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Patient Safety and Quality Program

The framework supporting continuous improvement in quality and patient safety is a comprehensive approach that impacts all aspects of an institution's operations. This approach includes:

  • Departmental involvement and participation in the quality improvement and patient safety program;
  • Using objective, proven data to assess the effectiveness of processes;
  • Effective use of data and benchmarks to focus the program;
  • Implementing and maintaining changes that lead to improvement.

The quality management program is led by the Quality Director.  Providing quality management and quality assurance at the American Hospital Tbilisi. Overseeing and being responsible for all activities related to quality, risk management and patient safety at the hospital; Leading a team that develops, implements and maintains a high level of healthcare quality in accordance with both internal and external standards and best practices; Leading the systematic monitoring of the patient care process and patient satisfaction. Responsible for planning and implementing programs focused on improving the quality of patient care, including assessing and improving the Environment of Care system. Also, ensuring the analysis, formulation and implementation of organizational policies, programs and procedures. Leading all performance improvement initiatives aimed at ensuring full compliance of the organization with applicable regulatory standards and relevant legislative/regulatory bodies. Work closely with clinical and administrative staff to improve patient safety and optimize outcomes at a system level. Be responsible for the quality of the facility as well as patient safety and risk management programs, with a particular focus on patient safety and harm reduction. Support the strengthening of a safety culture at all levels of the organization and promote its sustainable development. (For more information, see the CQO job description).

To implement a quality program in accordance with JCI accreditation standards, AHT has created a special team consisting of representatives from various departments. Each JCI chapter is led by a dedicated responsible member (Chapter Leader).

The Quality Program Team is involved in all activities related to the implementation of accreditation standards, including the development and implementation of policies, procedures, and programs, as well as staff training and development.
The quality program implements training programs for employees that are relevant to their roles in the quality improvement and patient safety process. The hospital uses a variety of training methods, including educational materials, presentations, video training, knowledge assessment questionnaires, and more.
The trainings meet all requirements of accreditation and regulatory standards.
The quality program team also assists in the data collection process in the hospital — creating forms, identifying data to be collected, and defining data validation methods. The quality program provides coordination and support to department/service leaders so that they use the same metrics throughout the hospital and determine priorities for hospital improvement.
The quality team is responsible for regular communication of quality-related issues with all hospital staff.

Indicator selection and data collection

Clinical Quality and Patient Safety Program staff provide hospital-wide support for the indicator selection process and coordinate measurement-related activities.
The indicators are selected by the management team and cover all areas, departments, and services at the clinical and managerial levels.
For example, the departments of pharmacy, infection prevention and control, and infectious diseases are setting priorities for reducing antibiotic use. The quality and patient safety program is instrumental in helping these departments agree on common measurement approaches and supporting the process of collecting data on selected indicators.

The program also ensures the integration of all measurement-related activities across the hospital, including safety culture and adverse event reporting systems. The integration of measurement systems creates the opportunity for unified decision-making and implementation of improvements.

Data collection is based on the hospital's internal information system. They are collected during operational processes by all employees who are responsible for data collection and storage. Analysis is carried out by a specially trained quality team. Measurement results are systematically transmitted to the heads of relevant departments and divisions, and reporting is carried out to the management team quarterly and to the governing body annually.
The Quality Department includes a clinical quality team responsible for monitoring patient outcomes and evidence-based treatment processes.
The hospital has implemented clinical quality indicators that are used to evaluate patient outcomes and clinical performance.
The Clinical Quality Team monitors these indicators and discusses them with clinical staff, identifies gaps in clinical processes, and sets priorities for improvement on a daily basis.
The team also monitors the compliance of patient medical records with applicable regulations, accreditation standards, and internal policies.
To standardize medical services, the hospital uses documents: Clinical Practice Guides, Care Maps.

Clinical practice guidelines and care maps;

  • Documents are prepared in accordance with the hospital's mission and the characteristics of the patient population;
  • Its suitability has been scientifically established;
  • Updates are carried out as needed, taking into account technological progress, drugs and other resources;
  • Approval and implementation are carried out by the Quality and Patient Safety Committee;
  • In terms of effectiveness, clinical practice guidelines and care maps are systematically monitored by the Clinical Quality and Patient Safety Committee;
  • Personnel are provided with appropriate training on the use of these documents;

Every year, clinical practice guidelines and care maps are reviewed and updated by the Quality and Patient Safety Committee.

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