Chapter I

Leadership (LD)

Introduction

The organization's leadership has a very essential role in ensuring the basis and the direction towards achieving a Total Quality Management culture. This is why leadership is the first chapter in this manual. Without the support of the leadership, the Quality initiative will not succeed. Every senior officer and Department head sees the Hospital leader as the person in the drivers seat who steers all of the effort. When the Hospital Director is personally involved and encourages and supports everyone in the organization involved in the quality Management initiative; a general atmosphere of confidence and inspiration to work harder and to achieve high quality care and the maximum degree of safety is created. The traditional and basic requirements have to be in place before a quality program is expected to flourish. Leadership, therefore, has to set up a system where patient and staff safety and satisfaction are the focus of the operation. This system should be based on an understanding of the organizations mission, scope, and organizational management structure. (Strategic and operational planning), proper resource allocation (Budgeting), as well as a system that encourages inter and intra organizational communication by establishing clear communication channels. It is also desirable that the Hospital Director and all of his senior leaders become acquainted with the new quality concepts and know that quality is now a science. Staff needs to understand the new quality language and tools that will help them be systematic and organized in implementing their quality plan. The hospital leaders as a group should collaborate between themselves in the form of working teams or a management team to study all of the problems and quality issues together. By doing this they will coordinate and unify their approach to quality improvement. The hospital leadership should ensure that the culture of quality is spread within their institution and make it clear to every employee that quality is the job of everyone and that coordination and collaboration between all department leaders is the only way to improve quality and patient safety.

Leadership (LD)

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Scoring: FM (3)
The facility is in compliance with all Saudi Arabian laws and health care regulating bodies including the Ministry of Health (MOH). The hospital has a defined and clear organizational structure that is known to all staff and includes the following: LD.2.1 There is an organizational chart which identifies the names and titles of the hospital leaders, and department heads. LD.2.2 The organizational chart is current. LD.2.3 The organizational chart is explained to all employees as part of his/her orientation. LD.3. Besides the hospital director, the following positions are identified by the organizational chart and hospital meetings as part of the leadership group: LD.3.1 Medical Director. LD.3.2 Administrative Director. LD.3.3 Nursing Director. LD.3.4 Quality Management Director /leader. LD.3.5 Department heads. LD.4. The leadership meets regularly (at least monthly) in a minuted formal meeting (like an executive committee) to discuss all aspects of medical care, and services provided to patients. There is evidence that all members of the leadership group are qualified by appropriate education and experience. Each member in the leadership group has a defined scope of responsibility as outlined in a current job description. The hospital has a mission, vision, and values statement that is clearly written known to all staff, and: LD.7.1 The mission, vision and, values statement is clearly written.
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Standard
LD.1.

PM MM NM NA (2) (1) (0)

Leadership (LD)

LD.2.

LD.5.

LD.6.

LD.7.

Standard
LD.7.2 The mission, vision, values statement is publicly displayed to all staff and customers. LD.7.3 All staff employed by the hospital can state the mission statement. LD.7.4 The mission, vision and, values statement will be included in the orientation program LD.8. The hospital has a written scope of service for the provision of medical care and includes: LD.8.1 The range of service i.e., Pediatrics, Gynecology or a general hospital. LD.8.2 The age groups who receive care. LD.8.3 The number of patients seen annually. LD.8.4 The major diagnostics or therapeutic methods used. LD.8.5 The scope of services is signed by the Medical Director, the Administrator, or both. LD.9. The leadership has a 3 year strategic plan for the hospital that is updated every year and has the following components: LD.9.1 Guided by the Mission, and Vision of the organization. LD.9.2 Based on the Strength, Weakness, Opportunity, Threat, (SWOT) analysis. LD.9.3 Summarized by at least 5 strategic Directions (customer, community, employee, education, continuous improvement, and financial). LD.9.4 Translated actions and timelines for implementation with identified staff responsibilities. LD.10. The hospital has the following essential committees that provide oversight and management for: LD.10.1 LD.10.2 LD.10.3 Pharmacy & Therapeutics Committee. Morbidity & Mortality Committee. Infection Control Committee.

