Quality Management & Patient Safety

Total Standards: 25 | Total Sub-Standards: 108 | Total ESR Standards: 2

Hospital leaders support a hospital-wide continuous quality improvement

QM.1
program.
QM.1.1 Hospital leaders provide resources required for the continuous quality improvement
program, including human, financial, and time resources.
Surveyor: LD
Activities: Observation, Document Evidence
QM.1.2 Hospital leaders actively participate in quality improvement activities including
improvement teams.
Surveyor: LD
Activity: Quality Committee
QM.1.3 Hospital leaders implement the recommendations resulting from the continuous quality
improvement program.
Surveyor: LD
Activity: Quality Committee
QM.1.4 Hospital leaders support staff to make and participate in quality improvement initiatives
and to attend quality improvement educational activities.
Surveyors: LD, NR
Activity: Staff Interview
Hospital leaders support staff training on their roles and responsibilities
QM.2
related to the continuous quality improvement program.
QM.2.1 Staff are trained on quality improvement by qualified professionals.
Surveyor: LD
Activity: Document Evidence
QM.2.2 Training on quality improvement includes the utilization of quality improvement
methodologies and tools (e.g., PDCA, lean six sigma, cause-and-effect analysis, process
map, Pareto chart, brain storming).
Surveyor: LD
Activity: Document Evidence
QM.2.3 Staff are trained (formally or through orientation and mentoring) on continuous quality
improvement in accordance with their roles and responsibilities in the quality
improvement program.
Surveyor: LD
Activities: Staff Interview, Personnel File Review
The hospital has a quality management department that is directed by a
QM.3
qualified individual.

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QM.3.1 The hospital has a quality management director responsible for directing all aspects of the
quality management department.
Surveyor: LD
Activity: Personnel File Review
QM.3.2 The quality management director is qualified by education, training, and experience in
healthcare quality.
Surveyor: LD
Activity: Personnel File Review
QM.3.3 The quality management department provides ongoing consultation to all departments
(e.g., on the development and use of indicators to evaluate and improve performance).
Surveyor: LD
Activity: Quality Committee
QM.3.4 The quality management director reports to the hospital leadership.
Surveyor: LD
Activity: Document Evidence
The hospital develops a quality improvement program that provides a
QM.4 structured framework for monitoring and improving performance as well as
supporting innovation.
QM.4.1 The quality improvement program covers processes of care involving high risk, high
volume, problem-prone, and high cost areas.
Surveyor: LD
Activity: Document Review
QM.4.2 The quality improvement program is in line with the hospital strategic plan.
Surveyor: LD
Activities: Document Review, Quality Committee
QM.4.3 The quality improvement program is integrated with the risk management and patient
safety activities.
Surveyor: LD
Activities: Document Review, Quality Committee
QM.4.4 The quality improvement program is based on a documented quality improvement plan
that is revised at least annually, with defined scope, goals, and objectives.
Surveyor: LD
Activity: Document Evidence
There is a multidisciplinary committee responsible for the coordination of the
QM.5
quality improvement program.
QM.5.1 The hospital has a multidisciplinary quality improvement committee that has members
from the leadership group (the hospital director, medical director, nursing director, quality
management director) and other members/invitees as appropriate.
Surveyor: LD
Activity: Document Review

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QM.5.2 The quality improvement committee provides coordination and oversight of the quality
improvement program throughout the hospital.
QM.5.2.1 The quality improvement committee is responsible for development,
implementation, and evaluation of the quality improvement program.
QM.5.2.2 The quality improvement committee approves all quality improvement
initiatives.
QM.5.2.3 The quality improvement committee receives quality reports and
provides feedback to the relevant stakeholders.

Surveyor: LD
Activities: Document Evidence, Quality Committee
QM.5.3 The quality improvement committee meets regularly and maintains appropriate
documentation of its activities.
Surveyor: LD
Activity: Document Evidence
The hospital monitors its performance through regular data collection and
QM.6
analysis.
QM.6.1 The performance monitoring is based on valid data that reflect the actual performance.
QM.6.1.1 Hospital leaders define and implement a set of hospital performance
indicators/measures that focus on important managerial and clinical areas.
QM.6.1.2 Clinical indicators are referenced to current evidence based practice
whenever applicable.

