QUALITY IMPROVEMENT AND

PATIENT SAFETY (QIPS)

PROGRAM

Head of Quality

Page 1 of 25
QUALITY IPROVEMENT AND PATIENT SAFETY PROGRAM

Policy Type  Clinical  Administrative Issue Date: 1 September 2021

BRFRH/QPS/P – 006 Review Date: NA

Policy No.:
Revision No.: NA

Reference Standard QPS Next Review Date: 1 September 2022

1. INTRODUCTION:

1.1. Quality is conformance or adherence to standards. It means doing the right things right. It is a
common concept for various organizations, but the processes differ according to types of
organizations.
1.2. This is what is termed as Quality of Care which emphasizes on aspects in terms for patient safety
and staff safety as well, because ultimately, it’s the staff who would be delivering Quality Services
from their end.
1.3. Rainbow Hospital is committed on delivering the utmost compassionate quality care as per
international standards. It is with intent, we achieved, and we will maintain compliance with the
Joint Commission International Accreditation standards.
1.4. BirthRight Fertility by Rainbow Hospital was set up to cater to the burgeoning healthcare needs of
the people in the city of Hyderabad. The hospital is a multi- facility offering state-of-the-art
treatment with medical experts and the latest technological developments in the field of healthcare.
The purpose of the Quality Improvement and Patient Safety Program is to establish, implement, and
monitor quality improvement activities in BRFRH in response to local needs and according to the
International standards (JCI) and National Accreditation Board for hospitals and healthcare
providers (NABH). The essentials of Quality Improvement can be thought of as consideration of
BRFRH’s Structure, Process and Outcomes (as they relate to stakeholder needs) utilizing the
Shewhart Cycle: (Plan, Do, Check, and Act (PDCA). If quality is embedded in the structure, then the
processes that we develop to engage our people and serve our patients will lead to better outcomes.

2. VISION AND MISSION

2.1. BirthRight Fertility by Rainbow is dedicated to manage the continuum of care by providing
coordinated, compassionate, quality health care in all of its components in response to the
population served. It is also incumbent to provide a safe environment enhancing patient satisfaction
and outcome, to maintain financial viability and to support all staff dedicated to this mission.
Rainbow is guided in its endeavours by the vision and mission statement.

2.2. VISION STATEMENT

Our aim at Rainbow Hospitals is to provide high standards of care for the mother, fetus,
newborn and children so that none of them is deprived of a tertiary care facility.

2.3. MISSION STATEMENT

The measure of our success is in the number of smiling faces.

Page 7 of 25
QUALITY IPROVEMENT AND PATIENT SAFETY PROGRAM

3. CONFIDENTIALITY

3.1. The confidentiality of all information pertinent to Quality Management (which encompasses Quality
improvement), including minutes and reports, will be strictly maintained in accordance with the
Rainbow confidentiality policy. Information submitted, collected and prepared for the purpose of
evaluating and reducing morbidity and mortality, or determining that healthcare services are
professionally indicated or performed in compliance with applicable standards, and the physician
profile, will be deemed confidential.

4. RAINBOW COMMITMENT TO QUALITY AND PATIENT SAFETY

4.1. The Rainbow’s Governance and the Leadership Team is committed to continuously improving the
quality of care and service provided here at Rainbow’s hospital.

4.2. The Governance body and the Leadership Team provide direction for the development of the
Hospital’s Quality improvement program and oversee corporate, operational and clinical policies.
They also provide strong leadership in improving performance, which is evidenced by the Medical
Director chairing the Hospital Quality Improvement and Patient Safety (QIPS) Committee.

4.3. The Quality Improvement & Patient Safety program will be reported and reviewed quarterly for
monitoring and actions to be taken and evaluated annually by the Governance.

5. RAINBOW – QUALITY OFFICE

5.1. Rainbow in line with the Mission, Vision & Core Values created a Quality Management Structure
that ensures consistent processes, appropriateness and standards of care across all
Departments/Sections.

5.2. The Quality Office is accountable to the Medical Director. A qualified individual guides the
implementation of the hospital’s program for quality improvement and patient safety and manages
the activities needed to carry out an effective program of continuous quality improvement and
patient safety within the hospital. The Quality Office is responsible for promoting practices yielding
in systems and process improvements throughout the hospital.

5.3. The function of the section can be summarized as follows:

5.3.1. Creating a Total Quality Management (TQM) culture within Rainbow hospital through
conducting educational activities to all levels of staff. This includes commitment from the
management, employee empowerment, fact-based decision making, continuous
improvement, patient centred care.
5.3.2. Working with the various Departments/Sections/units in the hospital to identify
opportunities for continuous improvement.
5.3.3. Coordinating with the various Departments/Sections/units in the hospital to identify the key
performance indicators (clinical & non-clinical) pertinent for each.
5.3.4. Analysing the data collected about each performance indicator (clinical & non-clinical),
identification of trends and recommending improvements when indicated.

Page 7 of 25
QUALITY IPROVEMENT AND PATIENT SAFETY PROGRAM

6. BRFRH QUALITY GOVERNANCE IMPROVEMENT STRUCTURE

Group Medical Director

Cluster Head

Unit Head

Quality Executive

7. QUALITY IMPROVEMENT AND PATIENT SAFETY PROGRAM

“Quality of care” is defined by JCI as “The degree to which health services for individuals and populations
increase the likelihood of desired health outcomes and are consistent with current professional
knowledge”.

7.1. Purpose:
7.1.1. This Quality Improvement and Patient Safety (QIPS) Program is the sum of the activities of
planning, organizing, directing, coordinating the work for continuous improvement to
support the Hospital’s Mission and Vision. The approach is collaborative and involves all
appropriate personnel of both clinical & non-clinical staff. Its primary focus is the systematic
coordination of key management functions concerned with the planning and design of
quality processes, as well as the measurement, analysis, and improvement of the quality of
health care delivered and the efficiency of the health care delivery system. Its goal and
purpose shall be to strive, within available resources, for optimal outcomes with continuous
improvement.

