Loading presentation...

Present Remotely

Send the link below via email or IM

Copy

Present to your audience

Start remote presentation

  • Invited audience members will follow you as you navigate and present
  • People invited to a presentation do not need a Prezi account
  • This link expires 10 minutes after you close the presentation
  • A maximum of 30 users can follow your presentation
  • Learn more about this feature in our knowledge base article

Do you really want to delete this prezi?

Neither you, nor the coeditors you shared it with will be able to recover it again.

DeleteCancel

Make your likes visible on Facebook?

Connect your Facebook account to Prezi and let your likes appear on your timeline.
You can change this under Settings & Account at any time.

No, thanks

Where We Are in CBAHI Preparation

No description
by

Nu Si

on 12 February 2017

Comments (0)

Please log in to add your comment.

Report abuse

Transcript of Where We Are in CBAHI Preparation

Where We Are in CBAHI Preparation
Hemodialysis
FMS Chapter
Nursing Department
Nursing Department improvements:

All policies are approved.

Improves nursing Job Description for Nursing Supervisor, Nursing Educators, Head Nurses, Charge Nurse.

Articulate understanding of professional leadership, efficient and effective interdisciplinary healthcare team.
Nursing Department
Nursing Department improvements:

Effective collaborators committed to improve best practices in health promotion, disease prevention, quality, safety and equality

Other documents review that were not present before are all now present, like the following:

PAR level monitoring of stocks

Braden Scale, Morse Fall Scale

Assessment and Reassessment form (inpatient, ER and outpatient)
Nursing Department
Nursing Department improvements:

Mandatory courses are ongoing.

ACLS courses are mandatory to all staff working in special areas.

Bedside teaching with the staff and case presentation.

Competency to all the staff.

Personnel files are collected from all staff.
Nursing Department
Nursing Department need for improvements:

Pain management Campaign are not done.
Poor hand-over of the nursing staff.
Poor documentation of nursing staff.
Increasing Medication Error Report for nursing staff.
Poor patient and family Education.
Improper handling of Medical records.
Non-compliance of Hospital dress code.
Nursing Department
Nursing Department need for improvements:

Non-compliance of staff in policy and procedures.
Staff must be aware about their job description and qualifications.
Strict compliance of nurse-patient ratio and according to patient acuity to be implemented in the department.
Coordination with the other department to improve the services. (infection control through linked nurse).
Patient and Family Education Department improvements:
All documented policy are ready and approved.
No existing health Educator.
Standard No. PFE.4.PT2
Patient/family education is documented the medical record.

Findings:
The healthcare workers (physician, nurses, social worker, dietician, dental and physiotherapist were given in service regarding the application of patient and family education and completion of the Multidisciplinary patient family education form, but
most of the healthcare workers are not complying with this standard.
Patient and Family Education
Infection Control Department improvements:

All required policies finished and approved.

The infection control manual distributed to all departments.

Continuous education to healthcare worker is implemented.

There is continuous surveillance of healthcare associated infection in the hospital.

The standard in CSSD are all met.
Infection Control Department
Infection Control Department improvements:

Workshops for BICSL done by infection control department.

Infection Control Department
Infection Control Department
Infection Control Department
The mortuary is not clean, no proper disinfection.
Infection Control Department
IC.27.2
states that: The temperature of the morgue is kept at 2-4°C and logged daily.
Findings:
The temperature of morgue for dead body is monitored but below 2 °C
Infection Control Department
No bathroom for the emergency Isolation room.
Infection Control Department
Infection Control Department improvements:
Infection control guidelines is being practice in Dental Department
Infection Control Department
ONLY
in kitchen area has the hanger for hanging the cleaning tools.
Radiology Department
Radiology Department improvements:

Radiology requesting and reporting by radiology information system.

All policy and procedures are approved.

PPM for most of their equipments are available.

Radiation Safety Protocols for staff and patient are followed.

Availability of equipped and accessible crash cart for all the imaging sections. (MRI, CT-SCAN, FLOUROSCOPY)

Key performance Indicators are monitored. ( Panic Finding and Staff Radiation Exposure)


Physiotherapy Department
Physiotherapy Department Improvements:
Documents (policies & procedures) are almost done.

Educating the PT staff in checking crash carts.

Key performance Indicators are monitored.

BCLS Certification of the staff still ongoing.
Patient and Family Rights
Patient and Family Rights Department improvements:

Availability of Patient Rights & Responsibilities banner in hospital areas.

Complaint process is posted.


Complaint Process is Posted
Human Resources
Human Resources Department improvements:

All Policy and procedures are approved.
Well staffed and equipped to match the size and needs of hospital.
Hemodialysis Department improvements:

Patients are screened for Hepa B, Heapa C and HIV and re-screened every 3-6 months.

HDU Nurses are screened for Hepa B, Hepa C and HIV and re-screened annually.

Water Quality is checked on a periodic basis (Monthly).

Hemodialysis Department need for improvements:
Remaining 4 Policies are not done.
Incomplete Personnel Files
AMBULATORY- Out Patient Department
Availability of Security personnel, screening clinics and vital signs room.
Pharmacy Department
Pharmacy Department improvements:

Floor stock medications list are available in all inpatient units.