FM (3)

PM MM NM NA (2) (1) (0)

Leadership (LD)

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Standard
LD.10.4 LD.10.5 LD.10.6 LD.10.7 LD.10.8 LD.10.9 Cardio Pulmonary Resuscitation (CPR) Committee. Credentialing and Privileging Committee. Operating Room Committee. Tissue Review Committee. Blood Utilization Review Committee. Safety Committee.

FM (3)

PM MM NM NA (2) (1) (0)

Leadership (LD)

LD.10.10 Quality Management Committee. LD.10.11 Medical Record Review Committee. LD.10.12 Patient Rights/Patient Advocacy/Patient Care Committee. LD.10.13 Utilization Review Committee *The above committees can be combined as needed according to the hospitals scope of service and resources. LD.11. All of the Hospital-wide committees have terms of reference that: LD.11.1 Clearly outline the committees functions. LD.11.2 LD.11.3 List the members and their titles. State the required percentage of attendance required to hold the meeting. State how often the committee is expected to meet (e.g. monthly for functional committees / quarterly for boards and councils). Outlines the distribution of the minutes to the Hospital Director, Medical Director, Quality Management Director/leader, and members.

LD.11.4

LD.11.5

LD.12.

The hospital committees meet as outlined in the terms of reference (no less than quarterly).

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LD.13. There is a uniform method in a policy and procedure that addresses how the chairpersons of a committee receives and refers the committee recommendations for approval by the responsible decision makers. There is an annual review of each committees accomplishments written by the committee chairman and submitted to the committees reporting authority and there is a policy to govern the process. The leadership recognizes and supports patients rights by: LD.15.1 Educating the patient with the necessary information on his/her rights and responsibilities as part of the admission process. Sponsoring ongoing educational sessions for staff on patients rights. LD.16. The hospital has a generalized consent form that provides authorization for general treatment and a policy to govern its use and completion. The leadership supports and oversees the patient complaint process by: LD.17.1 Assigning responsibility for receiving, resolving and aggregating data related to patient complaints. Taking quality improvement and strategic actions based on monthly, quarterly and annual trended report data.

FM (3)

PM MM NM NA (2) (1) (0)

LD.14.

Leadership (LD)

LD.15.

LD.15.2

LD.17.

LD.17.2

LD.18.

The leadership supports patient education by: LD.18.1 LD.18.2 Providing funding for patient education materials. Ensuring the creation and implementation of a patient educational plan.

LD.19.

The leadership develops a professional code of conduct for all employees which describes the hospitals expectations of the staff regarding their behavior and communication with each other and with their patients.

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LD.20. Facility general policies include policies that address methods of resolution for conflict between staff. The leadership supports the Infection Control program by implementing recommendations made by the Infection Control committee and the Infection Control Director. The leadership ensures that Staff Health Clinic implements the following processes to avoid the transmission of infection by: LD.22.1 Performing the necessary investigations following needle stick or sharps injury and this data is collected for trending and reported at the Safety committee and Infection control committee. LD.22.2 Conducting pre-employment physicals on every staff member as required by the Ministry of Health (e.g.., Hepatitis screen & etc.). LD.22.3 Ensuring that all staff can have an appropriate immunization and protection in the various work areas. Maintaining a current file on each hospital employee with the required immunization record.

FM (3)

PM MM NM NA (2) (1) (0)

LD.21.

Leadership (LD)

LD.22.

LD.22.4

LD.23.

The hospital has a Finance Director who is qualified by experience and education (A Bachelors degree in Finance with (2) years experience is preferred). The hospital has documents that provide evidence of a capital and operating budget process that addresses the manpower plan, consumable and capital assets resources and assigns resources to all patient care units based on the scope of care and complexity of patient needs. Members of the leadership group work collaboratively to provide quality care by: LD.25.1 Problem solving, planning together and documenting these meetings. LD.25.2 Collaborating with each other to develop policies.