7.2. QIPS Program

7.2.1. Rainbow is committed to the Mission and Vision statements, as well as to the Strategic Plan.
It aims to satisfy the needs and expectations of patients, their families, the served community
and all Internal & External Customers.

7.3. Goals:

7.3.1. CLINICAL QUALITY. To become the leader in providing the highest standard of quality care.
7.3.2. OPERATIONAL QUALITY. To become the leader Health Care provider through continuous
improvement in operations and financial Quality.

Page 7 of 25
QUALITY IPROVEMENT AND PATIENT SAFETY PROGRAM

7.3.3. SERVICE QUALITY. To create an environment in which patients, their families and community
customers are highly satisfied with the service provided to them in connection with the
delivery of care
7.3.4. EMPLOYEE SATISFACTION. To provide an environment that develops, supports and rewards
a well-trained, positively motivated and productive workforce.
7.3.5. COMMUNITY BENEFIT. To be a proactive catalyst in reaching out to the community we serve
to improve access to care and health outcomes.
7.3.6. INTERNATIONAL ACCREDITATION. To achieve and maintain compliance with the certified
international accreditation
7.4. Methodology

7.4.1. The Quality Improvement approach selected by BRFRH is an organization wide approach, to
be followed in implementing all interdisciplinary and departmental/service activities. An
action plan will be developed in alignment with the objectives based on the continuous
improvement methodology with the essentials of Structure, Process and Outcome. If
evaluation of the outcome demonstrates satisfactory levels of Quality, it can be generally
presumed that the Structure and processes are intact.

Find an Opportunity
Organize the Team
Clarify the Current Process
Understand Variations in the Process
Select an Intervention

Plan, Do, Check, Act (PDCA)

Pragmatically, the application of PDCA is the following:

7.4.1.1. Plan is the process of identifying changes or developing hypotheses in response to

the desire to improve. This includes planning process for improvement, developing
objectives and rationale and also developing action plan.
7.4.1.2. Do is the process of carrying out the changes identified in the "plan phase" or the
process of developing relevant databases. This includes description of
measurement process, performance measures and developing systems to access
and utilize data.
7.4.1.3. Check is the process of observing and evaluating the effect of the change through
measurement. This includes description of analysis process and its rationale,

Page 7 of 25
QUALITY IPROVEMENT AND PATIENT SAFETY PROGRAM

individual (Units/Sections) performance process and evaluation of comparison

levels.
7.4.1.4. Act is the process of reacting to the findings from the "check phase" including
formulating new goals, setting objectives, re-prioritizing activities, and
communicating to leadership and governing bodies

7.5. Prioritizing QI Activities

7.5.1. The Rainbow Leadership including the Hospital QPS Committee will be responsible for
establishing priority areas and measures for improvement.

7.5.2. Quality Improvement priorities will be based on the following:

Primary processes most directly related to the quality of care:
7.5.2.1. High risk
7.5.2.2. High Cost
7.5.2.3. High Volume
7.5.2.4. Problem-prone

7.5.3. Furthermore, prioritization for improvement will also be established based on a "Quality
improvement selection criteria" using the following Key Functions/Standards as described by
the JCI:
7.5.3.1. International Patient Safety Goals (IPSG)
7.5.3.2. Access & Continuity of Care (ACC)
7.5.3.3. Patient & Family Rights (PFR)
7.5.3.4. Patient & Family Education (PFE)
7.5.3.5. Assessment of Patients (AOP)
7.5.3.6. Care of Patients (COP)
7.5.3.7. Governance, Leadership and Direction (GLD)
7.5.3.8. Facility Management & Safety (FMS)
7.5.3.9. Quality Improvement & Patient Safety (QPS)
7.5.3.10. Management of Information (MOI)
7.5.3.11. Anesthesia and Surgical Care (ASC)
7.5.3.12. Medication management and use (MMU)
7.5.3.13. Prevention & Control of Infection (PCI)
7.5.3.14. Staff Qualification & Education (SQE)

7.6. Evaluation of Scope of Care

7.6.1. The Quality Improvement and Patient Safety Committee is responsible for evaluating the
scope of practice, taking into consideration the following elements:
7.6.1.1. Type(s) and age(s) of patients served;
7.6.1.2. Methods used to assess and meet patients' care needs;
7.6.1.3. Scope and complexity of patients' care needs;
7.6.1.4. The appropriateness, clinical necessity and timeliness of support services provided
directly by the hospital or through referral contacts;
7.6.1.5. The availability of necessary staff;
7.6.1.6. The extent to which the level of care or service provided meets patients' needs;

Page 7 of 25
QUALITY IPROVEMENT AND PATIENT SAFETY PROGRAM

7.6.1.7. Patient satisfaction;

7.6.1.8. Recognized standards or practice guidelines when available

7.7. Dimensions of Performance

7.7.1. The dimensions of performance include the following:
7.7.1.1. patient centred
7.7.1.2. equitable healthcare
7.7.1.3. patient perspective issues
7.7.1.4. safety of the care environment
7.7.1.5. accessibility, appropriateness, continuity, effectiveness, efficacy, efficiency and
timeliness of care

