Dear Colleagues,

In this issue of Leaps, I will discuss some of the aspects of quality

and safety at AUBMC, about the work we are doing or activities

we engage in to enhance care and ensure we meet the highest stan-

dards of quality. AUBMC’s Administration is especially passion-

ate about ensuring that high-quality care is available to everyone,

irrespective of their socio-economic status or insurance coverage.

In today's health care environment, as we know, there is an expec-

tation that hospitals, doctors, nurses, pharmacists and other health

care providers will work together, as a Team, to create opportuni-

ties to ensure the delivery of high quality care. Teamwork, coordination of care and communication

are critical for achieving the desired outcomes. The Medical Center has adopted a performance improvement strategy to achieve our goals of:

Patient-Centered Care

Quality and Safety

Service Excellence

Quality, a fundamental in our care:

In March of this year, we have launched multidisciplinary High Performance Clinical initiatives that

will advance quality standards and evidence based medicine. These initiatives include “Performance

Improvement” committees that are currently working on developing order sets, guidelines and path-

ways to standardize and improve care in cardiology, critical medicine, hematology, emergency medi-

cine, pediatric and medication management.

Safety, a priority in our care:

Creating a positive culture of safety is one of the key challenges that healthcare organizations face.

Therefore, we are working on having a robust event reporting system that encourages AUBMC staff to

report not only adverse events but also near misses and close calls. Our ultimate goal is better care, not

only lower numbers of events.

While often difficult for those directly involved in safety events, it is important for our hospital com-

munity to be as open and as transparent as possible about all safety-related issues, to ensure that we

can learn from and find ways to prevent such errors from occurring. Anytime an event occurs, we will

institute a multidisciplinary team to carefully and thoroughly review and analyze the event closely. We

are always looking for ways to improve our system and practice and not blame the individuals.

Delivering the highest quality and safest care is our commitment to patients that both defines us and

enables us to thrive as an institution.

Petra Khoury, Pharm D Clinical Executive Administrator

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Reviewer: Dr. Saleem Kiblawi

Editor: Dr. Rami Mahfouz

Layout: Ms. Shatha Abi Ghanem

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The only way to assure quality and excellence is to give people

something to believe in

Quality and Safety at Core of Care Redesign at AUBMC

LEAPSLEAPS Newsletter

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Q u a l i t y , A c c r e d i t a t i o n a n d R i s k M a n a g e m e n t P r o g r a m

Featured Article 1

Documentation in Phy-

sician Orders 2

Compliance with Initial Assessment by Medical

Staff for Inpatients 3

Documentation of Sur-

gical Site (Laterality) 3

Risk Management Cor-

ner 3

Use of Error-prone abbreviations, symbols and dose designations

4

Miscellaneous 4

Inside This Issue:

Volume 6, Issue 3

Layne Longfellow

Happy Holidays from the Quality Accreditation and Risk Management

December 2011

Proper documentation in physician orders is a requirement by the national (MOPH, MS.5.1, MS.5.3), and international (JCI,

MMU.4.1, MCI.13) accreditation standards, as well as the AUBMC policies and procedures (multidisciplinary policies on Physician

Orders and on Abbreviations).

A review was conducted by Ms. Rasiel Kabli, a 3rd year Health Information Management and Technology student from Dammam

University, whom I was honored to supervise during her training at our Program. The aim of the review was to check the physician

documentation on the Order Sheet, particularly for the presence of the physician name / stamp, date and signature, abbrevia-

tion use, allergy documentation, and proper correction of errors.

A random sample of 48 patient discharges was drawn out of the AUBMC June 2011 discharges. After excluding 10 pre-printed

orders, 38 medical records were reviewed, which contained 226 order sets (defined as a group of orders written at one time and

signed together).

The physician name was present in 134 out of the 226 order sets (59%); however, the name was legible only in 66 (49%) of those.

Compliance with the availability of name / stamp was 60%.

Of the order sets, 55% were signed by the physician; however, compliance dropped to 15% when checking for the availability of

the name / stamp AND signature. Five order sets (2%) did not contain any physician identifier. Compliance rates of 99%-100% were

noted for date and time documentation, and proper correction of error, versus 53% for allergy documentation.

More than half of the order sets (133) contained abbreviations, out of which 62 (47%) contained unapproved ones, including 34

error-prone and 29 unclassified abbreviations. The most common error-prone abbreviations were “D/C” and abbreviated drug

names, while the mostly used unclassified abbreviation was “PRN”.