LD.24.

LD.25.

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LD.25.3 Collaborating with each other to develop budgets. LD.26. All department heads have a comprehensive departmental manual that is available to staff and includes the following: LD.26.1 A mission, vision, values, and scope of service consistent with the hospitals mission. LD.26.2 An organizational chart. LD.26.3 Policies and procedures for staff members to implement that are current and clearly written. LD.27. LD.28. All departmental manuals are reviewed every (2) years and revised as needed. A policy on how policies are created, approved, revised, composed, and terminated is available. The leadership supports the Hospital wide Safety plan by providing the necessary resources as identified by the Safety officer and the Safety committee in order to minimize risk to patients and staff. The Hospital Director and/or his designee implements the No Smoking policy by: LD.30.1 Monitoring all areas within the hospital for compliance to the no-smoking rule. LD.30.2 Disciplining staff who do not adhere to the policy. LD.31. The hospital has a Hospital-wide disaster plan that includes. LD.31.1 Response to both internal and external disaster. LD.31.2 A description of the roles of every employee in the organization. LD.32. The leadership supports the implementation of the disaster plan by: LD.32.1 Planning, implementing evaluating disaster drills. (no less than annually)

FM (3)

PM MM NM NA (2) (1) (0)

Leadership (LD)

LD.29.

LD.30.

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LD.32.2 Making improvements in disaster readiness based on results of disaster drills. LD.33. The hospital has the following effective communication systems for contacting essential personnel in emergencies: LD.33.1 An overall paging system that is fully functional and is used for calling for help in case of emergencies. LD.33.2 Bleeps for all physicians and other staff as necessary. LD.33.3 Mobile telephones on the ambulances. LD.34. The hospital has essential signs in the hospital that are clearly marked and in appropriate designated places. LD.34.1 Handicap access signs. LD.34.2 All fire exits (at least (1) one emergency exit sign is visible from any point in the facility). Fire hydrants/fire extinguisher locations. No entry signs where needed. Hazardous material areas. Directional signs to assist customers and staff find designated locations.

FM (3)

PM MM NM NA (2) (1) (0)

Leadership (LD)

LD.34.3 LD.34.4 LD.34.5 LD.34.6 LD.35.

The leadership supports the hospital-wide Quality Management & Patient Safety plan by: LD.35.1 Providing the necessary resources for the Quality Management department. LD.35.2 Actively participating in Quality Improvement projects. LD.35.3 Implementing the recommendations made by the QI committee (when feasible).

LD.36.

The leadership has basic knowledge of Quality Management concepts and this includes:

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LD.36.1 How to analyze data. LD.36.2 How to use an improvement cycle (PDCA) or other method to make improvements. LD.36.3 How to work in teams. LD.36.4 How to perform root cause analysis. LD.37. The leadership supports the Hospital-wide information plan by: LD.37.1 Participating in defining the terminology related to management of information including data, information, aggregated data, correlated data, confidentiality, integrity and security. LD.37.2 Approving the Hospital wide Management of Information (MOI) plan. LD.37.3 Providing the necessary resources to implement the hospital wide information plan. LD.38. The hospital has an effective process for handling professional communication (vertical and horizontal) among hospital staff and that supports professional communication by: LD.38.1 Documented staff meetings. LD.38.2 Policy and procedure development. LD.38.3 Hospital newsletters. LD.39. The hospital has a policy that outlines the roles and responsibilities for handling all incoming requests from outside agencies (other hospitals and government) in a timely manner and this includes but is not limited to: LD. 39.1 Medico-legal cases. LD. 39.2 Receiving patients from other hospitals. LD. 39.3 Providing any services for outside hospitals. LD. 39.4 Participation with community events.