7.8. Guiding Principles

7.8.1. “Quality” as continuous improvement to be standing agenda item at all Committee meetings
in Rainbow hospital.
7.8.2. Quality Office staff will be the resource people to support improvement activities
organization-wide.
7.8.3. Quality will be the first point of contact for department-based quality initiatives and for
reporting quality related activities to the Quality Office on a monthly basis.
7.8.4. The Quality Office selects and supports qualified staff for the program and supports those
staff with quality and patient safety responsibilities throughout the hospital
7.8.5. The program provides support and coordination to department/service leaders for like
measures across the hospital and for the hospital’s priorities for improvement.
7.8.6. The program implements training activities for all staff that is consistent with staff’s roles in
the quality improvement and patient safety program.
7.8.7. The quality program is responsible for the regular communication of quality issues to all staff.
7.8.8. All Departments will be committed to improving its Quality and enhancing quality of care.
7.8.9. When opportunities for improvement are identified, they will be related to the mission,
vision and strategic plan, as well as the functions of the JCI standards.
7.8.10. Quality improvement will be based on data collection, aggregation and analysis by qualified
personnel with knowledge and experience to evaluate quality, measure outcomes, identify
areas for improvement, and to help determine priorities with application of statistical tools
as applicable.
7.8.11. The program will provide coordination for integration, aggregation and analysis of
measurement activities throughout the hospital.
7.8.12. For learning and finding opportunities for improvements, similar measures data will be
compared with external organizations who are of almost similar size and complexity. In such
case confidentiality and security of the data will be maintained.
7.8.13. Quality Improvement will be a multi-disciplinary, collaborative and continuous process.
Quality Improvement activities will be documented to provide a well-recorded
representation of the quality management process. Such documentation will contain a
description of the design, measurement, assessment, utilization, redesign and improvement
of the subject matter.
7.8.14. Provide for the integration of event reporting systems, safety culture measures, and others
to facilitate integrated solutions and improvements.
7.8.15. Track the progress on the planned collection of measure data for the priorities selected.

Page 7 of 25
QUALITY IPROVEMENT AND PATIENT SAFETY PROGRAM

7.8.16. The program will play a major role in proactively identifying and reducing risk and variation
along with safety manager within the organization
7.8.17. The program shall use current scientific and other clinical information to support patient care
and clinical education by utilizing current and up to date clinical guidelines and pathways.
These guidelines shall be made available to all concerned staff in the hospital wide shared
document and continuous evaluation of the compliance to these guidelines and pathways
shall be monitored.
7.8.18. The relevant results of Quality improvement activities will be utilized in the re- appointment
process of the medical staff and allied health staff as well as in the competency verification
process of other professionals. Clinical criteria and continuing education will also be taken
into consideration when determining the competency of individuals and the scope of
activities the practitioner/employee performs.
7.8.19. Rainbow hospital will have a mechanism for identifying and reporting sentinel events. A root
cause analysis will be conducted in order to understand the processes associated with the
adverse event.
7.8.20. An annual evaluation of all aspects of the monitoring and evaluation of the quality of patient
care will be conducted

7.9. Coordination of Services for Quality Improvement and Patient Safety

7.9.1.Role of Governance

7.9.1.1. Responsibilities, as pertinent to Quality Improvement include but not limited to

the following:
7.9.1.1.1. Approve the Quality Improvement and patient safety program annually.
7.9.1.1.2. Administering Rainbow Quality Improvement Program that includes
supporting efforts for improving organizational Quality at each
department.
7.9.1.1.3. The implementation and effectiveness of activities of the quality
improvement program will be reviewed including reports of adverse and
sentinel events quarterly and evaluated yearly. The actions taken and
follow-up will be reflected in minutes.

7.9.1.2. Responsibilities of Leadership in co-ordination with Quality Office / Department

Heads.

7.9.1.2.1. Participates in developing and implementing a hospital wide quality

improvement and patient safety program.
7.9.1.2.2. Selects, prioritizes and implements hospital wide process to measure,
assess data, plan change and sustain improvements in quality and
patient safety.
7.9.1.2.3. Identify measures and key performance indicators for improvement
throughout the hospital and departmental level based on available data
and priority for improvements in coordination with Quality Office and
department heads.
7.9.1.2.4. Provide coordination and integration of measurement activities
throughout the hospital.

Page 19 of 25
QUALITY IPROVEMENT AND PATIENT SAFETY PROGRAM

7.9.1.2.5. Determines how the program will be directed and managed on a daily
basis and provides adequate technology and other resources for the
program to be effective.
7.9.1.2.6. Assuring that staff at all levels, especially those at the patient care level,
are routinely and systematically appraised of Quality Improvement
activities and steps taken to resolve problems whenever appropriate.
7.9.1.2.7. Hospital leadership implements a structure and process for overall
monitoring and co-ordination.
7.9.1.2.8. Reports on the quality and patient safety program quarterly to
governance, also including the number and type of sentinel events and
root causes, whether the patients and families were informed of the
sentinel event, actions taken to improve safety in response to sentinel
event and if the improvements were sustained.
7.9.1.2.9. To make sure that information on the quality improvement and patient
safety program is regularly communicated to staff including progress on
meeting the International Patient Safety Goals.
7.9.1.2.10. Implement actions for ensure full compliance with International Patient
Safety Goals.
7.9.1.2.11. Hospital leadership assesses the impact of hospital wide and
departmental/service improvements on efficiency and resource use.
7.9.1.2.12. Assisting with the implementation of methodologies to standardize
healthcare.
7.9.1.2.13. Supervise implementing and maintaining a mechanism for addressing
patients' compliments and complaints.
7.9.1.2.14. Supervise preparation for Accreditation & Mock surveys (in
coordination with Department of Quality).
7.9.1.2.15. Providing support and education within the facility relating to Quality
Improvement.
7.9.1.2.16. Monitoring quarterly meetings of the Quality Committee.

7.9.2.Role of QIPS Committee

7.9.2.1. The QIPS Committee is the highest executive Quality Improvement Authority in
Rainbow with Medical Director as its chairperson. It will be responsible for overall
planning, directing, prioritizing, implementing and follow up of all Continuous
Quality Improvement (CQI) Initiatives and activities in Hospital. On the other hand,
the leadership will assure that, all necessary resources required for successful QI
Program Implementation are devoted at all functional levels.
7.9.2.2. Responsibilities, as pertinent to Quality Improvement include but not limited to
the followings:
7.9.2.2.1. To review and guide the implementation of JCI Accreditation Standards
in BRFRH.
7.9.2.2.2. To review and approve the QI Program including but not limited to
Quality & Performance Indicators as defined by JCI Accreditation
Requirements.
7.9.2.2.3. To review Quality Improvement Reports generated regarding Quality
Indicators as defined by the QI Program.

