CBAHI STANDARD CHAPTER 2

Medical Staff and Provision of Care

93 standards
187 sub-standards
 MEDICAL SERVICES DEPARTMENT

Chapter 2 : Medical Staff and Provision of Care (MS)

Chapter 6 : Anesthesia (AN)
Chapter 7 : Intensive Care Unit (Adult, Pediatric, Neonatal)
7.1 Adult, Pediatric (ICU/PICU)
7.2 Coronary Care Unit (CCU)
7.3 Neonatal Intensive Care Care Unit (NICU)
Chapter 8 : Operating Room (OR)
Chapter 9 : Labor and Delivery
Chapter 10 : Hemodialysis (HM)
Chapter 11 : Emergency Room
Chapter 12 : Radiology (RD)
Chapter 13 : Burn Care (BC)
Chapter 16 : Specialized Areas
16.1 Respiratory Services
16.2 Rehabilitation
Chapter 17 : Ambulatory Care
17.1 Ambulatory Care (AM)
17.2 Dental Services (DN)
Chapter 18 : Infection Control (IC)
Chapter 20: Pharmacy
Chapter 21 : Laboratory (LB)

CLINICAL DEPARTMENTS:
1. Internal Medicine
2. Pediatrics
3. OB – GYNE
4. General Surgery
5. Orthopedic Surgery
6. Special Surgery
 ▲ ALL STAFF TO BE GROUPED INTO:
1. PERFORMANCE IMPROVEMENT TEAM

MS 23 : 1.1 Sampling of quality improvement projects

1.2 Meeting minutes: ACTIONS
 prioritize the services needed.
 meeting minutes SHARED AND REVIEWED by
Chief/department with Medical Director
FINDINGS for DEFICIENCY CORRECTION

RECOMMENDATION: Every department/section/unit 

4-5 Performance Improvement Projects on the
Standard Format
 PERFORMANCE IMPROVEMENT PROJECT (FORMAT)

1. Project Title
2. Team Leader
3. Team Members
4. Project Date
5. Prioritization Criteria
5.1 High Risk
5.2 High Volume
5.3 High Cost
5.4 Problem Prone
6. Scope of the Project
7. Mission of the Project
8. Steps to identify and define improvement opportunities – FOCUS
8.1 Find an opportunity for improvement
“Do you have a problem”
8.2 Organize a Team
8.3 Clarify the Current Process: Flow Chart, Fish Bone
 8.4 Understand the Variation in the Process: Run Chart, Pareto
Chart, Histogram
8.5 Select the desired outcome
9. Steps to improve the Process: PDCA
9.1 Plan the improvement project assign Task Force: Gantt Chart
9.2 Do the improvement, Implement the selected intervention:
Force Field Analysis
9.3 Check the result, data collection and comparison: Check Sheet
9.4 Act to hold the gain, share the success, monitor the change
2. Indicators and Statistics Team
MS 13 Medical Director/department heads/Quality Director
monitoring activities for:
2.1 Morbidity and Mortality
2.2 Blood and Blood product usage
2.3 Outcome of Surgeries
2.4 Any discrepancies between pre-operative and
post-operative diagnosis
2.5 Appropriateness of admissions from ED
2.6 Appropriateness of admissions from OPD
▪ TOOLS FOR MORTALITY AND MORBIDITY REVIEW:
1. Surgical Care 4. Code Blue Evaluation/Review
2. Medical Care 5. Major Trauma Review (ED)
3. Chest Pain 6. Death/Mortality Review
MS 12 Chiefs of departments/Medical Director/Director of QMD
monitoring activities:
1. Patient Assessment
2. Adverse Events
3. Conscious Sedation
4. Rapid Response Team
5. Pain Management
6. Quality of Medical Records
7. OVR, Near Miss, Sentinel Events
8. High risk services and procedures
3. Continuing Education Team : Hospital Coordination Program
1. Human Resource
2. Ethical Conduct of Staff and Communication Process
3. Personnel Appraisal and Credentialing
4. Quality Improvement and Patient Safety Plan
5. Mission, Vision, Value Statement (Hospital, Departmental)
6. Organizational Chart, Job Description
7. Risk Management
8. Medical Staff Bylaws, Policies and Procedures
9. Medical Records
10. Patient Rights and Responsibility
11. Documentation
12. Overview on Abuse and Neglect of Children
13. Employee Health Clinic
14. Medication Errors, Drug Safety
15. Infection Control Program
16. Hazardous Material Management
 17. Safe Use of Equipment and Electrical Safety
18. External and Internal Disaster Preparedness
19. Fire Safety Demonstration
20. Hospital Round

▲ DEPARTMENTAL MEETINGS : (not less than 9 meetings/year)

▪ Mortality and Morbidity Committee
▪ Departmental Meetings
> Most important  Monitoring of:
1. Identified problems/areas of improvement
2. Recommendations
3. Actions taken/corrective actions done
4. Target date
5. Status of implementation of the recommendations
■ MEDICAL RECORD REVIEW REPORT
Proposed Form 1 (Content):
1. Patient and Family Rights (PFR)
2. Medical Assessment
3. Anesthesia
4. Surgical Care (SC)
5. Conscious Sedation
6. Radiology
7. Hemodialysis
8. Rehabilitation Service (RH)
9. Social Services
10. Medication
11. Out Patient
■ Proposed Form 2 (JCI)
1. Consents
2. Assessments
3. Others:
3.1 Anesthesia Plan
3.2 Assessment of Planned Procedure
3.3 Written Surgical Report
3.4 List of current medications taken prior to admission
3.5 Medications prescribed or ordered and administered are
written in the patient’s record
3.6 Patient’s Plan of Care
3.7 Discharge Summary
3.8 Record of transferred patients
■ MS 75 ▪ Policies and forms for admission and discharge criteria
for Intensive Care Units:
Admission and Discharge Criteria for :
1. ICU
2. IMCU
3. CCU
4. NICU
■ RECOMMENDATIONS FROM CBAHI SURVEYOR:
1. Sent E-Mail to CBAHI Office recommendation for training on:
Clinical Risk Management – Dr. Abdulmoaty Afifi, Chief of
Rehabilitation & Clinical Risk Manager
Pain Management - Dr. Ibrahim Saad, Specialist, Anesthesia
2. Dr. Mumtaz  recommended to be “full time” in Infection Control
3. Minutes of meetings and committees – appropriateness of
documentation  QMD to give training to “minutes recorders”
■ INTERNATIONAL PATIENT SAFETY GOALS
G-1 Improve the accuracy of patient identification
G-2 Improve effective communication among caregivers
G-3 Improve Safety of using high-alert Medication
G-4 Eliminate wrong site, wrong procedure, wrong patient
surgery
G-5 Reduce the risk of Health Care Associated Infection (HAI)
G-6 Reduce the risk of patient harm resulting from fall
■ RS 5: Availability of well structured education and training program
for respiratory therapists  Score 0 (not met)
Safar 1, 1433 – Chief of ICU had presented to Medical
Administration a teaching-learning program for
Respiratory Therapists. The Department of Education
and Training will have the final approval.