FM (3)

PM MM NM NA (2) (1) (0)

Leadership (LD)

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Standard
LD. 39.5 Requests for reports from government agencies. LD.40. The hospital has the essential administrative policies and procedures that are reviewed and updated every (2) years, that includes but are not limited to: LD. 40.1 Sentinel event. LD. 40.2 Incident report or occurrence, variance report (OVR). LD. 40.3 Medico-legal cases. LD. 40.4 Child Abuse. LD. 40.5 Patient rights. LD. 40.6 Code of conduct for staff. LD. 40.7 Informed consent. LD. 40.8 Conscious sedation. LD. 40.9 No code or don t resuscitate policy. LD. 40.10 Dress code. LD. 40.11 Admission, transfer and discharge. LD. 40.12 Transfer to another facility. LD. 40.13 Handling, use and administration of blood and blood products. LD.41. The hospital has a Human Resource Director qualified by appropriate experience and education. The hospital has a Human Resource department or unit that is well staffed and equipped according to the size of the hospital. The hospital has a Human Resource Employee manual that is given to all new employees during hospital orientation. LD.44. The Human Resource Employee manual has a policy for handling staff complaints and/or dissatisfaction. The department of Human Resources has a program for recruitment, retention, and development of staff.

FM (3)

PM MM NM NA (2) (1) (0)

Leadership (LD)

LD.42.

LD.43.

LD.45.

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LD.46. The hospital has a policy that requires all categories of staff to have clearly written job descriptions that are reviewed and revised as needed at least every (3) years and: LD.46.1 The job description is used when selecting employees for hire, internal promotions, and transfer. The job description outlines the necessary knowledge, skills, and attitude to perform the role. The job description is provided to every employee on hiring and is located in every employees personnel file and departmental manual. All job descriptions follow a prescribed format. All job descriptions are competency based

FM (3)

PM MM NM NA (2) (1) (0)

Leadership (LD)

LD.46.2

LD.46.3

LD.46.4 LD.46.5 LD.47.

The organization has an effective process for gathering, verifying, and evaluating the credentials (license, education, training, and experience) of those medical staff permitted to provide patient care without supervision. LD.47.1 The organization maintains a record of the current professional license, certificate, or registration, when required by law, regulation, or by the organization, of every medical staff member.

LD.48.

The hospital has a comprehensive mandatory general orientation that all new employees attend, and the content includes but is not limited to: LD.48.1 LD.48.2 LD.48.3 The hospital s mission, vision, values and organizational chart. Staff role in disasters and emergencies. (i.e., Fire). General information about hazardous materials including Material Safety Data Sheet (MSDS). General information on Infection control and sharps disposal.

LD.48.4

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LD.48.5 LD.48.6 Electrical safety. General information on communication devices: paging, telephone system, and bleeps. General information on staff evaluation process. The definition of Adverse events and Sentinel events along with the process of reporting including Who should report, When to report, How to report, and to Whom the report is routed. The Policy on Abuse and Neglect of Children and Adults

FM (3)

PM MM NM NA (2) (1) (0)

LD.48.7 LD.48.8

Leadership (LD)

LD.48.9

LD.48.10 Overview of Credentialing, Privileging and Competency policies. LD.48.11 General information about staff health clinic and its services. LD.48.12 General information about the cultural and social issues in the Kingdom. LD.48.13 General information about the quality and patient safety plan of the hospital and the importance of involvement of every member of staff. LD.48.14 Information on the expected ethical conduct of the staff and the expected professional communication in his/her interactions with others. LD.48.15 Information on protection of patients rights, privacy and confidentiality. LD.49. The hospitals general orientation is documented in each employees personnel file. All new employees receive a comprehensive departmental orientation conducted by the head of the department and/or designee as outlined by the departmental orientation policy that includes but is not limited to the following processes:
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LD.50.