Page 19 of 25
QUALITY IPROVEMENT AND PATIENT SAFETY PROGRAM

7.9.2.2.4. To review, prioritize and guide all Quality Improvements initiatives and
activities in all Departments and assure a satisfactory experience &
optimal outcome for all BRFRH patients.

7.9.3.Role of the Quality Manager

7.9.3.1. The Quality office / Quality Manager is accountable to the Medical Director. It is
responsible for promoting the use of Total Quality Management (TQM) philosophy,
principles, and practices throughout BRFRH. The scope of the Quality Governance
Office can be summarized as follows:
7.9.3.1.1. Developing and Implementing BRFRH Quality Improvement Program in
co- ordination with others concerned.
7.9.3.1.2. Regulatory preparation and compliance
7.9.3.1.3. Policy standardization
7.9.3.1.4. Performance Improvement
7.9.3.1.5. Outcome Management Support
7.9.3.1.6. Incidents & Sentinel Events

7.9.3.2. Also include responsibilities but not limited to the following:

7.9.3.2.1. Participating effectively in Implementing & Follow up of Quality
Improvement and Patient Safety Program.
7.9.3.2.2. Orchestrating Quality Improvement Initiatives & Activities Hospital
Wide.
7.9.3.2.3. Making quarterly review report of the program and submitting to
Governance.
7.9.3.2.4. Implement a training program for staff knowledge awareness and
effective implementations.
7.9.3.2.5. The Quality Office will be charged with supporting and coordination
departments in their activities to improve the quality of care delivered,
and to improve organizational Quality based on hospital priorities for
implementation.
7.9.3.2.6. Developing methodologies along key organizational functions including,
but not limited to, quality control, patient complaint/satisfaction, health
care standardized approaches such as clinical pathways and guidelines,
blood use, medication use, risk management and infection control.
7.9.3.2.7. Identify measures and key performance indicators for improvement
throughout the hospital and departmental level based on priority for
improvements in co-ordination with concerned.
7.9.3.2.8. Orchestrating all Rainbow Accreditation activities.
7.9.3.2.9. Maintain continuous knowledge and understanding of JCI functions and
standards.
7.9.3.2.10. Educate and support staff in all departments to meet new regulatory
requirements on ongoing basis.
7.9.3.2.11. Mock surveys co-ordination.
7.9.3.2.12. Conducting culture of safety surveys annually and actions
implementations.
7.9.3.2.13. Overviewing Medical Record Review activities & Peer Review Processes.

Page 19 of 25
QUALITY IPROVEMENT AND PATIENT SAFETY PROGRAM

7.9.3.2.14. Compile, review and reformulate standards and processes across the
institutions.
7.9.3.2.15. Identify and share across the system best practice models and care
processes (those, which achieve optimal patient outcomes, enhance
patient / family and staff satisfaction, are cost effective and resource
appropriate.
7.9.3.2.16. Selects and support qualified staff for the program and supports those
staff with quality and patient safety responsibilities throughout the
hospital.
7.9.3.2.17. Training key staff who need to be involved in the projects to be
undertaken. e.g. PDCA, RCA, FMEA, HVA, Fish Bone analysis , cost and
efficiency.
7.9.3.2.18. Communicate with and obtain input/approval as needed from Rainbow
Quality and patient safety Committee.
7.9.3.2.19. Guiding all Departmental Quality team to foster multidisciplinary
preparation.
7.9.3.2.20. Communicate quality activities to staff.
7.9.3.2.21. Support & Reporting of Outcomes to BRFRH Quality Committee.
7.9.3.2.22. Liaison to Risk Management.
7.9.3.2.23. Arrange with team throughout BRFRH for staff education, data
collection and analysis.
7.9.3.2.24. Communicate to staff on quality related activities on a regular basis.

7.9.4.Role of Department Heads

7.9.4.1. Being the highest authority in their departments, each Department Head will lead
the Quality Improvement Initiative in his/her department. Responsibilities, as
pertinent to Quality Improvement include but are not limited to the following:

7.9.4.1.1. Leading Departmental Quality initiatives with team comprising of QI

Champions, Department key persons and all/or as many as possible of
Department staff members.
7.9.4.1.2. Developing and implementing policies and procedures that guide and
support the provision of services;
7.9.4.1.3. Identifying the Performance Indicators within department and leading
department in all data collection and analysis activities to reduce
variation and improve processes. He will, in general, lead all initiatives
regarding improving department performance work Quality. Once the
measure is sustained, a new measure needs to be selected.
7.9.4.1.4. Recommending sufficient number of qualified and competent persons
to provide care and treatment.
7.9.4.1.5. Determining the qualifications, evaluating and ensuring competence of
personnel who provide patient care services.
7.9.4.1.6. Continuously assessing and taking actions to improve the quality of care
and services provided.
7.9.4.1.7. Maintaining quality control programs.
7.9.4.1.8. Providing orientation, in-service training and continuing education;
7.9.4.1.9. Recommending resources needed to support Quality Improvement.