Floor stock Cabinets are available in inpatient units and labeled properly.

LASA List, High Risk Medications List and Multi-dose Vial Guidelines are distributed to all Inpatient Department.

Workload Statistics Forms are done in all pharmacy units and to be monitored monthly
Pharmacy Department
Pharmacy Department improvements:
High-Risk and LASA Medications are labeled
Pharmacy Department
Pharmacy Department need for improvements:

Pharmacy store space is not enough.
Prescriber's privileges needs to be updated.
Medications are not prescribed using Generic Names.
No Staffing Plan Based on Workload.
No continuing Education Program with the pharmacy staff and trainees.
No IV Room.
Pharmacy Department
Pharmacy Department
MS Chapter
MS Chapter
MS Chapter
Anesthesia and Operation Chapter
The previous situation of the hospital
Location: Outside the building
FMS Chapter
FMS Chapter
Location: Outside the building
Before
After
FMS Chapter
furniture kept in the hospital corridor
FMS Chapter
Previous situation of the rooftop
FMS Chapter
The rooftop now..
FMS Chapter
FMS.10.EC1: Hazardous warning signs are posted in the hospital as appropriate
FMS Chapter
Wet floor warning signs are available but not used
FMS.6.1.4 Signs and warning lights for x-ray rooms.
FMS Chapter
6.1.3 No smoking signs are posted as appropriate in the hospital.
FMS Chapter
FMS.6.2.4 Fire exit signs are posted as appropriate
FMS Chapter
FMS.6.1.5 Signs to restrict cellular phones in sensitive areas as appropriate.
FMS Chapter
FMS.6.2.5 Signs to identify floor level at staircases and in front of elevators.
FMS Chapter
FMS.8.1 The patients bathrooms and showers are provided with the following safety measures:
FMS.8.1.2 Bars to support patients.
FMS.8.1.3 Bell or a system to call for help.
FMS Chapter
FMS.8.4 The Laboratory has safety equipment that include:
FMS.8.4.1 Eye wash stations.
FMS.8.4.5 Emergency shower.
FMS Chapter
FMS.8.4 The Laboratory has safety equipment that include:
FMS.8.4.2 Fire blankets.
FMS.8.4.3 First aid kit.
FMS Chapter
FMS.13: fire safety is implemented in the lab and includes, but not limited to:
FMS.8.4.6 Fire resistant safety cabinets for laboratory chemicals.
FMS Chapter
FMS.18 The hospital has a system for scheduling and conducting fire drills
regularly.
FMS Chapter
Sensitive areas are provided with lock system
FMS Chapter
FMS.22.2 The hospital has clean agent suppression system.
FMS Chapter
FMS.49.EC3: Fire extinguishers are adequate in number
FMS.49.EC4: Fire extinguishers are appropriately positioned
FMS Chapter
FMS.22.3 The hospital has wet chemical system.
FMS Chapter
FMS.22.1 The hospital has a functional sprinkler system.
FMS Chapter
FMS.21.1 There is a fire alarm system that is functioning and regularly inspected as per civil defense guidelines.
The emergency lights not checked for 3 months.
FMS Chapter
FMS.31.1 Education/training on signs/symptoms of exposure to hazmat and the appropriate treatment as per MSDS.
ICU Chapter
ICU Improvements:

All policy and procedures are approved.
Weekly multi-disciplinary meetings are implemented.
Bedside case presentation are implemented.
Unit Specific Competency are ongoing.





ICU Chapter
ICU Improvements:
Good environment structure (Rooms are labeled, there are 2 organized store rooms to make sure that ICU fully equipped).
ICU Chapter
ICU needs for improvements:

No proper Time Management of the staff.
Walls of medication room not clean.

Nursing staff are writing with pens on the wall of bed sides table for documentation.
ICU department doesn't have CI to finish all personal files & educated & evaluate staff.
ICU staff are not interested in Quality and needs more encouragement and follow up from nursing administration
Laboratory Chapter
Laboratory Department need for improvements:
Documents such as P&P, Manuals; still not finished/ not approved.
Staff are not fully aware about the P&P.
Staff are not following Infection Control protocols. (Working without PPEs).
Laboratory Chapter
Laboratory Department need for improvements:
Cleaner rooms are dirty and not well organized.
There is no enough space for Blood Bank.
Temperature of laboratory refrigerators is not recorded periodically.
Most of laboratory request forms not completed. Especially, histopathology department forms.
Continuing education on infection prevention and control practices to staff
MOI Chapter
Electronic Health Department improvements:

Staff are aware about their job description.

80% of personal files are completed.
Documents (P&P and departmental plans) are to be approved.
MOI Chapter
Electronic Health Department needs for improvements:
The department only working with one form of technical support. Form for training or for requesting username or password are not available.
Technical support staffs who visit the units are not fully aware about hand hygiene.
They don't have maintenance for the server of hospital data.
Dietary Chapter
Dietary Department improvements:

Documents are almost finished


Personal files are completed.

Staffs are qualified & fully aware about their job descriptions.

