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Services
The
Quality,
Accreditation, and Risk Management (QARM) Program assumes relevant
activities to
ensure efficient, high-quality, and safe patient care services at the
American University of Beirut Medical Center (AUBMC). It operates in
line with the Joint Commission International (JCI) and the Ministry of
Public Health (MOPH) standards, as well as the AUBMC core values and
goals.
The Program
coordinates its activities with the Infection Control and Prevention
Program, the Safety Office, the Medical Staff Office, and the
Utilization Review Office. The services
provided by the Program include:
Quality
The quality services aim to
ensure high-quality patient care at the Medical Center. The services
include:
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Provide leadership and guidance in the implementation of
quality management principles, and the design,
assessment, and
improvement of the organizational functions |
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Collection of monthly data on specific performance
improvement indicators, including admissions and readmissions, operations and
reoperations, and in-hospital mortalities |
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Review of unplanned avoidable reoperations and unexpected
mortalities with concerned individuals |
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Performing patient care reviews to assess conformity with
patient care standards |
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Monitoring the implementation of the AUBMC’s Performance
Improvement Plan |
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Participation in root cause analysis teams to investigate
sentinel events and near misses |
Accreditation
and Compliance
Accreditation services aim to ensure compliance of the Medical Center with the
national and the international accreditation standards, track and
monitor accreditation activities throughout the Medical Center. The main functions performed in this regard are:
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Maintenance of multidisciplinary policy manuals |
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Monitoring of a set of performance indicators
at the Medical Center level |
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Participation in performance improvement
projects and task-forces |
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Provision of follow-up reports to accreditation
agencies |
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Maintenance of updated records of the accreditation standards, dates and
schedules of survey visits, accreditation results, and copies of accreditation
certificates |
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Conducting periodic reviews to assess the level of staff compliance with the AUBMC
policies and procedures, the Joint Commission International and the Ministry
of Public Health accreditation standards. Compliance reviews are conducted according to an
annual
schedule, which is amended as the need
arises. |
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Oversight of other accreditation
activities throughout the Medical Center |
Policies and Procedures
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Preparation of support materials and write up of
multidisciplinary policies and procedures using the
AUBMC
format and
updating of such policies and procedures
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Distribution and maintenance of all policies and
procedures manuals by adding newly approved and
updating
revised
multidisciplinary policies and procedures
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Provision of assistance to the AUBMC departments and
sections in the preparation of their internal
operating
policies and
procedures manuals |
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Follow up with the standard accreditation
requirements of the Joint Commission International and the
Lebanese
Ministry of Public Health |
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Cross-referencing of data included in different
policies and manuals and indexing of the contents by
title / topic and
locations in the body of manuals and policies
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Data Management
Data management
and analysis services include the following:
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Collection, analysis, benchmarking and
reporting of Medical Center-wide performance improvement
monitors |
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Analysis of data pertaining to
quality and compliance reviews and patient-related incidents |
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Analysis of data on hospital satisfaction surveys |
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Provision of data management and analysis support to
the Quality, Accreditation and Risk Management
Program,
and to other Medical Center services / departments |
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Patient-Related Risk
Management
The Patient-Related Risk Management Program at AUBMC
is a systematic, coordinated and continuous approach to risk
identification, analysis, reduction, avoidance, and control. The Risk Management Office
staff work to promote patient safety
at the Medical Center through implementing preventive
and responsive risk management techniques. In this
regard, the following functions are carried out:
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Handling,
review and analysis of patient-related occurrences in accordance with the AUBMC
policy on Patient-Related Occurrence Reporting and Management |
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Benchmarking with available sources |
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Provision of patient safety and risk management training to the
medical and resident staff, nursing staff, and other healthcare
professionals |
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Staff Education
 The
Quality, Accreditation, and Risk Management Program provides educational
activities on the Medical Center policies and procedures, accreditation
standards, performance improvement and patient safety issues to the AUBMC
staff. Educational activities are also conducted on
specific patient care issues that are identified as a result of
root-cause analysis or upon receipt of new patient safety guidelines
from professional healthcare organizations.
Diverse educational tools are used
for this purpose:
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Lectures and workshops
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Daily and weekly tips
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Newsletters
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Educational questionnaires
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Staff information booklets
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Posters and brochures
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Support materials posted on the website
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External Services
-
Workshop # 1: CPHQ: October 2011
We in the Quality,
Accreditation and Risk Management (QARM) Program have the professional
expertise to provide the following external services to interested
healthcare organizations:
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Consultation & Facility Assessment: We conduct on-site
surveys based on the corresponding healthcare accreditation standards.
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Review of the Entire Quality Management
Program: We
design / critique the quality management program, structure, systems,
and staff qualifications. We help prepare the performance improvement
indicators and pathways.
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Preparation for Accreditation: We conduct baseline assessment,
gap analysis, and we
review the implementation and monitoring of organizational policies,
procedures and plans. We also help in
performing compliance reviews to monitor the compliance with established
policies and accreditation standards.
Conduct a follow-up facility assessment by
performing an on-site survey to determine the degree of improvement.
We also help in the preparation and provision of focused education
materials for staff development.
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Review of the Risk Management & Patient Safety Program: We conduct
assessment of the existing risk management and patient safety program
in healthcare organizations and perform gap
analysis. We design / critique the
occurrence reporting systems and help in
monitoring, trending, reporting, and benchmarking of results. We
also help in the preparation and provision of
focused staff education materials. |
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The
QARM program
staff conduct 3 to 5-day educational workshops to participants
from other healthcare organizations in coordination with the
Continuing Medical Education (CME) Office. These workshops
include topics on Accreditation, Quality Management, Patient
Safety and Risk Management, Certified Professional in Healthcare
Quality (CPHQ) Reviews. In addition to those workshops, the QARM
staff are ready to prepare other “custom-made” educational
programs to meet the specific requests of other
participants/organizations. All our educational programs are
accredited by authorized agencies with a specific number of
continuing education credits.
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