing staff on

time

management in

the workplace

and

prioritization of

patients needs.

Conduct

seminar on

time

management

and patient

triage.

-The HR Head

will conduct

seminar on

workplace time

management

-The Head

Nurse will

conduct

seminar on

patient triage

and

prioritization ofneeds.

-Budget for the

seminar.

1-2 days

in-house

seminar

The nurses

will be able to

gain

applicable

knowledge on

workplace

time

management,

patient triage

and

prioritization

of patientsneeds.



10/20


Areas of

Concern

Specific

Objectives


Frame

Expected

Outcome

3. Nurses

improve their

competence in

the following:

a. Render care

with

compassion

b. Knowledge ofthe condition

and treatment

of each patient

c. Interpersonal

relations with

patients and

their families

To enhance the

competence of

nurses by

designing

professional

development

programs for

the staff.

Provide professional

development

programs for the

nursing staff such

as:

-in-house lectures,

trainings and

seminars-encourage staff to

attend seminars and

trainings conducted

by reputable

institutions/

agencies.

-motivate staff topursue continuing

education in nursing

-Budget for the in-

house trainings as

well as budget for

the nurses who will

attend trainings

and seminars

outside the

institution.

1-2 days

in-house

training

per

quarter

Successful

professional

development

programs as

evidenced by

improvement in

the competency

of staff nurses.


11/20

Compliance of Infection Control

Policies

All hospital employees practice proper hand

washing technique


12/20

Proper use of personal protective equipment

Regular meeting of the Infection Control Team

Monitoring of Nosocomial Infection Maintaining the cleanliness of the entire

hospital each hospital employees have a

cleaning schedule aside from the routine

cleaning schedule of the maintenance staff.

*Bayanihan was conducted to address the

hospitals cleanliness.

Compliance of Infection Control

Policies


13/20

Proper segregation of waste is strictly followed

by all hospital employees

*Black- Non-biodegradable

*Green-Biodegradable

*Yellow-Infectious

*Red-Sharps*Yellow with Black line-

Compliance of Waste Management

Policies


14/20

Non-biodegradable/Biodegradable

and Infectious Waste Bins


15/20

Sharps Waste Bins


16/20

Each hospital area

are regularly

assessed and

monitored that itmeets the

standards of safety,

comfort,ventilation and

lighting.

Ensuring the Safety, Comfort,

Adequate Ventilation and Lighting


17/20

Each hospital area isclearly marked withits appropriatesignages and warningsigns as applicable.

Signages are Prominently Marked


18/20

Regular review of the existing hospital policies

and procedures.

Revision of policies as needed.

Attendance of the trainings, conventions,

seminars conducted by PhilHealth/DOH.

Compliance with DOH/PhilHealth

Standards


19/20

The top management evaluates its own

performance and the performance of the

organization.

Section heads also evaluate the performance

of each hospital staff.

Regular Performance Evaluation of

Hospital Management and its Employees


20/20

ContinuousQuality

ImprovementActivities

Professional Growth,Training and

Development ofEmployees

HospitalInformation

System

Equipment andSupplies

Maintenance ofHospital Facilities

and Medical Devices

Budget Allocation

CQI Activities

Documents

Transcript of CQI Activities