Performance Improvement- Jeddah Projects 2018

 

 SP1-Medical, Research and Academic Excellence

  1. Decrease Catheter Associated Urinary Tract Infection (CAUTI) in Adult Oncology Unit None Bone Marrow Transplant Service
  2. Decrease Incidence of Adult Hospital Acquired Pressure Injury in Cardiac Surgery Intensive Care Unit to ZERO Harm
  3. Decrease the number of hemolized sample in DEM
  4. Decrease turnaround time (TAT) of bone marrow aspiration (BMA) procedures in adult oncology treatment area (OTA) every Tuesday of the month
  5. De-prescribing Proton Pump Inhibitor (PPI) at the time of discharge from the Department of Medicine Clinical Teaching Unit (CTU) Service
  6. Enculturating Safety Environment In DEM By Eliminating Medication Errors Related To Nursing Practice Aiming To Reach Zero Harm
  7. Improve Head Nurse satisfaction related to candidate interview process
  8. Improve KFSHRC-J Patient and Visitor Experiences
  9. Improve Nursing Documentation Quarterly Result In “Reassessment Following The Administration of Pain Medication As Applicable
  10. Improve Nutritional High Risk Screening Compliance
  11. Improve Palliative Care Documentation of Physician, Palliative Nurse, Social Worker, and Dietician Note in ICIS
  12. Improve Patient Experiences Report On Discharge Written Information
  13. Improve Patient family Education (PFE) Documentation Compliance in Day Procedure Unit
  14. Improve patient satisfaction related to raising concern “During this hospital stay, did providers or other hospital staff tell you how to report if you had any concerns about mistakes in your child’s health care”
  15. Improve The Accuracy Of Parathyroid Abnormalities Detection
  16. Maintain the Central Line Associated Blood Stream Infection (CLABSI) rate to be below the National healthcare Safety Network (NHSN) Benchmark in MSICU by November 2018
  17. Prevention of Fall in OB/GYN ward
  18. Prevention Strategies to Achieve Zero-Harm in Catheter Associated Bloodstream Infection (CLABSI) based on evidence based practice, in a Renal Transplant Unit

  19. Reduce/Eliminate Out-patient Mislabeled Incidents

  20. Reduce Reported Pressure Injury Incidents (CAPI)
  21. Reduce The Number Of Non-Chemo Patient In Chemo Treatment Area
  22. Reduce Turn Around Time in Endoscopy
  23. Reducing the number of environmental pollution incidents
  24. Reducing the number of Falls with injuries below internal trigger of (1.1) in Cardiovascular Telemetry by the end of December 2018
  25. Reduction of Central line associated blood stream infection(CLABSI)in PICU at National healthcare safety network benchmark
  26. SEHATY Guidelines Barcode
  27. Standardization of Medical Evaluation Reports For All Medical Oncology Patients
  28. Towards Zero VAP in MSICU
  29. To decrease the number of hemolyzid, contaminated and clotted blood samples taken by 40%
  30. To improve ART patient-family education documentation compliance to 100% of patients seen in the infertility clinic
  31. TO IMPROVE HAND HYGIENE COMPLIANCE
  32. To improve the patient’s safety by decreasing the incidence of Hospital Acquired Pressure Injury (HAPI) Stage 2 and Above within the Surgical Unit to be at or better than the benchmark by November 2018
  33. To reduce and prevent neonatal hospital acquired conjunctivitis (HAC) in NICU
  34. To reduce the number of medication discrepancies dispensed from DEM Pyxis Machines

 