Surveyor: LD
Activity: Quality Committee
QM.6.2 For each indicator, there is a clear definition, sample size, data collection method,
frequency, analysis, and expression (e.g., a ratio, with defined numerator and
denominator).
Surveyor: LD
Activity: Quality Committee
QM.6.3 Indicators represent key care and service structures, processes and outcomes based on the
mission and scope of services.
Surveyor: LD
Activity: Quality Committee
QM.6.4 Data are collected and aggregated on a regular basis from qualitative and quantitative
sources.
Surveyor: LD
Activity: Quality Committee
QM.6.5 Data are coordinated with other performance monitoring activities such as patient safety
and risk management.

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Surveyor: LD
Activity: Quality Committee
Hospital leaders select a set of structure indicators based on the mission and
QM.7
scope of services.
QM.7.1 Hospital leaders utilize the information provided by structure indicators.
Surveyor: LD
Activity: Quality Committee
QM.7.2 Structure indicators may include, but are not limited to, the following:
QM.7.2.1 Availability of essential supplies and equipment.
QM.7.2.2 Availability of medical records.
QM.7.2.3 Availability of blood and blood products.
QM.7.2.4 Availability of emergency medications.
QM.7.2.5 Vacancy rates in all departments.
QM.7.2.6 Surgical volumes.
QM.7.2.7 Staffing ratios.

Surveyor: LD
Activity: Quality Committee
Hospital leaders select a set of process indicators based on the mission and
QM.8
scope of services.
QM.8.1 Hospital leaders utilize the information provided by process indicators.
Surveyor: LD
Activity: Quality Committee
QM.8.2 Process indicators may include, but are not limited to, the following:
QM.8.2.1 The timing and use of antibiotics prior to surgery.
QM.8.2.2 Blood and blood products administration.
QM.8.2.3 Documentation in medical records.
QM.8.2.4 Delay of physicians answering nurses’ phone calls and pagers.
QM.8.2.5 Waiting times for treatment.
QM.8.2.6 Venous thrombo-embolism prophylaxis for surgical patients.
QM.8.2.7 Neuropathy testing in diabetic patients.

Surveyor: LD
Activity: Quality Committee
Hospital leaders select a set of outcome indicators based on the mission and
QM.9
scope of services.
QM.9.1 Hospital leaders utilize information provided by outcome indicators.
Surveyor: LD
Activity: Quality Committee
QM.9.2 Outcome indicators may include, but are not limited to, the following:

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QM.9.2.1 Mortality rates.

QM.9.2.2 Healthcare associated infections.
QM.9.2.3 Staff satisfaction.
QM.9.2.4 Patient satisfaction.
QM.9.2.5 Unplanned return to the operating room.
QM.9.2.6 Return to the emergency room within 24 hours.
QM.9.2.7 Unplanned transfer to the critical care unit.
QM.9.2.8 Resuscitation of patients (cardiac/respiratory arrest).
QM.9.2.9 Readmission to the hospital within 30 days of discharge.
QM.9.2.10 Various adverse events (e.g., falls, injuries, and pressure ulcers).
QM.9.2.11 Medication errors.
QM.9.2.12 Sentinel events.
QM.9.2.13 Patient complaints.
QM.9.2.14 Length of stay.

