Quality Management and Patient Safety Program

Quality and Patient Doc No: YH/QAD/1
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Reference: Internal JCI -7th Edition
Benchmark
1. PURPOSE
[a.] The Quality Improvement and Patient Safety Program (QIPSP) is a description of the
organizational, multidisciplinary, and systematic performance improvement function
designed to support the Mission, Values, and Philosophy Core Values of the Yashoda
Hospital Hitec City
a.[b.] The intent of the QIPSP is to establish the facility’s systematic approach to improving
and sustaining its performance through the prioritization, design, implementation,
monitoring, and analysis of performance improvement initiatives.
b.[c.] The QIPSP is an ongoing program that demonstrates measurable improvement in key
performance indicators that support improving patient outcomes and identify and reduce
medical errors.
2. INTRODUCTION:
Please write an introduction of Yashoda Hospital Hitec city. The Policies & Procedures were
implemented and maintained on an ongoing basis.
3. MISSION:
Hospital Mission.
“To provide world class healthcare services at affordable cost in all medical departments with a
constant and relentless emphasis on quality, excellence in service, empathy and respect for the
individual”.
4. VISION:
Hospital Vision.
"To be the most trusted and preferred healthcare provider”.
Departmental Vision:
Promote Quality Awareness to its highest level throughout the Hospital (you may want to change
this)
5. Core Values:
a. CARE: We recognize that every patient is important, and hence deserves the very best care
possible. We will not be mechanical in our approach to work –we will be personal.
Prepared by: Approved by:
Mr. G. Vishwanath (Head of Quality)

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B. COURTESY: We understand that people walking through our doors are often going through a
stressful time. We will go the extra mile to help both patients and their loved ones, feel
completely at ease – through courteous interactions at every stage.
C. CAPABILITY: Whatever be the health problem, we will be fully capable of diagnosing and
treating it effectively. Through the use of advanced technology, techniques and processes.
D. CHARACTER: We will be true to the trust that is placed in us. We will be faithful in following
every procedure and principle. With our primary focus on always doing what is best for the
patient.
E. COMMITMENT: To continuous learning. To find better methods of prevention and cure.

Through undertaking, support and commissioning research, in various medical and
paramedical fields.
F. CONTRIBUTION: Ensuring that we give back significantly to the society we live in through
education, through planned charity and the supporting of local initiatives for better health.
6.[5.] GOALS
 Plan, organize and conduct hospital-wide Quality Improvement activities.
 Integrate Quality Improvement process into the existing Organizational Strategies.
 To organize Quality Improvement activities around the flow of patient care, using cross-
disciplinary and cross-departmental team approaches.
 Support and coordinate with Departmental service leaders in prioritizing the
improvement activities and also identifying the Key performance indicators
 To have continual education program for staff on their role in quality improvement and
patient safety
 Participation of all staff in QIPSP activities and regular communication on Quality Issues.
 Facilitate interdisciplinary communications and cooperation
 To provide a safe environment for patients, visitors, and staff.
 To perform patient care services in a timely and efficient manner.

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 To continuously improve patient outcomes
[6.] OBJECTIVES:
a. To fulfil Yashoda Hospital mission and vision statements.
b. To focus on direct patient care delivery processes & support processes that promote
optimal outcomes & effective business practices.
c. To identify, focus and analyze and correct processes or systems which impact or have the
potential to impact quality patient care.
d. To assess the healthcare provided, patient care outcomes, compliance with approved
Yashoda Hospital policies and procedures and appropriate use of equipment.
e. To promote effective, appropriate and efficient use of resources.
f. To integrate and coordinate Hospital-wide QIPSP and activities in order to increase
effectiveness, eliminate duplication of effort and promote utilization of staff and
resources.
g. To ensure that the results of QIPSP activities are recorded and reported, and that
recommended follow-up is implemented.
h. To prepare data that objectively describe current health-care practices and associated
activity which reflect an over or under utilization of Yashoda resources.
i. To assess the performance of those individuals involved in providing patient care as well
as those who support them
j. To provide and maintain a work environment which facilitates staff improvement
activities in their services.
k. To maintain the standards of the Joint Commission international Accreditation (JCIA).
l. To monitor and evaluate processes to ensure the Hospital’s commitment in providing high
quality patient care is maintained.
7. SCOPE OF SERVICES:
 The Yashoda Hospital QIPS Plan applies to all services provided to internal and external
customers of Yashoda Hospital. It includes inpatient and ambulatory care services, and all
departments and hospital functions. Every physician, clinician, manager, and hospital staff
is responsible for quality, and participates in the Yashoda Hospital Quality Improvement
and Patient Safety Program.
 Yashoda Hospital Departments/Committees/Teams must communicate the conclusions,
recommendations, and actions to improve performance with appropriate staff members
 who are affected by the performance measures.
 Department Managers, Committee Chairmen, or designated Team Leaders will present a

