Authors (including presenting author) :
Chau PY(3), NG SC(2), WONG WY(2), HO ML(1), LEUNG LM(3), Tsang LF(3)
Affiliation :
(1)Administrative & Supporting Services Division, Haven of Hope Hospital, (2)Department of Medicine, Haven of Hope Hospital, (3)Nursing Services Division, Haven of Hope Hospital
Introduction :
Hospital incidents are often preventable and if happened, are costly to the health care system. In order to mitigate the risks from different levels, HHH had implemented various continuous quality improvement (CQI) projects and through education and monitoring system to contain the risks. Quality and Safety (Q&S) Committee with multi-disciplinary professionals was set up, and together they were responsible to review, develop and implement quality & risk management strategies. They engaged different disciplines to provide a framework on prevention and management of both clinical and non-clinical risks.
Objectives :
1) To raise stakeholders (doctors, nurses, allied health care professionals and administrative staffs) awareness on prevention of incidents and continuous quality improvement 2) To promulgate Continuous Quality Improvement Programs and to promote quality & risk management strategies
Methodology :
From 2017-2018, annually Organization Wide Risk Management (ORM) & Risk Registry (RR) were developed in HHH. Multiple disciplines were involved which covered clinical and non-clinical area, in-patient and outpatient, day-patient and out-reach services. Departmental Coordinators were responsible for ORM & RR submission and coordinated the frontlines to develop action plans or programs to mitigate the identified risks. In sharing sessions, individual department shared incidents and risk management to frontline staff. Q&S Committee coordinated yearly CQI Forum and Q&S Nursing Forum for 5 years to share quality enhancement programs and share incidents respectively.
Result & Outcome :
In ORM and RR, there were 40 coordinators submitted 21 CQI programs in 2022. 4 CQI programs were selected to present in CQI Forum. Physiotherapy and Occupational Therapy departments shared training of supporting staff to improve staff safety and development of online cognitive stimulation. Department of Medicine (MED) shared adherence of joint commission mandated component of discharge summary. Nursing Services Division (NSD) presented a patient tracking system program with Administrative Department. In Q&S Nursing Forum, Pharmacy Department & NSD shared medication safety & clinical incidents and MED provided a sharing on “No sugar, just load sugar?” to nurses. There were 143 staff participated in these forums, including 14 doctors, 89 nurses, 22 physio-therapists, 5 occupational therapists, 5 other allied health staffs and 8 administrative staffs. A post evaluation form was used for collection of participants’ feedback. The satisfaction level was good with score of 5.42 to 5.46 over 6