Page 19 of 25
QUALITY IPROVEMENT AND PATIENT SAFETY PROGRAM

7.9.4.1.10. Integrating services into primary functions compatible with the mission
and vision.

7.9.5.Role of Clinical Department Heads

7.9.5.1. Participate in the reappointment / appraisal process of the medical staff / relevant
professionals.
7.9.5.2. Select, frame and Implement the Clinical practice pathways and guidelines.
7.9.5.3. Monitor and evaluate the following:
7.9.5.3.1.1. Scope of activities as defined by volume and Diagnosis
Categories of their patients, Quality of operative and invasive
procedures, Quality of medical record completion and the
appropriateness of the record as reflected in the patient focused
functions (patients' rights, assessments of patient, education and
continuum of care)
7.9.5.3.1.2. Blood usage evaluation
7.9.5.3.1.3. Infection rates
7.9.5.3.1.4. Sentinel events
7.9.5.3.1.5. Clinical indicators
7.9.5.3.1.6. Patient complaint/satisfaction, patient's rights
7.9.5.4. Integrate the services into the organization's primary functions compatible with the
mission and vision.
7.9.5.5. Identifying the Performance Indicators and leading his department in all data
collection and analysis activities. He will, in general, lead all initiatives regarding
improving department performance.
7.9.5.6. Coordinate and integrate interdepartmental and intra departmental services.
7.9.5.7. Develop and implement policies and procedures that guide and support the
provision of services.
7.9.5.8. Recommend a sufficient number of qualified and competent persons to provide
care and treatment.
7.9.5.9. Determine the qualifications and evaluate competence of department personnel
who provide patient care services.
7.9.5.10. Continuously assess and take actions to improve the Quality of care and services
provided on the inpatient and outpatient services.
7.9.5.11. Maintain quality control programs, as appropriate.
7.9.5.12. Orientation and provision on in-service training and continuing education of all
persons in the department.
7.9.5.13. Responsible for assuring the integration of department activities with the
organizational improvement program
7.9.5.14. Recommend space and other resources needed by the department or organization.

7.9.6.Role of Nursing
7.9.6.1. The Nursing Department is responsible for collecting nursing related data on an
ongoing basis, monitoring and evaluating those aspects of nursing care most closely
linked to quality, and presenting the data to the BRFRH QIPS committee. The role
of the Nursing Department is to:
7.9.6.1.1. Ensure the continuous and timely availability of nursing services to
patients;

Page 19 of 25
QUALITY IPROVEMENT AND PATIENT SAFETY PROGRAM

7.9.6.1.2. Ensure that nursing standards of patient care and standards of nursing
practice are consistent with current Nursing Findings, Accreditation
Standards and Nationally Recognized Professional Standards;
7.9.6.1.3. Implement the findings of from nursing and other literature into the
policies and procedures governing the provision of nursing care;
7.9.6.1.4. Assign responsibility to individuals or groups of nursing staff members
to act on improving the nursing services' Quality;
7.9.6.1.5. Actively participate in the BRFRH Leadership Functions;
7.9.6.1.6. Collaborate with other BRFRH leaders in designing and providing patient
care and services;
7.9.6.1.7. Participate with BRFRH leaders in providing for a sufficient number of
appropriately qualified nursing staff members to care for patients.
7.9.6.1.8. In co-ordination with BRFRH Quality Office, Director of Nursing will be
responsible for the overall monitoring of the quality improvement
initiatives and activities within the Nursing Department and evaluating
those aspects of care most closely linked to quality.
7.9.6.1.9. It is nursing responsibility to lead the process of identifying those
aspects of care that affect large numbers of patients, are of high benefit
or high risk for patients, and/or are suspected of producing problems.
Based on Nursing (and others') evaluation, such assessments will be
used to prioritize areas for improvement.
7.9.7.Role of Quality Champions
7.9.7.1. Quality champions will be submitting the indicator data to the Quality Governance
Office for their respective departments in the uniform format for all and are
responsible to implement quality initiatives within their department.
8. DATA GATHERING
8.1. Indicator: An indicator is a measurable variable utilized to initiate the FOCUS PDCA. Variables will
be grouped according to categories of analysis identified by Dona bedian. Indicators will be
developed to measure over time the structure, process or outcomes of care.
8.2. Base Line Performance Indicators: are indicators monitoring the aspects based on areas for
improvements and prioritization basis as JCI Standard GLD 5
8.3. The base lines Areas/Activities to be included are classified into following:
8.3.1. Measures for each of the International Patient Safety Goals
8.3.2. Measures for Identified Departments (Clinical and Non-Clinical) ▪ Measures for Identified
Outsourced Areas
8.3.3. Measures on important healthcare parameters listed below:
8.3.3.1. All serious adverse drug events
8.3.3.2. All significant medication errors
8.3.3.3. All major discrepancies between preoperative and postoperative diagnoses
8.3.3.4. Adverse events or patterns of adverse events during procedural sedation
regardless of administration site
8.3.3.5. Adverse events or patterns during anaesthesia regardless of administration site
8.3.3.6. Healthcare associated infections
8.3.3.7. Other adverse events

8.4. Indicator Database: This has been developed by in coordination with concerned Departments,
Quality Governance Office, selected by leadership and approved by Chief Operating Officer.

Page 19 of 25
QUALITY IPROVEMENT AND PATIENT SAFETY PROGRAM

8.4.1. Once implemented, the developed Indicator Database will utilize comparative data among
BRFRH Medical Facilities for benchmarking. These indicators can also be compared to
establish reference ranges or thresholds gleaned from the literature or from professional
practice parameters.
8.4.2. For each measure, the data are collected, aggregated and analysed by the direct process
owners, Quality Governance Office personnel and others concerned. The results are
reported to those accountable for taking appropriate actions.

8.5. Data Gathering Process

8.5.1. Data to be gathered depends on identified measure and the frequency of reporting for
various departments.
8.5.2. Departmental Quality Champions will collect the data and enter the details in the indicator
data sheet which is a uniform format throughout BRFRH and is made available in the
hospital shared folder.
8.5.3. Access is given to particular departmental Quality team to enter the data. It needs to be
completed by them by the 5th of each month (data for the previous month.
8.5.4. Only Quality Governance Office staff has complete access to all the data.
8.5.5. The Quality Governance Office reviews the data every month. If an identified measure has
frequency of reporting quarterly, then it will be reviewed on a quarterly basis for that
particular measure.