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verbal and written project report to the Unit head periodically, as outlined by the
reporting schedule approved by the Quality and Patient Safety Committee
Scopes of Services include:

 Quality Measurement, Monitoring, Assessment & Improvement
 Patient Safety
 Accreditation Management
8. AUTHORITY AND LEADERSHIP:
a. Roles & Responsibilities:
Board of Directors
Mission, vision, Core Values Strategic objectives, and Key
Prepared by: initiatives
Approved by:

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Hospital Executive committee

Provide resources required for continuous quality
improvement program
Data
Quality and Patient Safety committee Professional Performance

Approves PI Priorities and recommends resources Review
Priorities
Department of Quality
Coordinates all projects and KPIs and reports to quality and
patient safety committee
Standing Committees Sections, Departments, Divisions & Interdepartmental Task

Units Force/Teams
Overseas regular PI activities, aggregate and analyze 1.
data, recommend projects
Perform FOCUS- PDCA, aggregate data, sustain improvement Perform Major PI Projects
Yashoda Hospital Board of Directors delegates the responsibility of Quality Improvement and Patient
Safety Program implementation and maintenance to the Hospital Executive Committee. The
Hospital Executive Committee is responsible for defining the structure and providing the
necessary resources and support system for the Quality Improvement and Patient Safety Program:
a. Sets the direction and provides support for the quality management plan for
implementation.
b. Ensures that there are adequate resources provided to ensure success of the program.
c. Designates authority to the organizational committees to execute the quality
management plan.
d. Ensure that outside contracts are monitored and evaluated as part of the Quality
Improvement and Patient Safety Plan and that corrective action taken when necessary.
Leadership is accountable for contracts for clinical and management and support services

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e. The Quality and Patient Safety Committee will be responsible for developing,
implementing and monitoring the hospital wide Quality Improvement and Patient Safety
Program. Responsible for formal quality planning on at least an annual basis as part of
hospital strategic planning process and to establish direction and priority for quality
improvement initiatives.
f. Collaborative planning is performed resulting in the development of performance
improvement initiatives for the upcoming year.
g. Operational quality initiatives are to support and forward the accomplishment of strategic
objectives.
h. Is accountable and shares responsibility for organizational commitment to determine
patient expectations and satisfaction with the quality and safety of care and services
provided. Such information is used to improve performance and determine whether we
are meeting the organization’s mission, goals and objectives.
i. Reviews and recommends quality improvement and patient safety procedures and
systems for gathering, analyzing, and using information under the Quality Improvement
and Patient Safety Program.
j. Reviews the effectiveness of the Quality Improvement and Patient Safety Program and
authorizes necessary resources and/or changes in organizational structure, systems and
staff to improve program performance.
2. Group Head Quality
a. Identification, prioritization, and implementation of quality improvement and patient
safety activities including key performance indicator, the delivery of quality care services
within their service areas, and evaluation of its impact throughout the healthcare
continuum. This responsibility includes multidisciplinary coordination of the performance
improvement efforts and reporting of results.
b. Responsible for the quality of care and service provided by their staff; to encourage staff
participation in quality improvement and patient safety initiatives; and for followup of
actions related to quality improvement and patient safety initiatives.
c. Responsible to educate and empower staff in quality improvement methodologies.
Education is provided at time of orientation and at department meetings.
d. Assuring quality improvement and patient safety activities are carried out and
appropriately documented.
e. Reporting a summary of departmental review activities, finding conclusions,
recommendations, actions implemented, follow-up to resolution and examples of actual
performance improvement achieved.

