Professional Documents
Culture Documents
1. Ensure reliability of quality planning and patient safety with techniques and tools in carrying out
such activities;
2. Ensure the improvement of the quality and safety of patients through socialization, facilitation and
audit activities involving the participation of the parties in based on their respective accountability;
4. Ensure good communication and relationships with partners related to quality accreditation and
patient safety;
6. Carry out counseling and coordination with the accreditation supervisor in doing surveillance in
realizing the fulfillment of the quality standard and patient safety that have been established;
10. Monitor and evaluate all of patient quality improvement and safety programs;
13. Coordinate the plan and schedule activities related to quality accreditation;
14. Facilitate internal and external counselors related to the implementation of quality accreditation;
16. Collecting data and analyze it, related to the achievement of quality and patient safety indicators;
17. Doing consultation with all units related to the implementation of quality improvement and patient
safety.
1. Doing administrative activities of the quality improvement and patient safety program;
2. Collect and properly save data of quality indicators and patient safety every units;
3. Schedule meetings, both routine and incidental;
6. Prepare external and internal incident reports and periodic reports of KPRS Team activities;
7. Prepare quarterly and annual reports based on patient quality improvement and safety program;
9. Coordinate the activities of all coordinators in patient safety unit and quality assurance unit;
10. Coordinate committee / team activities related to quality improvement and patient safety program;
11. Monitor and evaluate activities about the programs in committees / teams / units related to the
quality improvement and patient safety program;
4. Coordinate with the SPI (Internal Supervisory Staff) for the preparation of internal quality audit
tools;
13. Facilitate the internal and external mentor regarding the implementation of national accreditation;
14. Coordinate with patient safety team and all unit to making RCA (Root Case Analysis) and FMEA
(Failure Mode and Effect Analysis) ;
15. Coordinate with patient safety team and related units with quality and patient safety mentor;
16. Facilitate activities related to the implementation of innovation development and quality control
cluster;
18. Coordinate to related committees / units about the implementation of patient-focused service
standards and management;
19. Attend meetings, workshops, and seminars related to the development of internal and external
clinical quality.
7. Comparing the monitoring results of clinical quality indicators periodically with national standards
and other similar hospitals;
9. Completed and prepared internal hospital socialization activities on the achievement of clinical
quality indicator;
11. Distribute recommendation matter about monitoring results of clinical quality indicators to related
units;
12. Make recaps and follow-up evaluation reports of recommendations from related units;
13. Doing internal and external communications about the achievement of the quality & patient safety
program to related units within internal and external hospitals by mail/ email / phone;
14. Assisting coordination in internal and external activities of the quality improvement team program;
15. Attend meetings, workshops, and seminars related to clinical quality development both internal
and external hospitals;
16. Collate internal data validation guidelines for clinical quality indicator;
19. Doing comparative analysis of internal validation results with data of related unit;
22. Coordinate the implementation of development, innovation and quality control cluster;
24. Make the reports of innovation development activities and quality control clusters;
7. Comparing of monitoring results of clinical quality indicators periodically with national standards
and other similar hospitals;
9. Completed and prepared internal socialization activities of the hospital about the achievement of
management quality indicators;
10. Collate recommendation matter about the achievement of management quality indicators;
11. Distribute recommendation matter about the monitoring results of management quality indicators
to related units;
12. Make recaps and follow-up evaluation reports of recommendations from related units;
13. Doing internal and external communications about the achievement of the PMKP program to
related units within the internal and external environment by mail/ phone;
14. Assisting coordination in internal and external activities of the quality improvement team program;
15. Attend meetings, workshops and seminars related to the development of internal and external
management quality of the hospital;
16. Collate internal data management validation guidelines for quality management indicators;
18. Doing validation activity of clinical quality indicator achievement result by coordination with related
unit;
19. Doing comparative analysis of internal validation results with related unit data;
20. Make specific internal validation outcome report of the quality management indicators;
22. Coordinate the implementation of development, innovation and quality control cluster;
24. Make the reports of innovation development activities and quality control clusters;
2. Responsible to the Director of Hospital for the implementation of hospital patient safety activities;
8. Give recommendation to resolve patient safety issue to the Director of Hospital for follow-up.
COORDINATOR OF INVESTIGATION
2. Give the solution of the problem submitted to the KPRS Team Leader;
3. Monitoring and evaluate to every units about the implementation of the patient safety program
related to the investigation; and
4. Create periodic reports and specific reports of investigative activities.
COORDINATOR OF REPORTING
3. monitoring and evaluate the implementation of patient safety programs related to incident
reporting;
5. Monitoring and evaluate about the patient's safety culture to staffs; and
6. Create periodic reports and specific reports about the implementation of patient safety related
training programs.
1. Establish a risk management program based on the organization's mission and plans, as well as
the needs of patients, communities, and staff;
2. Carry out management processes using current practice guidelines, medical service standards,
scientific literature and other information based on practicum, as well as in accordance with sound
business practices and relevant to current information;
5. Coordinate with Patient Safety team in case of KTD (not desirable incident) response;
6. Evaluate KNC (almost injured incident) and high risk process which can change it being sentinel
incident;
7. Doing RCA and /or FMEA activities for an incident that leads to high and sentinel risk;
8. Monitoring and evaluate to every units about the implementation of risk management program of
hospital and management of related matters;
9. Monitoring and make specific reports on risk management activities including RCA and FMEA
reports
1. Establish a risk management program based on organization's mission and plans, as well as the
needs of patients, communities, and staff;
2. Carry out management processes using current practice guidelines, medical service standards,
scientific literature and other information based on practicum, as well as in accordance with business
practices and relevant to current information;
5. As counselor and coordinate with the patient safety team in case of KTD's response;
6. Monitor and evaluate KNC (almost injured incident) and other high processes that may change it
being sentinel incident;
7. Coordinate the implementation of RCA and/or FMEA activities for an incident that leads to high risk
and sentinel;
8. Coordinate monitoring and evaluation of every units about the implementation of risk management
programs of hospitals and management from other related matters;
9. Prepare periodic and specific reports on risk management activities including RCA and FMEA
reports
COORDINATOR OF NON-CLINICAL RISK
1. Establish of non-clinical risk management program based the organization's mission and plan, and
meet the needs of patients, communities and staff;
2. Doing non-clinical risk management processes using current practice guidelines, medical service
standards, scientific literature and other information based on clinical practice design, and in
accordance with business practices relevant to current information;
4. Doing scoring and establish non-clinical risk priorities across units / installations / sections;
6. Evaluate KNC and other high risk processes that may change it being sentinel events;
7. Doing RCA and / or FMEA activities for an event that leads to high and sentinel risk;
8. Monitoring and evaluate to every units about the implementation of non-clinical risk management
program of the hospital and management from other related matters;
9. Prepare periodic and specific reports on non-clinical risk management activities including RCA and
FMEA reports
PIC
4. Report quality data that has been analyzed every month to the Person in charge;
11. Monitoring and evaluate of risk programs in the units under its responsibility;
12. Periodically report the results of the risk management program evaluation to the risk manager
ACTIVITIES OF QUALITY & PATIENT SAFETY PROGRAM IN HOSPITAL
3. Education & Learning program of PMKP – or it can be combined with Education & learning
program of hospital
5. Establish the Key of Quality Indicator – Clinical Area Indicator (11 Clinical area), Management
Area Indicator (9 Management Area), Patient Safety Area Indicator (6 Patient Safety Target)