Introduction About the Quality Department
The Quality Department in the Emirates Health Services, which is under the umbrella and scope of the Ministry of Health and prevention in the United Arab Emirates, is considered one of the central departments where it oversees the quality and patient safety program in addition to the international accreditation program. The department coordinates with all stakeholders at the level of different sectors and departments to carry out its main tasks in supporting quality programs, patient safety and international accreditation to achieve the best clinical results and improve the experience of patients and their families.
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Quality department Experience with the Covid 19 Pandemic
The role of the quality department was essential at this stage, as the team worked continuously to provide the necessary support to all members of the health team, including doctors, nurses, pharmacists, technicians and others, and provide them with the necessary information related to the policies, procedures and protocols approved by the Emirates Health Services, by following up on all the global and local recommendations and the official authorities in the country to adopt the best international practices in managing the pandemic. Some of the activities carried out by the Quality Department during this period were:
- 3 central policies for dealing with the COVID-19 pandemic have been updated
- 4 central policies for dealing with the COVID-19 pandemic have been issued
- Shifted all meetings to virtual meetings
- Review the mechanisms used for gap analysis
- Shifted the trainings to virtual trainings.
- Reviewed the content of the training plan in line with the response to the Covid 19 pandemic
- Maintained the international accreditation program in the healthcare facilities using digital technology.
Initiatives and Projects
The first initiative: Adopting international goals for patient safety and implementing them at the level of the healthcare facilities. The healthcare facilities have adopted the six goals recommended by the World Health Organization and the Joint Commission International for International Accreditation. The Quality Department periodically evaluates the commitment of health team members to these goals through approved central performance indicators.
The second initiative: investing in employees within the quality team through training them in the field of patient safety and adopting the international certificate in the field of patient safety, quality and patient experience as part of the qualifications required to work in this field. The quality department has 19 employees, 17 of whom have international certifications such as CPPS, CPHQ and CPXP
The third initiative: Empowering patients and enhancing their role in the treatment process provided in the healthcare facilities through the “IRMIS” initiative, which means “speak” in the Emirati dialect. Information collected from EHS health facilities indicates that the health team is committed to more than 91% of this initiative in 2021.
The fourth initiative: Measuring the patient safety culture for health team members in the healthcare facilities, using the Agency for Healthcare Research and Quality - AHRQ approved model and using the results of this measurement to take the necessary improvement actions.
The Fifth initiative: An electronic system for monitoring and managing errors and accidents (WN9, electronic OVR system).
The Six initiative: Root Cause Analysis - The RCA system embraces Sentinel and critical adverse events that may occur and develops an improvement plan to change systems as necessary.
The Seventh Initiative: Support for the Second Victim: This initiative aims to provide the required support to health care providers involved in Sentinel events, which may lead to psychological harm to health care providers and feelings of guilt
The Eighth initiative: the establishment of an advisory board for the patient and the family as part of enhancing the patient experience in Emirates Health Services, which is unique, as the Emirates Health Services is unique in establishing this council for patients and their families at the Enterprise level, which had a great impact on the participation of representatives of patients and their families in designing the service and making decisions regarding their care and obtaining effective and positive suggestions that help improve performance and results of the treatment process.
Programs and Activities Implemented by the Quality Department concerned with Building and Empowering Human Resources Capabilities
The Quality Department prepares an annual training plan that includes training courses, workshops and lectures to train and prepare employees. The courses are chosen for their importance and according to the training needs of the employees and the needs of accreditation. Among the most important of these courses are
- Feedback of the surveyors as part of the lessons learned
- Review New policies:
- Clinical Alarm System Management
- Clinical Data and information Management
- Survey Findings / challenges as part of the Learning Process
- How to maintain JCI Accreditation
- Healthcare providers Empowerment and Engagement
- World Patient Safety Day Webinar “Safe Maternal and Newborn Care”
- Launching of the TRUST Program
- Management of Central Policies and Measures
Activities of the Quality Department
The Quality Department holds the annual conference to support the participation of best practices in the implementation of quality programs, patient safety and international accreditation. The speaker comes from America, Britain, Australia and countries from the Middle East such as Saudi Arabia and Jordan, as well as from local speakers, where the speakers share their own experiences in best practices in providing quality programs, patient safety and international accreditation, which the attendees benefit from. The department has prepared seven conference consecutively since the department was established.
The Goals of the Department and its Future Plans.
The most prominent goals, future plans and expected achievements of the department for the year 2022
Goals of the department (2022)
Obtaining Enterprise accreditation by the Joint Commission International
Implementation of the Enterprise accreditation (EA)
Maintaining international accreditation for hospitals according to the 2022 plan
Continue to implement the international accreditation plan for hospitals
Obtaining international accreditation as a center of excellence in the field of acute coronary syndrome treatment for Fujairah Hospital
Implementation of the international accreditation program as a specialized center for the hospitals
Complete the required policies and procedures and setting the date of approval in the first quarter of 2023.
To initiate the international accreditation program for the centers of preventive medicine and public health
Integrate Wareed with the WN9.
Initiate the Arabic version of the system
Begin documenting outstanding practices (excellence reporting).
Implementation of the second phase of the WN9
Implementation of WHO standards for friendly hospitals for patient safety in one of the hospitals and obtain the accreditation by WHO (Fujairah Hospital).
Adopting WHO standards for patient safety-friendly hospitals
Implement infection control policies and standards in the EHS facilities according to evidence based and relevant international standards
Continuing to implement the infection control program at the Enterprise level in accordance with evidence based and relevant international standards
Implementing an integrated patient experience program by involving all stakeholders from the health team, patients and their families according to international best practices
Adopting the patient experience program at the institution level in accordance with evidence based and relevant international standards
Implementation of the Patient Experience Initiative (Husna)
Adopting the Patient Experience Initiative (Husna)
Implement globally approved performance indicators to measure patient experience
Adopting internationally approved performance indicators for measuring patient experience
A targeted achievement with regard to the organization’s commitment to international medical protocols by selecting 2 protocols (VTE and Antibiotic Stewardship) that contribute to enhancing the safety and health of patients
The rate of compliance to the international medical protocols and guidelines
Implementation of best practices for patient safety in the hospitals by following up on the indicators of the six international patient safety goals, which are applied to all hospitals
The rate of compliance to the international patient safety goals in the organization