Surveyor: LD
Activity: Quality Committee
QM.10 Data collected are aggregated and analyzed.
QM.10.1 Data collected are analyzed by staff qualified in data management.
Surveyors: LD, IC
Activity: Document Evidence
QM.10.2 Data collected are regularly aggregated and analyzed to yield useful trends and variances.
Surveyor: LD
Activity: Document Evidence
QM.10.3 Data are utilized for internal and external benchmarking to identify deficiencies and
opportunities for improvement.
Surveyor: LD
Activity: Document Evidence
QM.10.4 Information is communicated to the appropriate stakeholders in a way they can
understand and use.
Surveyors: LD, MD, IC
Activities: Medical Executive Committee, Quality Committee
The hospital uses the information resulting from data analysis to make
QM.11
improvements.
QM.11.1 Information resulting from data analysis is used for prioritizing quality improvement
projects as well as strategic and operational planning.
Surveyor: LD
Activity: Quality Committee
QM.11.2 When appropriate, the hospital tests improvement interventions prior to full
implementation.

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Surveyor: LD
Activity: Quality Committee
QM.11.3 After implementing improvement interventions, the hospital measures their effectiveness
to ensure that interventions have achieved a sustained improvement.
Surveyor: LD
Activity: Quality Committee
Quality improvement teams are selected by the service leaders and these teams
QM.12
use quality tools to improve processes.
QM.12.1 Quality improvement teams are assigned by the service leaders.
Surveyor: LD
Activities: Document Evidence, Quality Committee
QM.12.2 The quality improvement team includes staff members who are involved in the process
under study.
Surveyor: LD
Activity: Document Evidence
QM.12.3 The quality improvement team uses the quality tools to improve processes (e.g.,
brainstorming and fishbone charts).
Surveyor: LD
Activity: Document Evidence
QM.13 The hospital develops and maintains a risk management program.
QM.13.1 The risk management program addresses potential managerial and clinical risks.
Surveyor: LD
Activity: Document Review
QM.13.2 The hospital defines the scope and objectives of the risk management program as well as
the individual responsible for the program.
Surveyor: LD
Activity: Document Review
QM.13.3 The hospital educates the staff on their roles and responsibilities related to the activities of
the risk management program.
Surveyor: LD
Activity: Staff Interview
QM.13.6 The hospital adopts a proactive approach to identify, analyze, and reduce potential risks
(e.g. failure mode and effects analysis).
Surveyor: LD
Activity: Quality Committee
QM.13.7 Heads of clinical departments and other clinical leaders participate in the risk
management program.
Surveyor: LD
Activity: Quality Committee

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QM.13.8 Heads of clinical departments and other clinical leaders develop, implement, and evaluate
interventions to safeguard patients from unintended consequences of care/treatment.
Surveyor: LD
Activity: Quality Committee
QM.13.9 The risk management program addresses patient safety issues and makes use of the
information developed from investigation of the following:
QM.13.9.1 All litigations involving the hospital and its staff.
QM.13.9.2 Adverse incidents including near misses and sentinel events.
QM.13.9.3 Patient complaints.
QM.13.9.4 Cases of irregular discharges.
QM.13.9.5 Data and reports related to patient safety issues.
QM.13.9.6 Mortality and significant morbidity cases.

Surveyor: LD
Activity: Document Review
QM.13.10 The effectiveness of the risk management program is evaluated regularly and improved as
required.
Surveyor: LD
Activities: Document Evidence, Quality Committee
QM.13.11 The hospital maintains appropriate documentation of the risk management activities.
Surveyor: LD
Activity: Document Evidence
QM.13.12 The risk management activities and their results are communicated to the staff and other
relevant groups and used as a basis for improvement of the hospital’s processes.
Surveyor: LD
Activity: Staff Interview
QM.13.13 Relevant information developed from the risk management activities is integrated and
coordinated with the quality improvement and patient safety activities.
Surveyor: LD
Activities: Document Evidence, Quality Committee
QM.13.4 The hospital performs a systematic process to identify and analyze potential risks for
severity and likelihood of occurrence.
Surveyor: LD
Activity: Document Evidence
QM.13.5 The hospital develops interventions to manage identified potential risks (e.g., reduction
and/or prevention).
Surveyor: LD
Activity: Document Evidence
The hospital has an incident (occurrence/variance) management mechanism
QM.14
that supports improvements of care processes.

