Quality Management Developers

QQMD is one of Egyptian's Fastest Growing Healthcare Operation , Economic & Quality Management Company

Turning Quality Into Reality.

Technical Proposal

Prior to advanced package application all hospitals are to fulfilla detailed Hospital application form 'attached 'to determine its status quo and to start proposal components accordingly.

Eligibility for Advanced professional package:

           -   Top Management commitment and support.
           -   Established and staffed quality management department.
           -   Established Facility Management and safety department / Assigned responsibility.
           -   Established and staffed infection control department.

Components of Advanced professional package:

  1. Gap analysis
  2. Action plan reporting
  3. Advanced training
  4. Accreditation preparation and follow-up

       A. Gap Analysis

  • Components:

The scope and duration of gap analysis will depend up Size, Type and complexity of the organization, SeeHospital Information Form but, generally Gap analysis will be categorized as the following:

 

Category A

Category B

Category C

No of beds

Less than 120 Beds

120 to 220 Beds

More than 220 beds

No of days

3 days

3 days

4 days

No of surveyors

3 surveyors

4 surveyors

4 surveyors

Gap Analysis Methodology:

-      Documents Review

-      Staff Interview

-      Facility Tour

-      Patient Tracer Methodology

-      System Tracer Methodology

Gap Analysis Plan

-      Gap analysis A will be conducted by 3 Surveyors for 3 days

-      Gap analysis B will be Conducted by 3 Surveyors for 4 days

-      Requirements at the openingmeeting of Gap analysis:

  • Hospital or General Policies & Procedures
  • List of Employees
  • List of Forms
  • List of patients and Surgical patients


Activities Time Table: For category A "Less than 120 Beds"

Day 1

Surveyor 1

Surveyor 2

Surveyor 3

9:00 am

9:15 am

15

Minutes

Document review session and overview of organization services

(soft copy or hard copy) include all policies and procedures required in English from the organization

9:15 am

11:00 am

75

Minutes

Opening meeting

( with top management and organization key players)

11:00 am

1:00 pm

60 minutes

Review quality management plan and dashboard

Medication management review

(with pharmacy team)

Personal files review

(appointment , credentialing , reappoint)

60 minutes

IPSG tracing in OR

KPI analysis and follow up (data handling )

1:00 pm

1:30 pm

30

Minutes

Lunch break

1:30pm

3:00 pm

45 minutes

IPSG tracing

in intensive care units

Closed medical record review

(different specialties)

Facility tour

(facility management review)

45 minutes

IC tracing activity

(through the hospital)

3:00 pm

4:00 pm

60

Minutes

Team meeting


 

Activities Time Table: For category A "Less than 120 Beds"

Day 2

Surveyor 1

Surveyor 2

Surveyor 3

9:00 am

9:15 am

15

Minutes

Opening Meeting and Debriefing

( With Top management and Organization Key Players)

9:15 am

11:00 am

105

Minutes

Review Six Hospital Plan

(Safety , Security , Medical equipment , utility Management, Hazardous)

11:00 am

1:00 pm

60 minutes

Staff Interview

(JD ,Training and orientation)

Ancillary services Tracing

(lab , BBK , and Radiology)

Patient safety

IC control Team meeting

(Data analysis and Findings)

60 minutes

Personal Files Review

(JD , Training and orientation)

1:00 pm

1:30 pm

30

Minutes

Lunch break

1:30pm

3:00 pm

90 Minutes

Hospital Forms Overview

(Open medical Record and Consents)

Facility Tour

(Facility management Review)

Review Emergency and Intensive Care

(Access to care, assess. Of patient, Care of pt.)

3:00 pm

4:00 pm

60

Minutes

Team meeting


Activities Time Table: For category A "Less than 120 Beds"

Day 3

Surveyor 1

Surveyor 2

Surveyor 3

9:00 am

9:15 am

15

Minutes

Opening Meeting and Debriefing

( With Top management and Organization Key Players)

9:15 am

10:30 am

75

Minutes

Leadership Meeting and utilization management review

10:30 am

11:30 pm

60 minutes

Review the Committee Structure and effectiveness of Decisions

Review Medical Staff Privilege

11:30 am

1:00 pm

45 minutes

Committee Session(CONT'D)

Facility Tour

(Facility management Review)

Tracer Methodology

( ER patients and Long term patients)

45 minutes

Review the Customersatisfaction and Complaint Cycle

1:00 pm

2:00 pm

45

Minutes

Lunch break

2:00pm

3:00 pm

60 Minutes

Nursing Qualifications and performance , and other professionals

Occurrence Variance session and Root Cause analysis

Tracing Outpatient Clinics and other ambulatory services

3:00 pm

4:00 pm

60

Minutes

Team Meeting and Leadership Exit Report


Activities Time Table: For category B "from 120 to 220 Beds"

Day 1

Surveyor 1

Surveyor 2

Surveyor 3

Surveyor 4

9:00 am

9:15 am

15

Minutes

Document review session and overview of organization services

(soft copy or hard copy) include all policies and procedures required in English from the organization

9:15 am

11:00 am

75

Minutes

Opening meeting

( with top management and organization key players)

