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OTL Quality Improvement Plan 15nov2020

This document outlines a quality improvement and patient safety plan for a healthcare facility. It establishes the facility's mission, vision, and values. It defines the goals of continuously improving quality and setting priorities. It describes the facility's quality structure including responsibilities of the ministry of health, facility director, quality improvement coordinator, department managers, and quality and patient safety committees. It discusses approaches to quality improvement and how data is measured, assessed, and reported to monitor progress. An annual evaluation of the plan is also conducted.

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Iyad Shahatit
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72 views6 pages

OTL Quality Improvement Plan 15nov2020

This document outlines a quality improvement and patient safety plan for a healthcare facility. It establishes the facility's mission, vision, and values. It defines the goals of continuously improving quality and setting priorities. It describes the facility's quality structure including responsibilities of the ministry of health, facility director, quality improvement coordinator, department managers, and quality and patient safety committees. It discusses approaches to quality improvement and how data is measured, assessed, and reported to monitor progress. An annual evaluation of the plan is also conducted.

Uploaded by

Iyad Shahatit
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 6

Health Care Accreditation Council

Quality and Patient Safety Plan

FACILITY

DATE

OTL Quality Improvement Plan 15Nov2020 Page 1 of 6


Health Care Accreditation Council

Table of Contents

OTL Quality Improvement Plan 15Nov2020 Page 2 of 6


Health Care Accreditation Council

1 Introduction
1.1 WHO ARE WE? (Enter 2-3 sentences regarding your organization)
1.2 Mission
1.3 Vision
1.4 Values
1.5 Strategic Directions

2 Purpose
3 Definition of Quality
4 Overall QI Goals and Priority Setting
The goals of the Quality and Patient Safety Plan are to:

Priorities for quality activities are established annually based on the strategic goals and
objectives of the governing body and facility administration. High risk, high volume and
problem-prone areas of practice as well as new processes, procedures or systems are
taken into account when priority-setting.

5 Quality Structure
5.1 Authority and Responsibilities

Ministry of Health or Governing Body


The Ministry of Health has overall responsibility for the quality of care and services
provided in the country.

Facility Director

Quality Improvement Coordinator


The Quality Improvement Coordinator conveys the message that quality is the
responsibility of every member and department within the healthcare system. The
Coordinator is responsible for facilitating the process of quality improvement (Refer to
job description).

OTL Quality Improvement Plan 15Nov2020 Page 3 of 6


Health Care Accreditation Council

Department Managers

Quality and Patient Safety Committees

The Quality and Patient Safety Committees are responsible for creating a commitment to
continuously improving the quality of care at the facility level. The hospital and clinic
committees assess and prioritize process improvement activities, monitor the progress of
quality improvement and patient safety initiatives and manage the flow of information at
the facility level. (Refer to the Quality Improvement Committee terms of reference).

6 Quality Improvement Approaches and Models


The quality improvement process at FACILITY is based on several guiding principles.
Quality methods and tools are used to identify opportunities for improvement and
implement actions. Data and assessment systems are used to
Identify gaps in quality and measure progress toward improving quality and safety of
patient care and services.

7 Data Measurement and Assessment


Each department is responsible for developing and measuring indicators and
implementing changes to make improvements. The monitoring activities for each
department are attached to this plan. In addition, a grid outlines a timeline for the various
monitoring activities. Some indicators are monitored routinely, e.g. medication errors and
patient falls; whereas, other indicators are measured intermittently or as a “spot check”.

8 Information Flow
Reporting systems consist of systematic communication of information and the feedback
related to the surveillance, analysis of data, and the improvement of specific processes
and outcomes. Each defined and agreed-upon measure is reported according to an
established schedule and in a consistent written format to the Quality and Patient Safety
Committee.

The Quality and Patient Safety Committees at all levels analyze, ensure action and
sustained improvement. The Infection Control, Safety, and Departmental Quality
Committees submit reports to the Hospital Quality Committee on a monthly basis. The
Quality Improvement Coordinator provides quarterly reports on these quality
improvement activities to the leadership and Governing Body.

OTL Quality Improvement Plan 15Nov2020 Page 4 of 6


Health Care Accreditation Council

Governing Body

Hospital Director

Management Team

QI Committee

Department QI Safety IC
Committees Committee Committee

9 Approval of Plan
10 Evaluation of Plan
An evaluation of the Quality and Patient Safety Plan is completed at the end of each
calendar year. The annual evaluation is conducted by the QI Committee and kept on
file in the facility, along with the Quality and Patient Safety Plan.

OTL Quality Improvement Plan 15Nov2020 Page 5 of 6


Health Care Accreditation Council

Annex 1 Annual Operation plan


Annex 2 Quality Indicators

OTL Quality Improvement Plan 15Nov2020 Page 6 of 6

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