National Guidelines for Improvement of Quality and Safety of ...
National Guidelines for Improvement of Quality and Safety of ...
National Guidelines for Improvement of Quality and Safety of ...
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2. Arrangements <strong>for</strong> <strong>Improvement</strong> <strong>of</strong> <strong>Quality</strong> <strong>and</strong> <strong>Safety</strong> inHospitalsIn order to initiate the quality <strong>and</strong> safety improvement programme, organizational arrangements withinhospitals need to be modified. The critical step in this respect is to establish a <strong>Quality</strong> ManagementUnit within each hospital. The <strong>Quality</strong> Management Unit (QMU) serves as the secretariat <strong>for</strong>organizing training activities on quality <strong>and</strong> safety improvements as well as implementation,monitoring <strong>and</strong> evaluation <strong>of</strong> the programme in the hospital. In addition, at the ward/unit level, Work<strong>Improvement</strong> Teams (WITs) are to be <strong>for</strong>med to implement the programme. The <strong>Quality</strong> ManagementTeam, consisting <strong>of</strong> the Hospital Director, QMU staff <strong>and</strong> the leaders <strong>of</strong> the WITs will serve as thedecision making body. Suggestive organizational arrangements are provided in the table below.<strong>Quality</strong> Management Team <strong>Quality</strong> Management Unit(QMU)Work <strong>Improvement</strong> Teams(WIT)Unit QMU Respective wards <strong>and</strong> otherunitsMembers - Hospital Director - 1-3 full-time staff - All staff members <strong>of</strong> the- QMU staffrelevant units- Leaders <strong>of</strong> WITsLeader Hospital Director MO or NO A committed staff member2.1. Establishment <strong>of</strong> <strong>Quality</strong> Management Unit (QMU)All hospitals need to have a dedicated QMU. According to the “General Circular No.01-29/2009” <strong>of</strong>the Ministry <strong>of</strong> Healthcare & Nutrition dated 22 September 2009, QMU is to coordinate the qualityassurance <strong>and</strong> client safety program <strong>of</strong> hospitals. Its functions described in the Circular aresummarized below. The original Circular document is attached as APPENDIX.(1) Strengthening institutional setup <strong>and</strong> staff participation in the quality programme• Facilitating management leadership in the quality programme• Establishing Work <strong>Improvement</strong> Teams (WIT)/<strong>Quality</strong> Circles• Training Work <strong>Improvement</strong> Teams (WIT)• Facilitating involvement <strong>of</strong> medical consultants in the quality improvement process(2) Building staff capacity <strong>and</strong> awareness• Conducting quality <strong>and</strong> safety improvement workshops <strong>for</strong> staff members• Facilitating in-service training programmes• Maintaining database <strong>of</strong> staff training• Promoting a quality culture by introducing 5S concept leading towards Total <strong>Quality</strong>Management (TQM)• Promoting environmental friendly hospitals3
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