11:00 am

1:00 pm

60 minutes

Review quality management plan and dashboard

Medication management review

(with pharmacy team)

Personal files review

(appointment , credentialing , reappoint)

60 minutes

IPSG tracing in OR

KPI analysis and follow up (data handling )

1:00 pm

1:30 pm

30

Minutes

Lunch break

1:30pm

3:00 pm

45 minutes

IPSG tracing

in intensive care units

Closed medical record review

(different specialties)

Facility tour

(facility management review)

45 minutes

IC tracing activity

(through the hospital)

3:00 pm

4:00 pm

60

Minutes

Team meeting


 

Activities Time Table: For category B "from 120 to 220 Beds"

 

Day 2

Surveyor 1

Surveyor 2

Surveyor 3

Surveyor 4

9:00 am

9:15 am

15

Minutes

Opening Meeting and Debriefing

( With Top management and Organization Key Players)

9:15 am

11:00 am

105

Minutes

Review Six Hospital Plan

(Safety , Security , Medical equipment , utility Management, Hazardous)

11:00 am

1:00 pm

60 minutes

Staff Interview

(JD ,Training and orientation)

Ancillary services Tracing

(lab , BBK , and Radiology)

Patient safety

IC control Team meeting

(Data analysis and Findings)

Personal Files Review

(JD , Training and orientation)

60 minutes

1:00 pm

1:30 pm

30

Minutes

Lunch break

 

1:30pm

3:00 pm

90 Minutes

Hospital Forms Overview

(Open medical Record and Consents)

Facility Tour

(Facility management Review)

Review Emergency and Intensive Care

(Access to care, assess. Of patient, Care of pt.)

Facility Tour

(Facility management Review)

3:00 pm

4:00 pm

60

Minutes

Team meeting

 


Activities Time Table: For category B "from 120 to 220 Beds"

Day 3

Surveyor 1

Surveyor 2

Surveyor 3

Surveyor 4

9:00 am

9:15 am

15

Minutes

Opening Meeting and Debriefing

( With Top management and Organization Key Players)

9:15 am

10:30 am

75

Minutes

Leadership Meeting and utilization management review

10:30 am

11:30 pm

60 minutes

Review the Committee Structure and effectiveness of Decisions

Review Medical Staff Privilege

11:30 am

1:00 pm

45 minutes

Committee Session(CONT'D)

Facility Tour

(Facility management Review)

Tracer Methodology

( ER patients and Long term patients)

Review the Customersatisfaction and Complaint Cycle

45 minutes

1:00 pm

2:00 pm

45

Minutes

Lunch break

2:00pm

3:00 pm

60 Minutes

Nursing Qualifications and performance , and other professionals

Occurrence Variance session and Root Cause analysis

Tracing Outpatient Clinics and other ambulatory services

Individual Tracer Methodology

In Different Settings

3:00 pm

4:00 pm

60

Minutes

Team Meeting and Leadership Exit Report


Activities Time Table: For category C "More than220 Beds"

Day 1

Surveyor 1

Surveyor 2

Surveyor 3

Surveyor 4

9:00 am

9:15 am

15

Minutes

Document review session and overview of organization services

(soft copy or hard copy) include all policies and procedures required in English from the organization

9:15 am

11:00 am

75

Minutes

Opening meeting

( with top management and organization key players)

11:00 am

1:00 pm

60 minutes

Review quality management plan and dashboard

Medication management review

(with pharmacy team)

Personal files review

(appointment , credentialing , reappoint)

60 minutes

IPSG tracing in OR

KPI analysis and follow up (data handling )

1:00 pm

1:30 pm

30

Minutes

Lunch break

1:30pm

3:00 pm

45 minutes

IPSG tracing

in intensive care units

Closed medical record review

(different specialties)

Facility tour

(facility management review)

45 minutes

IC tracing activity

(through the hospital)

3:00 pm

4:00 pm

60

Minutes

Team meeting


 

Activities Time Table: For category C "More than220 Beds"

 

Day 2

Surveyor 1

Surveyor 2

Surveyor 3

Surveyor 4

9:00 am

9:15 am

15

Minutes

Opening Meeting and Debriefing

( With Top management and Organization Key Players)

9:15 am

11:00 am

105

Minutes

Review Six Hospital Plan

(Safety , Security , Medical equipment , utility Management, Hazardous)

11:00 am

1:00 pm

60 minutes

Staff Interview

(JD ,Training and orientation)

Ancillary services Tracing

(lab , BBK , and Radiology)

Patient safety

IC control Team meeting

(Data analysis and Findings)

Personal Files Review

(JD , Training and orientation)

60 minutes

1:00 pm

1:30 pm

30

Minutes

Lunch break

 

1:30pm

3:00 pm

90 Minutes

Hospital Forms Overview

(Open medical Record and Consents)

Facility Tour

(Facility management Review)

Review Emergency and Intensive Care

(Access to care, assess. Of patient, Care of pt.)