Standard
LD.50.1 All new employees read the appropriate departmental policies and sign that they have read and understood them. LD.50.2 All new employees read their job description and sign that they have read and understood it. LD.50.3 All new employees receive an assessment of the knowledge, skills and attitude required of the employee to function successfully in his/her position. LD.50.4 All new employees receive education on the proper use of equipment including troubleshooting and reporting malfunctions. LD.50.5 All new employees receive more clarification as needed on all topics provided in the general orientation and this is signed by the employee and immediate supervisor. Orientation for new employees are located in the employees personnel file.

FM (3)

PM MM NM NA (2) (1) (0)

Leadership (LD)

LD.50.6

LD.51.

The leadership supports education for staff by granting financial support and/or time off for staff to attend educational activities. The hospital has an educational program (academic program) with an ongoing schedule of educational activities and training based on hospital need. Department heads recommend, implement and evaluate the necessary courses and skills to update and maintain staff s competence to provide care. This process is linked to performance improvement and documented in the employees file.

LD.52.

LD.53.

LD.54.

The leadership ensures that appropriate medical and nursing staff maintains current certification in BCLS, ACLS, NALS, and ATLS by: LD.54.1 Supporting all critical care physicians and nurses to maintain certification in BCLS, ACLS, and NALS as appropriate to the age groups.

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LD.54.2 Supporting all Internal Medicine physicians to maintain certification in BCLS and ACLS. Supporting all surgical physicians to maintain certification in BCLS and ATLS. Supporting all pediatric physicians to maintain certification in BCLS, NALS, PALS or appropriate to the age groups.

FM (3)

PM MM NM NA (2) (1) (0)

LD.54.3

Leadership (LD)

LD.54.4

LD.55.

The needs identified for training and education are based on, as appropriate: LD.55.1. The hospital mission, vision, and values LD.55.2. The patient population served and the type and nature of care provided by the hospital and the department/service LD.55.3. Individual staff members education and training needs

LD.55.4. Information from quality assessment and improvement activities LD.55.5. Needs generated by advancements made in health care management and health care science and technology LD.55.6. Findings from department/service performance appraisals of individuals LD.55.7. Findings from review activities by peers, if appropriate LD.55.8. Findings from the organizations plant, technology, and safety management programs LD.55.9. Findings from infection control activities LD.56. The leadership has an effective process to evaluate staff within the probationary period of employment and this includes: LD.56.1 A policy that outlines the roles and responsibilities for evaluating staff during their probationary period.

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LD.56.2 Documentation in the employee s personnel file. LD.57. The leadership has an effective process to evaluate staff at least annually and this includes: LD.57.1 A policy that outlines the roles and responsibilities for evaluating staff at least annually. LD.57.2 A comprehensive evaluation form that covers all aspects of expected performance levels as outlined in his/her job description (e.g. competence, attitude, etc). LD.57.3 Documentation in the employee s personnel file. All staff reading and signing their evaluation.

FM (3)

PM MM NM NA (2) (1) (0)

Leadership (LD)

LD.57.4 LD.58.

The hospital has a duty manager who is qualified by experience and education to coordinate the care during off duty hours with a clear job description. The duty manager has the necessary resources to perform his role and this includes: LD.59.1 LD.59.2 A dedicated office to perform his role in the hospital. A dedicated phone number.

LD.59.

LD.60.

The hospital has a policy to handle cases of suspected child abuse, criminal acts and it complies with MOH regulation. The hospital leadership ensures safe medical practice by: LD.61.1 The availability of sufficient resources and staffing levels to carry out safe medical practice. Sufficient staffing is maintained at all times, including staff vacation periods.

LD.61.

LD.61.2

LD.62.

The leadership oversees any contracts for clinical or operational services and:

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LD.62.1 Monitors compliance to the appropriate standards on a regular basis. Takes corrective actions for improvement when standards are not met. Documents the contract oversight process.

FM (3)

PM MM NM NA (2) (1) (0)

LD.62.2

Leadership (LD)

LD.62.3

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