 SP2-KFSH&RC Experience

  1. Eliminate Computed Tomography missing exams
  2. Enhancing Turn Around Time for Tuberculosis (TB) Chest X-ray Screening For Employee
  3. Expediting the Permit-To-Work (PTW) Issuance and Closure
  4. Improve clean linen delivery Turn Around Time (TAT)
  5. Improve Head Nurse satisfaction related to candidate interview process
  6. Improve KFSHRC-J Patient and Visitor Experiences
  7. Improve Patient Experiences Report on Discharge Written Information
  8. Improve Patient Family Education (PFE) Documentation Compliance in Day Procedure Unit (DPU)
  9. Improve patient satisfaction related to raising concern “During this hospital stay, did providers or other hospital staff tell you how to report if you had any concerns about mistakes in your child’s health care”
  10. Improve Patients Satisfaction Related to Food Services In Adult Oncology Ward
  11. Improve the appointment turnaround time for sleep deprived (SDE) Electroencephalography (EEG) patients in 2018
  12. Improve the percentage of patients with discharge orders before 1pm under the Department of Medicine
  13. Improving Patients Flow in Cardiac Cath LAB
  14. Improving Press Ganey Results of Pain Management
  15. Reduce Resident Complaints Related to Air Conditioner’s (AC)
  16. Reduce the MRI, CT and US outpatients no show rate to less than 10%
  17. Reducing the number of falls with injuries below internal trigger of (1.1) in Cardiovascular Telemetry (CVT) by the end of December 2018
  18. Reduce waiting time for Nuclear Medicine (NM) patients undergoing Computed Tomography (CT) and/or Magnetic Resonance Imaging (MRI)
  19. Reducing the Number of Incorrect Out-Patient Arm Fistulogram and Arm Vegenogram Booking
  20. Reduction of new candidates’ recommendation process turnaround time
  21. SEHATY Guidelines Barcode
  22. To improve Assisted Reproductive Technology (ART) patient-family education documentation compliance to 100% for patients seen in the infertility clinic

 

SP3-Organizational Sustainability

  1. Arrangement of the cables and hoses of the Anesthesia machines
  2. Collection of soiled linen all over the hospital in a short period of time in the morning shift
  3. Decrease the number of Hemolized sample in Department of Emergency Medicine (DEM)
  4. Expand Discharge Medication Education Program to Include Discharge Orders Faxed Before 4pm And Achieve A 95% Rate of Education for Applicable Patients
  5. Improve compliance with eligible IV Stat orders turnaround time to be processed within 30 minutes
  6. Improve D- Dimer Turn Around Time
  7. Improve efficiency of detection of Carbapenemases in gram negative bacterial isolates of Enterobacteriacea
  8. Improve Handling Process of Cardiology Non-invasive Laboratory Transesophageal Echocardiography (TEE) probes
  9. Improve Nutritional High Risk Screening Compliance
  10. Improve Staff Documentation Compliance Related to General Consent Form
  11. Improve the compliance rate of completing Donor History Questionnaire (DHQ) to reducing Whole Blood (WB) wastage
  12. Improve the documentation compliance of Blood Component Administration Audits conducted by Nursing
  13. Improve Timely Renewal of Medication Order In ICIS as per Hospital Policy
  14. Improving clinical dietitians’ reassessments documentation compliance rate
  15. Improving the Pregnancy Rate in In-vitro Fertilization (IVF) Patients Who Supposed to Have Fresh Embryo Transfer
  16. Increase the total number of claims delivered for cash patients
  17. Optimize efficiency of utilization of antibiotic discs in the microbiology section
  18. Reduce accessing time of Blood Gas Analyzers
  19. Reduce Energy Consumption in the Main Hospital Parking Areas
  20. Reduce Percentage of Vitamin D Re-testing
  21. Reduce Regulated Medical Waste Weight by 50%
  22. Reduce the Cancelation Rate of External Activities (Conferences, Symposia, workshops, Courses)
  23. Reduce the number of outdated (expired on the shelf) PLATELET products
  24. Reduce the rate of rejected blood specimen for NICU patients
  25. Reduce Turn Around Time in Endoscopy
  26. Reduce Turnaround Time (TAT) for Letter Motion, In Contract Services
  27. Reduce turnaround Time of Pre-employments serology Marker Tests
  28. Reducing overtime utilization for CT, MRI, US and Nursing sections
  29. Reducing the number of changes in Graphic Designing requests
  30. Reducing US cancelled requests due to wrong order entries
  31. Reduction of Cost of Materials
  32. Reduction of rejected samples prior to analysis
  33. Reduction Of Tube Feeding Process Turn Around Time (TAT)
  34. Reduction of Unnecessary Repeats of Serology Tests
  35. Remodeling The Filing Process, In Financial Services Division
  36. To decrease (TAT) Turnaround time from the Time of Lab Results Available (CBC) in ICIS to Faxing Protocol to Pharmacy on each Sunday
  37. To reduce the percentage of Incomplete Radiation Booking form
  38. Transformation Project (budget level)

 

SP4-Community Relations