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f. Distributing required reports of quality improvement activities as appropriate

3. Unit Head Quality
a. Accountable for the quality improvement and patient safety program and provides
oversight and guidance for the staff in monitoring, evaluating and ensuring timely action
on quality improvement and patient safety opportunities.
b. Is accountable for establishing standards for ensuring the delivery of safe and quality care
and services.
c. Responsible for the identification, prioritization, and implementation of quality
improvement and patient safety initiatives within and across the departments.
d. Quality Improvement and Patient Safety Program Coordinator to develop criteria as an
indicator database for identifying and evaluating specific areas of actual or potential risk
in the clinical aspects of the delivery of patient care and safety.
e. Implementation and evaluation of appropriate corrective action to the extent possible, to
alleviate or resolve identified problems or concerns with patient safety issues.
f. The quality program staff , students and interns help to support data collection
throughout the hospital by assisting with data collection issues such as creating a forms to
collect data, identifying which data to collect, and how to validate data.
g. Implement and maintain a system for monitoring continued quality of patient care.
h. Collaborative planning is performed resulting in the development of performance
improvement initiative for the upcoming year.
i. Implementation of quality improvement and patient safety initiatives to support and
forward the accomplishment of hospital-wide strategic goals and objectives.
j. Ensure the effectiveness of the QIPS program and recommend necessary resources and/or
changes in organizational structure, systems and staff to improve program performance.
k. Ensure that members are sufficiently educated in quality improvement principles and
methods to allow them to support and encourage necessary organizational change
4. Staff Level:
a. Support the QIPS Plan by:
i. Reporting any environmental hazards and/or any safety issues through
established channels such as incident reporting.
ii. Learning about QI concepts and simple Continuous Quality tools that are used to
problem solve with the aim to provide better patient care.
iii. Looking for opportunities for improvement and reporting them to the appropriate
staff (QI designee, department head).
iv. Assisting with QI activities as assigned by the department head.

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v. Attending QI meetings at the unit level and support the QI Designee in their role
5. EDUCATION AND TRAINING
Staff throughout the hospital may need assistance in data validation and analysis, implementing
improvements, and evaluating if improvements were sustained. The quality program staff is thus
constantly involved in training and communicating quality and patient safety issues throughout
the hospital. The quality program implements a training program for all staff that is consistent
with staff’s roles in the quality improvement and patient safety program.
Education of Quality Improvement and Patient Safety efforts and methodologies will be provided
to the staff on Induction, and will include information regarding data collection, aggregation, and
statistical process control as the need arises with participation in the process.
Education and Training will be required and conducted on several levels:

1. Senior Management.
2. Middle Management.
3. Medical Staff.
4. Employees/ Staff
5. Interns
6. Students
Types of Education and Training will consist of both internal and external activities and include
different learning approaches as follows:
a. Formal Classroom instruction.

b. Use of department meetings of clinical and non-clinical staff.
c. Just in time training.
d. Induction Training program for all new hires, interns and students
Educational instructional materials include the following:
a. Reading materials.
b. Informal discussion groups.
c. Hands- on experiences; application exercises.
d. Attendance at external and internal symposiums.
e. QI Projects.
Quality Improvement education and training program:

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Purpose of Educational Activities is to familiarize staff, interns, and students with