There is good environmental structure in the kitchen (temperature, humidity, & safety measure).

Staff are following infection control protocol.
Dietary Chapter
Dietary Department needs improvements:

Dietary Manual for updating and to be distributed in the hospital inpatient & outpatient departments.
Workshops conducted for Nursing Department
Daily lectures in the department..
Workshops conducted for Nursing Department
Competency Fair
Workshops conducted for Nursing Department
Competency Fair
Workshops conducted for Nursing Department
Workshops conducted for hospital staff
Hazmat Lecture
Workshops conducted for Nursing Department
Clinical Instructor CBAHI Orientation Program
Laboratory Chapter
Laboratory Department improvements:
Environmental structures are acceptable (temperature, humidity, & safety measures).

Staff knows about their roles & responsibilities according to their job descriptions
Laboratory Chapter
Laboratory Department need for improvements:

Non-Serology blood room is used as store room.
Quality Management Rounds
Quality Management Rounds
Areas for improvement
Head of department should participate more in the preparation of CBAHI requirement
Medical staff awareness about quality and CBAHI very weak and this will affect the implementation
Quality coordinators in some department (medicine and surgery ) are too busy to commit for Quality work.
No proper handover on vacation
Importance of weekly meeting in all medical departments by the presence of HD with quality issues as one of constant agenda
no proper listing ,observation and tracking of hospital forms
Thank You
Minimizing Pressure Ulcer Improvement Project
Costumer Service Plus Lecutre
Pharmacy Department need for improvements:
No active reporting of adverse drug reactions.
No safety cabinets.
Hospital Formulary to be updated.
No available Policy and procedure manuals.
Insufficient Book reference for drug information
No Pharmacy monthly evaluation of nursing staff performance of IV admixture.
No Protocol for medication substitution
Patient’s profile are used as inpatient prescriptions.

Cleaning equipment kept in the floor outside the mortuary
fire drill is not conducted as required in the hospital
there is clean agent (FM-200) but no periodic maintenance
wet chemical system is not available in the kitchen
The hospital has no maintenance on sprinkler system
there are no PPM record and no regular inspection
Nursing Department
Nursing Department improvements:

Policy and procedures orientation campaign.

IPSG campaign ongoing.

High-Alert Medication cabinets are available, kept locked and refrigerator storage are monitored to proactively prevent medication error.
Nursing Department
Nursing Department improvements:

Director of Nursing along with his Assistant are having a regular meeting with his staff and in the entire Nursing Department. Departmental meetings are done twice a week with the head nurses:

standards,

Policies and Procedures, Guidelines and etc

monitoring of proper implementation.
Nursing Department
Nursing Department
Emergency Department
Emergency Department improvements:

All policy documents of emergency department are ready and approved.

Availability of two Clinical Instructors.

Unit specific competency and mandatory courses are ongoing.
Emergency Department
Emergency Department Needs for improvement:

Proper communication between the red crescent and ER staff must be recorded in the log book .
No ER Quality Coordinator
No active triaging.
No available bathroom in Isolation room.
Overstocked of medications in the unit.
No Medication room. ( medications are easily accessible to patients)
Emergency Department
Patient and Family Education Department improvements:

All policy documents of PFE department are ready and approved.

Available forms for implementation.
Radiology Department
Radiology Department needs for improvements:


Radiologist ( Staff Shortage)
Only requested X-ray reports are done.
Knowledge deficit of crash cart use.
Infection Control Department
Respiratory Services improvements:

PPM for all their equipments are available.

Personnel files are finish.

Staff are BCLS Certified and for ACLS Certification.

Documents are almost done.
Competency Assessment for the RT ongoing.

Respiratory Services need for improvements;
Staff needs educational training related to Respiratory Services.
Human Resources
Human Resources Department needs for improvement:
Employee Manual for finalization.
Probationary evaluation should be continuously implemented.
No departmental staffing plan.
Data flow for non-Saudi must be stamped and verified.
Personnel files in archive must be completed.
No training needs assessment of the staff.
Staff health and safety program not implemented.
MS Chapter improvements:

Out of 34 polices, 28 are finished, and 6 are remaining.
Privilege: 115 from out of 196 total number of medical staff in the hospital (needs follow up and update).
Departmental Staffing plan: done but need update and follow-up.
Implementation of policies and procedures (peer review, mortality and morbidity, plan of care)

MS Chapter
Patient and Family Education Department needs for improvements:

No Quality coordinator

Patient education is not properly done neither by doctors nor nurses
Infection Control Department improvements:

All required policies finished and approved.

The infection control manual distributed to all departments.

Continuous education to healthcare worker is implemented.

There is continuous surveillance of healthcare associated infection in the hospital.

The standard in CSSD are all met.
Infection Control Department
Radiology Department
Medical Records Department
Medical Records Department need for improvements:

Not enough space for the inactive medical records.
No fire exit in medical record department.
Poor documentation of the clinical staff.
No continuous monitoring of Key performance Indicator (KPI).
No system to manage voluminous Medical records.
No continous monthly medical record review.
To include medical record department in vacation clearance.
Full transcript