9. DATA ANALYSIS AND REPORTING

9.1. Analysis
9.1.1. The data analysis is done jointly by the Quality Governance Office and departmental Quality
champions which is minuted as part of the Quality Improvement and Patient Safety
committee meeting.
9.1.2. The data gathered shall also be analysed using statistical tools (as applicable) such as:
9.1.2.1. Cause and effect / fishbone diagram
9.1.2.2. Pareto charts
9.1.2.3. Run charts, which display summary and comparative data
9.1.2.4. Control charts, which display variation and trends over time
9.1.2.5. Histograms

9.1.3. The statistical analysis of data allows BRFRH to carry out the Quality improvement process.
9.1.4. Depending on the performance of a measure, data aggregation and action plan shall be
developed for implementation. In the subsequent months, the data will be reviewed to see
the effectiveness of the actions being implemented. Intense analysis of the data will be
performed for adverse events, unusual trends/patterns.
9.1.5. Results of the analysis are used to implement actions to improve the quality and safety of
the service.
9.1.6. Both Quality Governance Office and IT Department are dedicated to developing and
maintaining secure databases and providing and assisting leadership with data analysis

9.2. Reporting:

Page 19 of 25
QUALITY IPROVEMENT AND PATIENT SAFETY PROGRAM

9.2.1. The reporting of the data is part of the monitoring activities for improvements of Quality
Improvement and Patient Safety Program and will be reported quarterly to governance by
Quality Governance Office
9.2.2. BRFRH Quality champions will be trained on commonly used statistical techniques as
required. This includes the use of control charts, histograms, Pareto diagrams, etc. Process
flow diagrams (which can identify specific assignable causes of variation of quality
characteristic in a process) and cause and effect diagrams (which allow one to organize
hypotheses specifically for use in quality control and improvement) are also used to analyse
and illustrate data.
9.2.3. BRFRH Performance Indicators will conform to current and advanced standards of
acceptable practice while fulfilling accreditation standards

10. VARIANCE ANALYSIS AND BENCHMARKING

10.1. Variance in BRFRH Service Quality will be evaluated from four perspectives:
10.1.1. With itself over time, such as month to month, or one year to the next
10.1.2. With other similar organizations, such as through reference databases
10.1.3. With standards, such as those set by accrediting and professional bodies or those set by
laws or regulations
10.1.4. With recognized desirable practices identified in the literature as best or better practices
or practice guidelines

11. IMPROVEMENT:

11.1. Improvement will be achieved by fine-tuning processes that already function well, or through
wholesale redesign. The intent will be to reduce or eliminate undesirable variation in processes
or outcomes that were identified in the "do" and "check" phase of the Quality improvement cycle.

11.2. Corrective action, in the "act" phase, will include but is not limited to: new policies or
procedures, education, adding resources or modifying resource allocation, or disciplining and/or
releasing individual staff (in case of repeated gross misconduct) . Such actions may be
implemented initially on a limited, pilot, or trial basis while measurement continues. After
corrective action is implemented, actual and desired Quality will be compared. The measurement
exercise will continue to test and confirm the efficacy of the improvement strategy. The
department, facility, or body that provided the original momentum for improvement will be
obliged to continue to monitor the process and be involved until successful changes are fully
implemented. Quality improvement records such as minutes, reports, plans, etc., must document
this process.

11.3. Individual or group performance issues, not only "process" issues, will also be at the centre of
Clinical & Managerial Quality Monitoring. BRFRH will meet the intent of the JCI Standards
pertaining to the Staff Qualification & Education. In that regard, the areas of competency,
credentialing and education are of primary importance.

Page 19 of 25
QUALITY IPROVEMENT AND PATIENT SAFETY PROGRAM

12. COMMUNICATION
12.1. The Quality Structure in BRFRH, previously described will demonstrate that the
12.2. System itself is organized to facilitate communication. The formal Quality Management process
and reporting structure that link all BRFRH Functional Levels and culminates at BRFRH Quality
Improvement & Patient Safety Committee will foster accountability and awareness. In addition,
numerous other strategies and processes will facilitate and enhance communication including:
12.3. JCI Monthly Status Presentation presented to all BRFRH Staff.
12.3.1. Technical and structural modalities such as: inter-office e-mail capabilities between
Departments as well as with other BRFRH Facilities & telephone lines, various local and
wide area computer networks in addition to ordinary mail.
12.3.2. BRFRH Quality Committee attended by appropriate facilities representation. The
purpose will be to share information, work collectively on System wide projects, and
develop as groups within the Network.
12.3.3. Regularly functioning Committees at BRFRH level.
12.3.4. BRFRH-Wide Initiatives will be instituted across BRFRH as well as all BRFRH.
12.3.5. Facilities for the purpose of assessing and improving specific processes.
12.3.6. Building on the previously described measurement and assessment activities, BRFRH will
have the capability to identify improvement opportunities. Like most organizations,
BRFRH will identify more improvement opportunities than can be addressed at any one
time. Hence, there is a substantial need to set priorities. Implicit and explicit criteria will
be used when selecting improvement opportunities. e.g.:
12.3.6.1.1.1. Priorities will also be given to these would certainly reflect the relevance to
the Organization's mission, vision, values and strategic plan.
12.3.6.1.1.2. Priorities will also be based on the problems' relationship to the JCI
accreditation standards/functions and dimensions of Quality and
whether the opportunities for improvement are "high volume or problem
prone".
12.3.6.1.1.3. Resource availability and customers’ interest will also be taken into
consideration.
12.3.6.1.1.4. BRFRH will pay special attention to opportunities for improvement that has
the greatest chance of positively affecting the greatest number of patients and
customers. When opportunities for improvement exist, BRFRH Quality
Governance Office will adopt a variety of ways that improvement actions can
be developed and implemented

13. COMPETENCY AND PRIVILEGES

13.1. Opportunities for improvement will originate from various monitoring systems measuring existing
activities. When improvement activities lead to finally a determination that an individual has a
Quality issue or that the individual is unable or unwilling to improve, that individual will have their
clinical competency/privilege or job assignment modified, or appropriate action taken as
required.

13.2. The role of peer review and staff competency review will be integral to this process. Resources
will be devoted for appropriate remedial action when indicated. Improvement will be measured
along the dimensions of Quality for each function in terms of appropriateness, availability,
timeliness, continuity, efficacy, safety, continuity, efficiency, and respect and caring.