fundamentals of quality and create opportunities to participate in QI and Patient Safety
activities.
 Staff Participants: Doctors, Nurses, Paramedical, Staff from Laboratory, Radiology,
Pharmacy, Dietary, Interns, and Students.
 Special sessions will be held for Leadership (Hospital Director, Medical Director, Nursing
Director Administrative Director, Development & Planning Director, and Department.
Chiefs and Supervisors) on QI & Leadership topics.
 House Keeping staff shall be addressed in local language either in telugu / hindi Arabic,
Urdu & Bangladesh languages/in the language that the staff could understand.
6. STRATEGIES
a. Management of Quality and Patient Safety Activities When opportunities for improving
performance are identified, a proactive systematic approach is used to redesign the
involved process, or to design a new process. The hospital leadership, through the Quality
and Patient Safety Committee will establish hospital-wide priorities and provide adequate
resources to be effective.
b. When a department or service identifies an opportunity for improvement, the
department / service shall determine if other disciplines or departments will have an
impact on the design/redesign of the process. If other disciplines or departments are
involved, the opportunity for improvement will be referred to an appointed team.
c. The assigned team/department will establish priorities for improvement based on the
guidelines established in this program. When necessary, the Group Quality head will assist
the team or department/service in establishing priorities.
d. The QIPS program with the support of leadership shall be implemented by the Group
Quality head. The program shall be implemented with the support of staff with
capabilities for data collection, validation and analysis and implementing sustainable
improvements.
e. The quality program staff shall coordinate at the department level for continuous
monitoring of quality improvement and patient safety priorities and turn them into a
coordinated overall program. This department quality program staff coordinates and
organize measures for the department and shall provide support with measurement
activities related to hospital priorities.
f. The quality program shall provide support and coordination to department leaders for like
measures across the hospital and for the hospitals priorities for improvements All

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required support shall be extended to the various department with information and
assistance to ensure effectiveness of the program.
g. Yashoda Hospital utilizes the FOCUS -Plan – Do – Check – Act performance improvement
methodology for improving performance. Plan – Do – Check- and Act is a continuous
cycle.
Focus PDCA
Find a process or problem to improve
F
Organize a Team
O
Clarify current knowlledge of the process

C
Understand sources or causes of process variation

U
Select the improvement or intervention

S

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Measures, Plan Do Implement plan&

Achievements & actions capture Results
Process Process
Development impementation
Act
Check
Process
Actions
Enhancement Quality Review and Analyze
Assurance results
Corrective, Preventive,
Brealthrough
Measure Selection
 The primary responsibility of hospital leadership shall set a hospital-wide measurement and
improvement priorities. These are measurement and improvement efforts that impact or reflect
activities in multiple departments.
 Hospital leadership shall provide focus for the hospital’s quality measurement and improvement
activities, including measurement and activities regarding the hospital’s full compliance with the
International Patient Safety Goals. Priorities may focus on the achievement of strategic objectives
 Hospital leadership shall give priority to projects that increase efficiency, reduce readmission
rates, eliminate patient flow problems in the emergency department, or create a monitoring
process for the quality of services provided by contractors.
 Hospital leadership shall consider priorities at a system level to spread the impact of
improvements broadly throughout the hospital.
 Hospital leadership shall ensure that, when present, clinical research and medical education
programs are represented among the priorities.
 Hospital leadership shall assess the impact of improvements.
 Measuring the impact of an improvement supports an understanding of the relative costs
for investing in quality and the human, financial and other.

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 Understanding both the impact of an improvement on patient outcome and the relative
cost resulting process efficiency contributes to improved priority settings in the future
both at an organizational level and at a departmental level
 All departments, clinical and managerial, select measures related to their priorities. In certain
cases, there is some opportunity for similar measures to be selected in more than one
department.
 An integrated and comprehensive safety measure including measurement of the safety culture
and adverse event reporting system facilitates effective data collection and provide opportunity
for integrated solutions and improvements.
Measure Selection Criteria:

 An Indicator is a well-defined, objective, measurable variable used to monitor the quality
of an important aspect of patient care (for Indicators used in various Departments of the
Hospital see Appendix A).
 Indicators shall be related High Risk, High Volume and Problem Prone
 Indicator shall reflect the following Dimensions of Quality
 Efficacy (The degree to which the care provided has been shown to accomplish
the desired or projected outcome along; evidence-based medicine guidelines).
 Appropriateness of a specific test, procedure, or service to meet the patient's
needs.
 Availability of a needed test, procedure, treatment, or service to the patient who
needs it.
 Timeliness with which a needed test, procedure, treatment, or service is provided
to the patient.
 Effectiveness with which tests, procedures, treatment, and services are provided
 Continuity of the services provided to the patient with respect to other services,
practitioners, providers and overtime.
 Safety of the patient (and others) to whom the services are provided.
 Efficiency with which services are provided.
 Respect and caring with which services are provided.
Flowchart in the Development of Quality Indicators for Quality Improvement and Patient Safety
& Monitoring of Healthcare Quality
1. Clinical (Structure, Process, outcome)
Indicator Selection 2. Managerial (Structure, Process, outcome)
3. International Patient safety goals indicator