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QM.14.1 There is a policy and form that are utilized for reporting incidents including adverse
events and near misses.
Surveyor: LD
Activity: Document Review
QM.14.2 The hospital defines reportable incidents.
Surveyor: LD
Activity: Document Review
QM.14.3 Incidents are reported and investigated in a timely manner.
Surveyor: LD
Activity: Staff Interview
QM.14.4 Immediate remedial actions are taken as well as actions to prevent recurrence of similar
incidents.
Surveyor: LD
Activities: Document Evidence, Quality Committee
QM.14.5 Patients receive response when involved in significant incidents with documentation in
the medical records.
Surveyor: MD
Activity: Closed Medical Record Review
QM.14.6 Incidents are monitored over time and the resulting information is used for improvement.
Surveyor: LD
Activities: Document Evidence, Quality Committee
QM.14.7 Staff are educated on the incident reporting process.
Surveyor: LD
Activity: Staff Interview
QM.15 The hospital has a process to handle sentinel events.
QM.15.1 There is a policy for management of sentinel events.
Surveyor: LD
Activity: Document Review
QM.15.2 Sentinel events are identified in the hospital’s policy and include the following:
QM.15.2.1 Unexpected death.
QM.15.2.2 Unexpected loss of limb or function.
QM.15.2.3 Wrong patient, wrong procedure, or wrong site.
QM.15.2.4 Retained instrument or sponge.
QM.15.2.5 Serious medication error leading to death or major morbidity.
QM.15.2.6 Suicide of a patient in an inpatient unit.
QM.15.2.7 Infant abduction or discharge to a wrong family.
QM.15.2.8 Maternal death.
QM.15.2.9 Hemolytic blood transfusion reaction.
QM.15.2.10 Air Embolism.

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Surveyor: LD
Activity: Document Review
QM.15.3 Reportable sentinel events are reported to CBAHI within five working days of the
internal notification of the event.
Surveyor: LD
Activity: Document Evidence
QM.15.4 The hospital forms a team to complete the root cause analysis along with an action plan
for all sentinel events. The team should bring together those who have an intimate
knowledge of the normal process.
Surveyor: LD
Activities: Document Evidence, Quality Committee
QM.15.5 The root cause analysis and risk reduction plan are sent to CBAHI within thirty working
days from the date of the internal notification of the event.
Surveyor: LD
Activity: Document Evidence
QM.15.6 Reportable sentinel events are reported as required to other relevant authorities.
Surveyor: LD
Activities: Document Evidence, Quality Committee
QM.16 The hospital develops and maintains a patient safety program.
QM.16.1 Hospital leaders adopt a just culture that promotes both professional accountability and
reporting of adverse events/near misses.
Surveyor: LD
Activity: Quality Committee
QM.16.2 Hospital leaders provide direction and resources to support the patient safety program.
Surveyor: LD
Activities: Staff Interview, Quality Committee
QM.16.3 The hospital assigns a qualified individual to provide coordination and supervision of the
organization-wide patient safety program.
Surveyor: LD
Activity: Personnel File Review
QM.16.4 Hospital leaders establish a multidisciplinary patient safety committee (can be integrated
with quality improvement committee) to provide direction and oversight of the patient
safety program.
Surveyor: LD
Activity: Document Review
QM.16.5 Hospital leaders conduct patient safety culture assessment at least once annually. Data are
analyzed and improvements are made accordingly.
Surveyor: LD
Activities: Document Evidence, Quality Committee

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QM.16.6 Hospital leaders conduct regular leadership patient safety rounds in patient care services
to encourage reporting of incidents/near misses and to identify potential risks and
hazards.
Surveyor: LD
Activities: Document Evidence, Quality Committee
QM.16.7 The hospital adopts safe practices that have been proven to improve patient safety and
reduce harm to patients such as those from the World Health Organization (WHO) and
other national and international organizations concerned with patient safety.
QM.16.7.1 The hospital develops and implements policies, procedures, protocols,
and guidelines for implementation of the patient safety practices.
QM.16.7.2 The hospital provides equipment/devices with technological features
proven to reduce errors and improve safety.