Facility Tour

(Facility management Review)

3:00 pm

4:00 pm

60

Minutes

Team meeting

 


Activities Time Table: For category C "More than220 Beds"

Day 3

Surveyor 1

Surveyor 2

Surveyor 3

Surveyor 4

9:00 am

9:15 am

15

Minutes

Opening Meeting and Debriefing

( With Top management and Organization Key Players)

9:15 am

10:30 am

75

Minutes

Leadership Meeting and utilization management review

10:30 am

11:30 pm

60 minutes

Review the Committee Structure and effectiveness of Decisions

Review Medical Staff Privilege

11:30 am

1:00 pm

45 minutes

Committee Session(CONT'D)

Facility Tour

(Facility management Review)

Tracer Methodology

( ER patients and Long term patients)

Review the Customersatisfaction and Complaint Cycle

45 minutes

1:00 pm

2:00 pm

45

Minutes

Lunch break

2:00pm

3:00 pm

60 Minutes

Nursing Qualifications and performance , and other professionals

Occurrence Variance session and Root Cause analysis

Tracing Outpatient Clinics and other ambulatory services

Individual Tracer Methodology

In Different Settings

3:00 pm

4:00 pm

60

Minutes

Team Meeting and Leadership Exit Report


Activities Time Table: For category C "More than220 Beds"

Additional day

Day 4

Surveyor 1

Surveyor 2

Surveyor 3

Surveyor 4

9:00 am

9:15 am

15

Minutes

Opening Meeting and Debriefing

( With Top management and Organization Key Players)

9:15 am

11:30 am

105

Minutes

Other Building(s)

Or Extra Intensive Care Or Other Operating Theater

11:30 am

1:30 pm

120 minutes

Staff Interview

(IPSG Tracing and Training and orientation)

Facility Tour

(Facility management System)

Individual Tracer Methodology

In Different Settings

(Assess. of Patient Anesthesia care , Care of patient)

1:30 pm

2:15 pm

45

Minutes

Lunch break

2:15 pm

4:00 pm

105

Minutes

Team Meeting and Leadership Exit Report

      B. Action planning Report

Based on the preceded gap analysis, a detailed report is going to be provided within 10 working days determining the accreditation preparation journey and specific requirements if existing

     C. Advanced Training Package For Hospital

Advanced Quality Training Program "Turning Quality into reality"

QMD provides Quality training on different levels of training; advanced training is parallel to functions implementation of organization preparation for accreditation.

  • Core level of advanced training

Training on the main functions of quality management provide the knowhow of implementation and monitoring

  • On job training "OJT" module

Provided on-site training for technical quality issues

  • Optional training module

More advanced techniques for deep management strategies

  • Customized training module

During Organization gap analysis consultation team will initiate a training needs assessment "TNA" system to be conducted and maintained by Human resources "HR", based on the results of initial TNA, a customized training is going to be conducted. Note: positions to be assessed will be nominated by top management based on Job complexity and criticality.

Topics covered in core level of advanced training:


Topic

Number of sessions "2 hours per session"

Quality as a strategy:

5 sessions

Process Management

1 session

Quality Strategy

1 session

Quality planning

2 session

Skills of Gap analysis

1 session

The Know-how of quality functions:

40 sessions +18 optional sessions

Auditing and survey Function

5 session + 9 optional sessions

Departmental Audit

2 sessions

Medical record Auditing

2 sessions

IPSGs practice

1 session

Optional

QMS "ISO 9001 – 2008"

6 sessions

Optional

Effective
"beyond vertical auditing"

3 sessions


Measurement Function

11 sessions + 2 optional sessions

Key performance indicator overview

2 sessions

Dashboard follow-up

2 sessions

Medical record System Indicators

1 sessions

IPSGs measurement

2 sessions

FMEA tool of proactive control

2 sessions

Customer satisfaction Index

2 sessions

Optional

Work Performance index

2 sessions

Improvement function

7 sessions + 5 optional sessions

Improvement of Major 4 process

2 sessions

Plan Do Check Act Methodology of Improvement

2 sessions

Policy and procedure consolidation campaign

3 sessions

Optional

Six Sigma

5 sessions

Communication

4 sessions

Committees

2 sessions

Interdepartmental relationship

2 sessions

Risk Management

6 sessions

Implementation of Root cause analysis

3 sessions

Risk Management in Hospitals RCA & FMS

3 sessions

Quality integration with Clinical Performance

6 sessions

Clinical Audit "Monitoring clinical Practice"

2 sessions

Clinical Pathway "Standardization of Clinical Practice"

2 sessions

Patient and family rights in hospitals

2 sessions

Use of IT in Quality management functions

2 optional sessions

Optional

Excel and Minitab

2 sessions

Demonstration of Complete Model:

3 sessions

Medication   management and use "MMU" from Quality perspective

1 session

Monitoring of   MMU Workshop

1 session

Root Cause analysis on a medication problem Workshop

1 session

Infection Control

6 sessions

Advanced Infection Control methodologies

6 session

Presentation of a full year quality functions

2 sessions


 

Advanced Program specifications

Provided as: 55 training sessions + 18 optional sessions

Timing: 2 hours / session

Duration: Program can be conducted in flexible schedule within the first 6 months of accreditation

No. of trainees' limits:

Max trainees no.: 20 trainees