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Definition Function, Dimension, Rationale, target
Logbooks, Medical record review, Questionnaire, Surveys,

Data Collection Computerized data source, Observation, Check Sheets
Data validation process should be used when:

Data Validation
Changes in – Source of data, Existing measure
Data collection tools, Implementing new clinical measures
Data abstractor process, before publishing – website, posters, newspaper Unexplainable

changes in the resulting data
QI Tools
Flow chart, Control chart, Run chart, Pareto chart, Histogram, Cause
Data Analysis
& Effect diagram, scatter diagram
Apply P-D-C-A, Focus PDCA
Action Plan Determine what needs to be done and create a plan for
achieving the goal, modify or revise the plan to improve
performance
1. Committees
Reporting
2. Quarterly reports
3. Dashboard reporting to Governing body
Data Collection

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Data collection is an on-going activity. The quality department shall be responsible for the development of
techniques and instruments for data collection, management and analysis. It is the basis of all quality
improvement and patient safety activities and provide a means of measuring performance through which
informed decisions can be made.
Program data is collected for a comprehensive set of performance measures based on the priorities
established by the leaders of the organization in order to:
 Establish a baseline when a process is implemented or redesigned.

 Describe process performance or stability.
 Describe the dimensions of performance or stability.
 Describe the dimensions of performance relevant to functions, processes, and outcomes.
 Identify areas for improvement including the effect on patients.
 Determine whether changes in a process have met objectives
 Implement a strategy for maintaining the effectiveness of the redesigned process over time.
 Data is collected as a part of continuing measurement, in addition to data collected for priority
issues.
 Data collected considers measures of processes and outcomes.
 Data collection includes at least the following processes or outcomes:
o Processes related to medication usage/errors
o Processes related to the use of blood and blood components
o Needs, expectations, safety, and satisfaction of patients
o International Patient Safety Goals
o Risk Management
o Utility System Management
o Infection Prevention and Control
o Utilization Review
o Clinical Research
Data Collection for Monitoring the Data Collection designed supports further study of areas identified for
improvement and also supports the evaluation to be able to determine if the improvement made was
effective.
For each monitor the leadership must decide the following:

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 The process, procedure, or outcome to be measured.

 How the measurement will be accomplished.
 The data that will be collected.
 The areas involved for data collection.
 Who will collect the data?
 How frequently the data will be collected.
 New measures are selected when a current measure no longer provides useful information for
analyzing the structure, process, or outcome.
Data Sources will include medical records, incident reports, department logs and registers patient
questionnaires, computer reports, statistics report, patient activity reports committee minutes, infection
control reports, nursing and clinical activity reports etc.
Data Comparison (Benchmarking) shall take place internally and externally.
Data Sampling shall not be fewer than 30 cases or less than 5 % of population whichever greater. The
general guide for sampling is based on a four week period.
Analysis of Measurement Data
Program activities involve the assessment process, which includes the necessary discipline of departments
to draw conclusions about the need for more intensive measurement. A systematic process is used to
assess collected data in order to determine whether specifications for newly designed processes were met
and the level of performance and stability of important existing processes. Priorities for possible
improvements or redesign of existing processes, actions taken to improve the performance improvement
processes and whether changes in the processes resulted in improvement are also assessed.
Collected data is reported monthly and analyzed quarterly. Findings are documented and are forwarded
through the quality improvement communication structure. Quarterly reports are prepared through the
Directorate of Quality and Safety and reviewed by Quality and Patient Safety Committee. The hospital
leadership is responsible for ensuring at least quarterly quality improvement reports are prepared for
governance review and discussion, and to ensure that the actions of the governance to quality reports are
carried out. The quality improvement report includes the following:
 Sentinel event are one source of identification of opportunities for improvement

 Root Cause Analysis is a process for identifying the basic or causal factors that underlies variation
in performance, including the occurrence or possible occurrence of a sentinel event. A root cause
analysis focuses primarily on systems and processes, not individual performance.

