cqi activities
TRANSCRIPT
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Quality
AssuranceRadiology Laboratory
Nursing
Pharmacy
Medical
Dietary
Administrative
Maintenance
Sayre Highway, Valencia City, Bukidnon
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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.
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4 Elements of CQI
Assessmentand
Monitoring Action
Evaluation Feedback
PDCA is arepetitive
cycle
PLAN
DO
ACT
CHECK
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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.
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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.
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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
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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.
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Areas of
Concern
Specific
Objectives
Strategies Resources Time
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.
Quality Improvement Plan
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Quality Improvement Plan
Areas of
Concern
Specific
Objectives
Strategies Resources Time
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.
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Compliance of Infection Control
Policies
All hospital employees practice proper hand
washing technique
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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
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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
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Non-biodegradable/Biodegradable
and Infectious Waste Bins
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Sharps Waste Bins
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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
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Each hospital area isclearly marked withits appropriatesignages and warningsigns as applicable.
Signages are Prominently Marked
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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
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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
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ContinuousQuality
ImprovementActivities
Professional Growth,Training and
Development ofEmployees
HospitalInformation
System
Equipment andSupplies
Maintenance ofHospital Facilities
and Medical Devices
Budget Allocation