Page 19 of 25
QUALITY IPROVEMENT AND PATIENT SAFETY PROGRAM

13.3. Work will be continued in the area of ensuring staff competency including the development of
criteria-based Quality evaluations, the determination of standards for certain practice areas
(emergency services, critical care areas), standard requirements for hiring requirements, and
continued employment requirements

13.3.1. THE CURRENT COMPETENCY INSTRUMENT WILL HAVE THE FOLLOWING CHARACTERISTICS:
13.3.1.1. A criteria-driven, objective and measurable assessment of competency and
Quality.
13.3.1.2. Information that can identify patterns, trends, and issues pertaining to employee
competence and Quality, as well as opportunities for improvement.
13.3.1.3. Take into account the measurement of knowledge, skills and attitude in the
assessment process.
13.3.1.4. Establish any relationship between competency, Quality, and other relevant
Organizational activities i.e., Quality improvement, service excellence initiatives,
etc.

13.4. CREDENTIALING

13.4.1. As per the credentialing policy, a credentialing methodology will be maintained to coordinate
the credentialing process, maintain specific responsibility and accountability, as well as
facilitate the physician driven integration of Utilization, Quality Management and Medical Staff
Credentialing. An important component of this initiative includes credentialing of all Allied
Health Professionals e.g. nursing. In order to accomplish these goals, specific improvement
actions will be taken.
13.4.2. Relevant findings from monitoring and evaluation activities of various activities will be used
for the re-appointment and reappraisal process, and the renewal or revision of privileges
through the credentialing process. The credentialing methodology will:
13.4.2.1. Ensure reassessment and continual monitoring of qualification requirements for
staff appointments (not less than every other year), as well as competency
requirements regarding new procedures in accordance with the Bylaws.
13.4.2.2. Maintain each individual's profile with standardized Quality based indicators for re-
appointment. These indicators may include an activity profile, utilization
management review, surgical/invasive procedure review, medication usage review,
blood and blood product monitors, infection control data, mortality and morbidity
review, meeting attendance and medical record review. Competency of low volume
providers will be followed and verified by the Chairman prior to reappointment.
13.4.2.3. Delineate privileges for Physicians and competency assessment for Pharmacists,
Nurses, Other all Allied Health Professionals.

13.5. EDUCATION

13.5.1. Staff education will be an important activity to assure competency. Often, Quality issues are
the result of a group or individual knowledge deficit that may be easily corrected and
improved with orientation, continuing education, or training. Staff education efforts begin
with training to achieve Quality improvement.

Page 19 of 25
QUALITY IPROVEMENT AND PATIENT SAFETY PROGRAM

13.5.2. All staff will be educated concerning the theory and application of total quality management
that includes the principles developed by Deming, Juran and Crosby. In addition, staff will
learn about statistical methods in order to measure and assess their Quality. BRFRH Quality
Improvement Training Grid Mix Attachment 1

13.5.3. Staff education in response to improvement opportunities will be a legitimate and often first
sought solution. Continuing medical education (CME) will be offered to the medical staff of
BRFRH. Topics will be offered based on requests and needs identified through the Quality
improvement program.

14. DISEASE MANAGEMENT

14.1. Disease management will be the next step in health care management. Disease management is an
extension of several trends in directing health care delivery. It differs from previous efforts because
it seeks to manage patient treatment across a continuum of care, not just in a hospital setting.
Clearly, the implementation and evaluation of practice guidelines at BRFRH will be an important
function in BRFRH in the future.

14.2. Key issues in successful disease management programs will include completing high quality
research, using computers for data collection, and standardizing clinical data from different sources
so it can be compared and analysed. Physicians will be central to this process. High quality
databases will be utilized. BRFRH believes that Disease Management can be an organizational
means of effective process change

15. ANNUAL EVALUATION

15.1. An evaluation of the BRFRH Quality Improvement Program shall be completed annually by the
governance. It is a summary of activities and improvements from the prior year as well as goals and
objectives for the year to come. The effectiveness of the education, and orientation program of
BRFRH will be evaluated. It shall be based on analysis of Monitoring Systems and input from the
various quality management initiatives.
15.2. The governance will review the implementation activities of the program and suggest actions for
improvements quarterly. (See Attachment 2).
15.3. An Annual Evaluation with suggestive actions for improvements shall be done by governance. A
copy of the Annual Evaluation shall be distributed to all concerned

16. CONCLUSION
16.1. In summary, the BRFRH Quality Improvement Program is designed to:
16.1.1. Incorporate the Organization's mission, vision and planning
16.1.2. Meet patient and community expectations.
16.1.3. Encompass the changes in our health care field.
16.1.4. Implement methodologies for resource and disease management.
16.1.5. Provide consistent, ethical guidelines for clinical operations.
16.1.6. Address changes in methodologies required by the JCIA.
16.1.7. This program shall assist BRFRH to improve performance, and in turn, improve Health
Outcomes by improving performance of clinical, governance, and support processes
through heightened integration and coordination of services

Page 19 of 25
QUALITY IPROVEMENT AND PATIENT SAFETY PROGRAM

17. REFERENCES:
17.1. Joint Commission International: Joint Commission International Accreditation Standards for
Ambulatory Care, 4th Edition, 2019 USA;
17.2. Specification Manual for the Joint Commission International Library of Measures Version 2.0,
effective for January 2013 discharges (1st Quarter 2013) ©2011 Joint Commission International

18. APPROVAL:

Name Designation Signature & Date

Prepared by: Ms.Karunamrutha Sr. Manager Quality

Reviewed by: Dr. Prashanth K Medical Director

Whole time Board of

Approved by: Dr. Dinesh Kumar Chirla
Director

Page 19 of 25
QUALITY IPROVEMENT AND PATIENT SAFETY PROGRAM
Attachment 1: Quality Training Grid Matrix

TOPICS Top Leadership Dept Heads Doctors Nurses Section Heads Front Line Staff
1. IPSG TRAINING      