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 Near Miss a near miss represents an opportunity to proactively identify and implement a risk-
reduction strategy and action plan that includes measurement of the effectiveness of process and
system improvements to reduce risk.
The assessment process includes the use of statistical process control techniques/tools as appropriate.
When assessment of data indicates a variation in performance or potential risk to patient safety, more
intensive measurements and analysis will be conducted, and in addition, the department/service or
team will reassess its performance measure.
When a performance measurement does not reach the predetermined optimal threshold, or if it is
attained but further evaluation indicates that performance is not acceptable, the Performance
Improvement process should continue. If the level of performance shows no improvement for the
time frame established by the identified department/service or team plan, an intensive evaluation
should be conducted with input from the Hospital Executive Committee or Quality and Patient Safety
Committee, regarding the need for continued measurement and additional corrective action. When
any process remains stable or minimal variation is demonstrated in overall performance for at least
four measurement periods of data collection, the performance measure should be re-evaluated to
determine the need to continue measurement, and reprioritization of performance measurements
should occur.
Validation of Measurement Data
The Unit head of Yashoda together with the data owner and the quality team ensure that good, useful
data have been collected. Data validation is implemented when:
 A new measure is implemented (in particular, those clinical measures that are intended to help a
hospital evaluate and improve an important clinical process or outcome).
 Data will be made public on the hospital’s website or in other ways.
 A change has been made to an existing measure, such as the data collection tools have changed or
the data abstraction process or abstractor has changed.
 The data resulting from an existing measure have changed in an unexplainable way;
 The data source has changed, such as when part of the patient record has been turned into an
electronic format and thus the data source is now both electronic and paper.
 The subject of the data collection has changed, such as changes in average age of patients,
comorbidities, research protocol alterations, new practice guidelines implemented, or new
technologies and treatment methodologies introduced.
Gaining and Sustaining Improvements

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To design or redesign effective processes, functions or services, the following key elements are
considered when relevant and available:
 The process design is based on the organization’s mission, vision and strategic imperatives.
 Consideration is given to the needs and expectations of patients, staff, and others, as well as,
the direct effect or criticality of the design on patients.
 Research of current literature and practice guidelines are reviewed for successful or best
practice(s).
 Design is consistent with evidence-based practices.
 Baseline performance expectations are utilized to guide measurement and assessment
activities.
Performance monitoring and evaluation standards are department, division, service line and/or
population focused. Certain processes are measured on an ongoing basis both in response to
occurrences and proactively. Selected processes which are high volume, problem prone, high risk, and
high cost are measured on an ongoing basis using the FOCUS PDCA Cycle for Improving Organizational
Performance.
Identification of Improvement Opportunities:
Performance Improvement projects that are designed or redesigned to monitor expected

performance within the hospital are developed to measure, assesses, improve and maintain process
improvements.
When opportunities for improving performance are identified, a systematic approach is used to
redesign the involved process, or to design a new process. The leadership, through the unit head
Quality of Yashoda will establish hospital-wide priorities.
The assessment process involves the necessary disciplines or departments to draw conclusions about
the need for more intensive measurement. A systematic process is used to assess collected data in
order to determine whether specifications for newly designed processes were met, the level of
performance and stability of important existing processes, priorities for possible improvement of
existing processes, actions taken to improve the performance improvement processes, and whether
changes in the processes resulted in improvement.
 Comparative data is used from the Agency for Healthcare Research and Quality (AHRQ),
Institute of Healthcare Improvement (IHI), Center for Disease and Control (CDC), National
Healthcare Safety Network (NSHN) or current/past department performance.