Surveyors: MD, NR, LB

Activities: Observation, Staff Interview
QM.16.8 Relevant information developed from patient safety activities is integrated into quality
improvement and risk management activities.
Surveyor: LD
Activity: Quality Committee
QM.16.9 Patient safety activities and their results are communicated to the staff and other relevant
groups and used as the base for improving the hospital’s processes.
Surveyor: LD
Activity: Document Evidence
QM.17 The hospital has a process to ensure correct identification of patients.
QM.17.1 At least two patient identifiers (e.g., patient full name and medical record number) are
required whenever taking blood samples, administering medications or blood products, or
performing procedures.
Surveyors: MD, NR, MM, LB
Activity: Staff Interview
QM.17.2 The hospital has a standardized approach to patient identification (e.g., use of ID bands
with standardized information).
Surveyors: NR, LB
Activity: Observation
QM.17.3 Patients are actively involved in the process of patient identification.
Surveyors: MD, NR, MM, LB
Activity: Staff Interview
The hospital has a process to prevent wrong patient, wrong site, and wrong
QM.18
surgery/procedure.
QM.18.1 There is a process implemented to prevent wrong patient, wrong site, and wrong
surgery/procedure during all invasive interventions performed in operating rooms or other

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locations.
Surveyors: MD, NR
Activity: Staff Interview
QM.18.2 The process consists of three phases: verification, site marking, and time out.
Surveyor: NR
Activity: Closed Medical Record Review
QM.18.3 A pre-procedure verification of the patient information is carried out including the
patient’s identity, consent, full details of the procedure, laboratory tests and images, and
any implant or prosthesis.
Surveyor: NR
Activity: Closed Medical Record Review
QM.18.4 The surgical/procedural site is marked before conducting the surgery/procedure.
QM.18.4.1 The site is marked especially in bilateral organs and multiple
structures (e.g. fingers, toes, and spine).
QM.18.4.2 The site is marked by the individual who will perform the procedure.
QM.18.4.3 The patient is involved in the marking process.
QM.18.4.4 The marking method is consistent throughout the hospital.
QM.18.4.5 The mark is visible after the patient is prepped and draped.

Surveyor: NR
Activity: Closed Medical Record Review
QM.18.5 A final check (time-out) is conducted before the procedure is initiated.
QM.18.5.1 The time-out is conducted in the location where the procedure will be
done, just before starting.
QM.18.5.2 The time-out is initiated by a designated member of the team and
involves the members of the team, including the individual performing the
procedure, the anesthesia providers, and the nurse(s) involved.
QM.18.5.3 The entire procedure team uses active communication during the time
out.
QM.18.5.4 During the time-out, the team members agree on the correct patient
identity, the correct procedure to be performed, the correct site, and when
applicable, the availability of the correct implant or equipment.

Surveyor: MD
Activities: Observation, Staff Interview
QM.18.6 The hospital documents its processes for preventing wrong patient, wrong site, and wrong
surgery/procedure.
Surveyors: MD, NR
Activity: Open Medical Record Review
QM.19 The hospital ensures availability and safety of infusion pumps.

