SNHI QUALITY IMPROVEMENT AND ASSURANCE PROGRAM

SNHI QUALITY IMPROVEMENT AND ASSURANCE PROGRAM

1.DEPARTMENT NAME : QUALITY IMPROVEMENT AND ASSURANCE DEPARTMENT.

2. SERVICES PROVIDED;

It is a department constituted of 8 service elements in the improvement of quality services in SNHI. Each service element has its services it provides to both internal and external customers.

The service elements in quality improvement and assurance are:

1.      Customer care( Patients and family rights)

2.      Resuscitation

3.      Infection and Prevention control

4.      Health and Safety.

5.      In- service Department

6.      Wellness.

7.      Policy review.

8.      Community health

9.      Quality improvement itself.

All the above mentioned service elements form one big team called the SNHI Quality improvement and Assurance steering team with a total number of 13 members. Some of them are full time on the job and some are coordinating QI services while working in other departments full time.

Each service element has its own team running the service which is in form of committees and they provide specific duties as per their establishment.

5 MAIN SERVICES PROVIDED BY THE QUALITY IMPROVEMENT AND ASSURANCE OFFICE.

The department ensures the smooth running of the quality improvement services in the whole SNHI (the 62 hospital departments and the 17 clinics) through:

v  Formulation of institution quality improvement plan on yearly basis.

v  Organization of quality improvement steering team monthly meetings and writing reports.

v  Training of SNHI staff on quality improvement concepts with the assistance of partners, MoH and management.

v  Assisting and supporting all institution departments in the identifying, development, running and monitoring of quality improvement projects.

v  Running of assessments and audits at SNHI departments, eg: General audits, Departmental visits, Clinical monitoring and Management rounds so to improve the quality of care rendered in the institution.

 

 

3. SCHEDULES FOR SERVICES

Activity

Objective

Measurement

 

 

1. General assembly meetings

 

 

1. To improve and sustain the quality rendered in the institution departments.

 

 

-        1 meeting /month.

-        1st Tuesday

-        3 hour meeting.

-        47 attendees at most.

 

2. Experience sharing meetings.

 

2. To sustain and share experiences gained while doing our quality improvement projects.

 

-        1 meeting /quarter.

-        1 day long.

-         80 attendees

 

3. Committee meetings

 

3. To ensure all quality activities are running smoothly in the institution and aligned to national strategic plan.

 

-        1 meeting /month.

-        3rd Thursday

-        2 hr. meeting

-        At least 7 members.

 

4. SNHI staff trainings on QI.

 

4. To empower staff with knowledge on quality improvement concepts rendering and quality improvement concepts.

 

-        1 training / quarter.

-        25 trainees / quarter.

 

5. General  audits

 

 

5. To ensure that SNHI departments and staff follow laid QA activities and are working as per expected standards.

 

-        Visit 1 department /month.

 

6. Community clinics visitation for assessments.

 

6. - To ensure all clinics have benchmarked at Mliba and to get the baseline data for each clinic.

   - To ensure all clinics work at a standardized manner as far as quality is concerned.

 

-        1 visit/quarter

 

-        2 clinics/month.

 

-        3rd Wednesday

 

7.Clinical monitoring

 

7. To ensure and verify that departments are documenting well in patients files (including all staff who come into contact with the files)

 

-        1 audit in 2 months.

 

 

 

8. Documentation audit

 

v  8. To ensure that departments are able to evaluate themselves on documentation.

 

-        Every other month.

 

 

9. Clinical audits

 

9. to ensure patients are managed according to protocols and guidelines

 

-        At least 1 audit /month /department.

 

10.Team building meetings

 

10. To refresh staff & motivate them to work as teams in their departments as they continue working for the institution.

 

-        1 session/quarter

 

11. Certificate awarding

 

11. To have evidence that staff were trained on QI concepts.

 

-        120 certificates

 

 

12. Departments visit

 

12. To hear staff complaints & comments so to motivate them to work as teams in their departments and have own strategies of working on their challenges.

 

-        79 department schedule.

-        Ad hoc visits

 

13. Management rounds

 

13. To ensure that SNHI departments and staff follow laid QA activities and are working as per expected standards.

 

- Visit 1 department    /month.

         -  4th Tuesday

 

14. Incident reporting

 

14. To ensure that department incidents are reported and actions have been taken.

 

-        # of incidents received

 

15. QIP exercise

 

15. To ensure departments are running their QIPs as per expected standard

 

-         Availability of projects in departments.

 

 

4. QI TEAM

 

1.Chairperson

 

Dr J. Mavundla

 

2.Secretary

 

Matron R. Mamba

 

3.Coordinator 1

 

Sr S. Msibi

 

4.Coordinator 2

 

SN M. Ginindza

 

5. IPC Chairperson

 

SN S. Simelane

 

6. IPC Coordinator

 

SN S. Simelane

 

5.Patients &Family Rights

 

Matron G. Zwane

 

6.Customer care officers

 

SN Z. Nsibande

 

7.Health&Safety coordinator

 

Mr. N. Hlomula

 

8.Rescuscitation focal person

 

Dr G. Mtshali

 

9.Policy review chairperson

 

SN Z. Nsibande

 

10.Wellness Coordinator

 

Sr Z. Tsabedze

 

11.Community clinics focal person

 

Sr P. Sibandze

 

5. LOCATION OF DEPARTMENT IN THE INSTITUTION.

The department is located in the old pharmacy office at the centre of the hospital.

 

6. CONTACT DETAILS

-Dr J. Mavundla (2508 4011)

-Sr S. Msibi (2508 4051)

-SN M. Ginindza (2508 4051)

 

7. PICTURE GALLERY

 

Team buildings during staff trainings on QI concepts

 

For more gallery get flash for pictures and even results.

 

 

10.  PROGRAM VISION

VISION-SNHI QA.

—  By December 2017, RFMH and its Clinics will be a benchmarking site in provision high standard of care in health delivery in a positive work climate.

 

 

11.  PROGRAM OBJECTIVES

-          To make all staff to understand the mission and vision of the quality assurance program and of SNHI.

-          To certify that all services provided are of high quality to clients and are delivered in a proper environment in compliance with the institutions policies and guidelines.

-          To measure the quality of care is provided in all SNHI service elements (SE)

-          To empower staff and clients with knowledge on quality assurance and improvement projects

-          To ensure and maintain a healthy and safe environment for staff and clients at SNHI

-          To ensure that all activities in service elements are aligned to the SNHI strategic plan.

 

 

12.  DEPARTMENT OGANOGRAM