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 Each activity monitored has an established performance level or threshold to measure

expected performance. A strategy for maintaining the effectiveness of the redesigned process
over time is also implemented. The reference used may include the following:
 Internal comparisons in performance of processes and outcomes are made over time
(Trending) Performance comparison of data is made about processes with up-to-date
information (Evidenced Based Practice)
 Performance comparison of data is made about processes and outcomes with other hospitals
utilizing reference databases when possible (Benchmarking)
 When assessment of data indicates a variation in performance, more intensive measurement
and analysis will be conducted and in addition, the department/service or team will reassess
its performance measurement activities and re-prioritize them as deemed necessary.
Performance levels may be established through comparison performance with other “like”
facilities to identify variations or “failure modes.” Intensive assessment is initiated when
statistical analysis shows the following:
o Important single events, levels of performance, and patterns or trends that vary
significantly and undesirably from those expected
o Performance that varies significantly from other organizations
o Performance that varies significantly and undesirably from recognized standards
When an opportunity for improvement is identified by a department or service, the

department/service will determine if other disciplines or departments have an impact on the
process in the design/redesign of the process. If other disciplines or departments are involved, the
opportunity for improvement will be referred to the appropriate established team.
The appropriate team/department will establish priorities for improvement based on the
guidelines established in this plan. When necessary, the Directorate of Quality and Safety will
assist the team or department/service in establishing priorities.
 When findings of the assessment process are relevant to an individual’s performance,

the pertinent information will be provided to: The medical staff leaders responsible
for determining their use in credentialing, privileging and peer review.
 When no opportunities to improve are found after two quarters of data collection, the
performance measure should be re-evaluated to determine the need to continue
measurement, and re-prioritization of performance measurements should occur.
PI teams will use the FOCUS PDCA & Plan-Do-Check-Act approach to improve performance

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Take Action:
Action shall be taken to improve processes, and solve problems. The heads of the departments shall
collaborate with their respective Directors before taking corrective action. Each corrective action taken
shall be notified to the Unit Head quality. An action plan should be prepared, before implementing the
required action. Following steps shall be followed for the preparation of an action plan:
 Identify what is expected to change.

 Test the proposed change on a trial basis, if necessary and study the effects.
 Identify who is responsible for implementing the improvement.
 Estimate of when the change is expected to occur.
Assess Effectiveness:
All action taken shall be assessed for their effectiveness. Performance Improvement Coordinator in
collaboration with the department heads shall be responsible for presenting reports of their Quality
Improvement and Patient Safety Programs to Quality and Safety committee on a scheduled basis, as
desired by the leadership.
Communicate Relevant Information:
Communication of required information shall be reported by the delegated individuals to the quality and
safety committee, for submission to the leadership. The quality and safety committee shall forward a
summary report to the Hospital Executive Committee through the Quality and Patient Safety Committee
Feedback shall be provided to the concerned individuals about Quality Improvement and Patient Safety
activities on continual basis. All Quality Improvement and Patient Safety information shall be forwarded to
respective Chairman of the Department.

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Data owners
Departments, committees, Project teams, Task Forces
Performance improvement team
Leaders Leaders
Feedback Clinical Measures select and Managerial Measures select and PI Project Feedback
Prioritize Prioritize Data
measures measures
Key Performance measures and other measures

Department of Quality aggregate and analyze data
Comparisons to excellence
Communication Hospital Executive committee Methods:
 Coordination Clinical performance measures, other process measures, of all quality

improvement Survey results projects is
through the Quality and
Patient Safety Committee and Directorate of Quality and Safety that provides effective oversight
of quality improvement and patient safety activities throughout the organization.
 Communication is done through Quality and Patient Safety Committee upward to Hospital
Executive Committee and through the Unit Head quality to Departmental Staff.
Reports
The department should submit a quarterly report to the quality and safety committee. The report should
aggregate and analyze the data collected for each performance measure for that time period. The

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quarterly reports must be received in the quality and safety committee by the 15th of the month following
the end of the quarter, as follows:
April 15 (January - March Report due)
July 15 (April - June Report due)
October 15 (July - September Report due)
January 15 (October - December Report due)
If the report is to be delayed for any reason, the quality and safety committee must be notified, preferably
in writing, of the reason for the delay, and the expected date of completion.
The quarterly reports must be submitted on designated forms to provide a consistent format. There are
no exceptions.
The component to be submitted quarterly is the form titled "Performance Improvement Report – Part
One: Performance Measurement Plan and Findings" and "Performance Improvement Report – Part Two:
Analysis and Plan for Improvement."
ANNUAL REVIEW OF EFFECTIVENESS
The Quality Improvement and Patient Safety Program will be reviewed, evaluated, and revised as
necessary to incorporate the most current Joint Commission International standards. A summary of
evaluation results will be presented to the University Council, Hospital Executive Committee and Medical
Executive Committee. The annual review will assess, at least, the objectives, scope, organization
effectiveness and appropriateness of the program. The plan will be modified as needed based on the
results of the annual evaluation. Individual committees and departments will review, evaluate and revise
their performance improvement activities and plans annually as part of the organization-wide review.
Quality department outcome Indicator
 Number of Key performance measures with positive outcome