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QM.19.1 Infusion pumps are available with adequate numbers throughout patient care areas.
Surveyor: NR
Activity: Observation
QM.19.2 Infusion pumps have "free-flow" protection.
Surveyor: NR
Activity: Observation
QM.19.3 Infusion pumps have documented preventative maintenance, inspection and testing on a
regular basis.
Surveyor: NR
Activity: Document Evidence
QM.20 The hospital ensures the safety of the alarm systems of patient care equipment.
QM.20.1 All alarm systems for patient care equipment (such as infusion pumps and monitors) have
documented preventative maintenance, inspection and testing on a regular basis.
Surveyor: FMS
Activity: Document Evidence
QM.20.2 All staff are trained on the safe use of alarm systems for patient care equipment and the
use of appropriate settings for sound.
Surveyor: FMS
Activity: Staff Interview
The hospital ensures appropriate communication of patient care information
QM.21
during patient handovers.
QM.21.1 Patient care information is appropriately documented in a clearly understandable form to
all care providers within and between care settings.
Surveyors: MD, NR
Activity: Open Medical Record Review
QM.21.2 The hospital implements a standardized approach to handover communication between
staff (e.g., Situation, Background, Assessment, Recommendation-SBAR), change of shift,
and between different patient care units in the course of a patient transfer.
Surveyor: NR
Activities: Staff Interview, Document Evidence
The hospital has a process for effective identification, assessment, and
QM.22
intervention for patients who are at risk for pressure ulcers.
QM.22.1 All patients are assessed for pressure ulcers on admission using a standard risk
assessment tool.
Surveyor: NR
Activity: Closed Medical Record Review
QM.22.2 All patients are re-assessed for pressure ulcers every twenty four hours.
Surveyor: NR
Activity: Closed Medical Record Review

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QM.22.3 The hospital implements evidence-based interventions that prevent pressure ulcers.
Surveyor: NR
Activity: Closed Medical Record Review
The hospital has a process for effective identification, assessment, and
QM.23
intervention for patients who are at risk for falling.
QM.23.1 Patients are assessed for the risk of fall on admission.
Surveyor: NR
Activity: Closed Medical Record Review
QM.23.2 Patients are reassessed for the risk of fall after a change in risk factors (e.g., post-
operatively, after receiving sedating medications) and upon transfer from another unit.
Surveyor: NR
Activity: Closed Medical Record Review
QM.23.3 The hospital implements evidence-based interventions for falls reduction according to the
risks identified.
Surveyor: NR
Activity: Staff Interview
The hospital implements evidence-based interventions to prevent catheter and
QM.24
tubing misconnections.
QM.24.1 Patients and families are informed not to connect or disconnect devices or infusions.
Surveyor: NR
Activity: Staff Interview
QM.24.2 High-risk catheters (e.g., epidural, intra-thecal, arterial) must always be labeled.
Surveyor: NR
Activity: Observation
QM.24.3 All lines (tubes or catheters) are always traced from the patient to the point of origin
before connecting any new device or administering medications or infusion.
Surveyor: NR
Activity: Staff Interview
QM.24.4 All lines (tubes or catheters) are always traced from the patient to the point of origin upon
the patient's arrival to a new setting or service as part of the hand-off process. The
hospital standardizes this "line reconciliation" process as part of the hand-over
communication.
Surveyor: NR
Activity: Staff Interview
QM.24.5 The hospital prohibits the use of standard luer-connection syringes for oral medications or
enteric feedings.
Surveyor: NR
Activity: Staff Interview
QM.24.6 The hospital conducts acceptance testing (for performance, safety, and usability) and, as
appropriate, risk assessment on new tubing and catheter purchases to identify the

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potential for misconnections and take appropriate preventive measures.

Surveyor: LD
Activity: Document Evidence
There is a written policy on verbal or telephone orders and telephone reporting
QM.25
of critical test results.
QM.25.1 The policy defines situations for accepting verbal or telephone orders.
Surveyor: MM
Activity: Document Review
QM.25.2 The policy defines the time frame for orders authentication.
Surveyor: MM
Activity: Document Review
QM.25.3 The policy defines staff who may accept verbal or telephone orders.
Surveyor: MM
Activity: Document Review
QM.25.4 The complete verbal or telephone order or critical test result is written down by the
receiver of the order or test result.
Surveyors: NR, MM, LB
Activities: Staff Interview, Open Medical Record Review
QM.25.5 The complete verbal or telephone order or critical test result is read back by the receiver
of the order or test result.
Surveyors: NR, MM, LB
Activity: Staff Interview
QM.25.6 The order or test result is confirmed by the individual who gave the order or test result.
Surveyors: NR, MM, LB
Activity: Staff Interview

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