2. FOCUS PDCA    

3. PATIENT RIGHTS      

4. CLINICAL INDICATORS  

5. INCIDENTS / SENTINEL EVENTS REPORTING     

6. PDCA  

7. KPI  

8. JCI GENERAL      

9. JCI STANDARDS  

10. JCI SURVEY PROCESS      

11. JCI MONITORING  

12. RISK MGT. INTRO.      

13. AUDIT PROCESS   

14. FIRE & EMERGENCY RESPONSE      

15 PRINCIPLES OF TQM     

16 RISK ASSESSMENT     

17 Ethics and code of conduct      

Page 20 of 25
QUALITY IMPROVEMENT AND PATIENT SAFETY PROGRAM

Attachment 2: Quality Improvement Activities (Quarterly Review) Format

SN Activity Frequency
1. Framing policies according to guidelines laid down by BRFRH and JCI in liaison with concerned Hospital Staffs. On Going
Also, according to new departmental set up, new polices to be inducted.
2. Reviewing all existing hospital policies from the Issue Date or as required. As per the need or changes required in
the existing policies
3. Orientation
Orientation for new joined staff. Monthly (Organized by HR department)

4. Training on Quality Concepts

a) For Quality Department Staff
i) ii) Quality topics like PDCA, TQM, RCA, FMEA, etc will be covered. Quarterly/ As
per need
Topics on different JCI standards will also be covered.
b) For Hospital Staff
i) Training on Specific Quality concepts and Training on various topics/standards as laid down by JCI Monthly/ As per need.
Topics will be selected as per need.
Relevant topics according to JCI
standards will be conducted at any time
as per need in additional to monthly
trainings.

Page 21 of 25
QUALITY IMPROVEMENT AND PATIENT SAFETY PROGRAM

5. Departmental Training Co-ordination (HOD’s) as per training plan Minimum Quarterly

6. Committee Meetings – To be held as per the frequency of meetings (monthly or quarterly) as mentioned in Terms Quarterly and as on required
of Reference The committees include
 Hospital Executive Management Committee (HEMC)
 Quality and Patient Safety Committee
 Hospital Infection Control Committee
 Safety and Risk management Committee
 Drugs and Therapeutics Committee
 Credentialing and Privileging Committee
7. Monitoring of Performance Indicators and Analysis, Trending, Action plan for improvements Quarterly
8. Implementing actions recommended by QPS committee in liaison with Department Heads and concerned As required. Implementing as per the
members of other Committees discussions and the
recommendations of the QPS Committee

9. Incident Reports Analysis Monthly / Trending – Quarterly

10. Co-ordination with IT Department for maintaining and upgrading at regular intervals all relevant hospital policies As required
for access to staff in the BRFRHJ Quality Folder and implementation for any new forms.
11. Patient Complaints and Feedbacks monitoring to assess the outcome of healthcare delivery and to identify areas Monthly/Trending Quarterly
for improvements.
12. Sentinel Events Quarterly
i) Sentinel Event Review ii) Reporting to Governance with highlighting the number and type of sentinel events
and associated root causes, whether the patients and families were informed of the event, actions taken to
improve safety in response to events and if the improvements were sustained.

Page 21 of 25
QUALITY IMPROVEMENT AND PATIENT SAFETY PROGRAM
13. Maintains records of policies procedures, guidelines, forms and other documents and ensuring the circulation of On-Going
current document and the de-circulation of expired documents.
14. Clinical Pathways & Guidelines On-Going
PROJECTS

15. Risk Assessment will be performed throughout the hospital. It will be undertaken using the Risk Assessment Yearly – Once / More if required
Tools.
16. FMEA (Failure Mode & Effect Analysis) Project on any one of the Prioritized Areas. Yearly – Once / As required depending
on the need to evaluate our systems
and processes, make action plan for
effective implementations.

17. FOCUS PDCA Projects As per the need. Minimum 1 projects

every yearly to be initiated.
18 Implementation of hospital wide Culture of Safety Program. Annually
19 Implementation of hospital wide cost efficiency project. Annually
20 RCA As applicable

Page 21 of 25
QUALITY IMPROVEMENT AND PATIENT SAFETY PROGRAM

Quality Priorities and Plan for 2022

Key Priority Areas for 2022 (See Appendix A) Hospital wide Objectives
priorities
100%compliance to International Patient Safety Goals
1. Patient Safety Culture of Safety surveys analysis and action plans for improvement

Patient satisfaction survey analysis and action plans, complaints resolution,

2. Patient Experience analysis and action plans

Audit for compliance to hand hygiene

3. Reduced Healthcare associated infections Increased compliance to bundles and checklist

Reduction of wait time and improved utilization of services

4. Utilization of services

Enhanced staff satisfaction and robust staff retention program

5. Staff satisfaction

Page 21 of 25
QUALITY IMPROVEMENT AND PATIENT SAFETY PROGRAM

Quality and Patient Safety Department Key Priorities 2022 Objectives

1. All sentinel events will be identified and follow:
Sentinel Event Reporting Policy and conducting thorough A thorough Root cause analysis and feedback to be completed within 45 days
Root
Cause Analysis
2. International Patient Safety Goals will achieve 100% IPSG links to perform real time/ concurrent and retrospective audits
compliance in all hospitals and services.
3. Patient Satisfaction will be improved. BRFRHJ will select at least one question (Usually lowest) on the patient satisfaction
returned questionnaire or complaint (Most frequent complaint) and improve it by
at least 5%.
4. BRFRH will identify five areas of strategic priority against Five guidelines selected for implementation and monitoring
which to develop, implement and monitor at least five
clinical practice guidelines and clinical pathways. 90%
compliance is set as a target.

5. Analysis of available data, information trending and the BRFRH will use appropriate statistical tools and techniques in their analysis
application of evidence-based decision making, will be used processes and decision-making. Data will be displayed whenever appropriate in run
to support quality improvement and patient safety. charts/control charts. All relevant action plans shall be implemented to monitor
and sustain improvement.

Page 21 of 25