 Number of closed Performance Improvement Project with positive outcome
CONFLICT OF INTEREST STATEMENT:
No Physician or other healthcare provider at Yashoda shall review services for which they are, or have
been directly responsible for providing such service.
CONFIDENTIALITY POLICY:

Safety Program
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Benchmark
Conflict of Interest shall be respected in all activities of the Department.
All documents, minutes, reports, memos, letters, findings, conclusions, and recommendations that involve
Yashoda Hospital and its patients, staff and other customers, which are used in the course of quality
improvement and patient safety activities shall be strictly confidential and shall be used only for the
assessment and improvement of patient care.
Providers of care/service in all reports will not be identified by name. Individual identification will only be
made available when it has been shown that a person has a performance problem. Only the individual
responsible for taking action will be given the name of the person. Any information related must be
requested in writing and be approved by the unit head of the Yashoda Hospital.
Commitment
Yashoda Hospital makes a commitment to provide for the safe and professional care of patients and the
safety of visitors and employees. The commitment is made through the quality improvement and patient
safety process, which will proactively identify, evaluate and control the risk.

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Quality and Patient Doc No: YH/QAD/1

"To be the most trusted and preferred healthcare provider”.

Prepared by: Approved by:

Mr. G. Vishwanath (Head of Quality)

E. COMMITMENT: To continuous learning. To find better methods of prevention and cure.

Prepared by: Approved by:

Mr. G. Vishwanath (Head of Quality)

 To continuously improve patient outcomes

Prepared by: Approved by:

Mr. G. Vishwanath (Head of Quality)

Scopes of Services include:

8. AUTHORITY AND LEADERSHIP:

a. Roles & Responsibilities:

Mr. G. Vishwanath (Head of Quality)

Hospital Executive committee

Quality and Patient Safety committee Professional Performance

Standing Committees Sections, Departments, Divisions & Interdepartmental Task

Prepared by: Approved by:

Mr. G. Vishwanath (Head of Quality)

Prepared by: Approved by:

Mr. G. Vishwanath (Head of Quality)

f. Distributing required reports of quality improvement activities as appropriate

Prepared by: Approved by:

Mr. G. Vishwanath (Head of Quality)

Education and Training will be required and conducted on several levels:

a. Formal Classroom instruction.

Educational instructional materials include the following:

Quality Improvement education and training program:

Prepared by: Approved by:

Mr. G. Vishwanath (Head of Quality)

Purpose of Educational Activities is to familiarize staff, interns, and students with

Prepared by: Approved by:

Mr. G. Vishwanath (Head of Quality)

Clarify current knowlledge of the process

Understand sources or causes of process variation

Select the improvement or intervention

Prepared by: Approved by:

Mr. G. Vishwanath (Head of Quality)

Measures, Plan Do Implement plan&

Prepared by: Approved by:

Mr. G. Vishwanath (Head of Quality)

Measure Selection Criteria:

Mr. G. Vishwanath (Head of Quality)

Definition Function, Dimension, Rationale, target

Logbooks, Medical record review, Questionnaire, Surveys,

Data validation process should be used when:

Data collection tools, Implementing new clinical measures

Data abstractor process, before publishing – website, posters, newspaper Unexplainable

Apply P-D-C-A, Focus PDCA

Prepared by: Approved by:

Mr. G. Vishwanath (Head of Quality)

 Establish a baseline when a process is implemented or redesigned.

For each monitor the leadership must decide the following:

Prepared by: Approved by:

Mr. G. Vishwanath (Head of Quality)

 The process, procedure, or outcome to be measured.

Data Comparison (Benchmarking) shall take place internally and externally.