Recommendations:

1. Quality, Accreditation & Risk Management Program:

Unify the requirements on abbreviation use in Physician Orders & Abbreviations policies (DONE)

Update the Physician Orders policy to request the physician pager number in the order set to help in physician identification

Update the lists of approved & of error-prone abbreviations to clarify the possibility of use of unclassified abbreviations

Re-assess compliance with the policies

2. Chief of Staff: Send a circular to the Medical Staff to:

Promote the legibility of physician orders including the physician name

Request the physician pager number in the order set

Allow a significant space between orders to avoid signing over the previous physician’s signature

3. Medical Records Committee:

Provide separate columns for the physician name & signature on the Order Sheet

Conduct educational sessions to Medical Staff about appropriate documentation in physician orders

Lina Mekawi, MS Senior Data Analyst

Page 2 L E APS NE W SL ETT E R

Documentation in Physician Orders

If there are no common

values, there can be no

image of the future.

Robert Bundy

Laterality pertains to a side of the body i.e., left or right according

to Joint Commission International (JCI). In relation to the AUBMC

multidisciplinary policies on pre- operative/ pre-procedure verifi-

cation (COP-MUL-003), the laterality of the planned procedure

shall be specified. If pertinent, the correct person, procedure, and

site/side shall be verified in all settings.

According to JCI: The International Patient Safety Goal number 4

states that “correct site, correct procedure and correct patient

surgery shall be ensured”. In addition, the Lebanese Ministry of

Public Health Accreditation MOPH standard on patient safety (PS

8.9) emphasizes: “Identification of right patient, right side, and

right procedure in surgery”.

A compliance review was done in September 2011 to assess the

degree of medical and nursing staff compliance with AUBMC

policies on pre- operative/ pre-procedure verification (COP-MUL-

003) and Abbreviations (MCI-MUL-006), international patient

safety goal and national standards. The overall compliance rate

has slightly increased from 68 % (June 2011) to 79%. Our aim is

100%!

Layal Mohtar, MPH , CPHQ

Quality Review Analyst

Risk Management Corner

Page 3 L E APS NE W SL ETT E R

The IHI Improvement Map

The Institute for Healthcare Improvement (IHI) launched the Improvement Map which is a free, interactive, web-based

tool designed to bring together the best knowledge available on the key process improvements that lead to excep-

tional patient care. IHI experts selected a total of 73 processes and prepared the individual elements of implementa-

tion, expected outcomes, and metrics for measurement of each process.

The Improvement Map can be an instrumental tool in guiding your quality improvement journey. No matter where you

are on your improvement journey, you’ll be able to find yourself in the Improvement Map and chart a path to achieve

your aspirations.

The Improvement Map aims to help hospitals to:

Provide safer care

Make patient care transitions smoother

Effectively lead improvement efforts

Reduce costs and increase quality

All hospitals around the world can join the IHI in this vibrant network,

so that we can all benefit from the collective knowledge and energy.

Khalil Rizk, MHA, CPHQ

Quality, Accreditation and Risk Manager

Documentation of Surgical Site (Laterality)

Initial assessment is a JCI and MOPH requirement for all patients

admitted to the Medical Center for the first time. The AUBMC

policy on “Assessment and Reassessment of Inpatients” (AOP-

MUL-003) defines the scope and components of patient assess-

ment for each clinical specialty. The policy also specifies the

timeframe for completing the assessment.

During the month of September 2011, a retrospective review

was conducted on patients admitted to the AUBMC during the

month of August 2011 to check for evidence of initial assess-

ment and completeness of documentation by the medical

staff. A Random sample of 79 (3%) medical records from 11

clinical specialties was reviewed.

Some common problems were identified in the assessment

forms of the clinical specialties: The use of unapproved abbre-

viations, improper correction of error, completion of the assess-

ment items by drawing a line through all the items instead of

documenting each item, and missing signature of the attend-

ing physician on the initial assessment forms. Furthermore, some

initial assessment forms were completed by medical students

and they were not countersigned by the resident or the attend-

ing physician. It is also worth mentioning that most of the spe-

cialties complete the initial assessment forms within 4 hours

when they document the time on the initial assessment form.

In conclusion, the initial assessment forms for all the clinical spe-

cialties have to be revised to ensure compliance with the re-

quirements. Moreover, it is important to ensure that medical

staff perform proper documentation including name, signature,

date, and time on the assessment forms.

Lisa Sekilian, BSN, MPH

Accreditation Compliance Officer

Compliance with Initial Assessment by Medical

Staff for Inpatients

Access to Care and Continuity of Care

(ACC)

Admission and Care of Pre-Admission

Unit Patients (ACC-MUL-010)

Care of Patients (COP)

Child Protection (COP-MUL-024)

Government, Leadership and Direction (GLD)

Non-Punitive Reporting (GLD-MUL-002)

Paging Medical Staff (GLD-MST-003)

Facility Management and Safety (FMS)

Use of Personal Non-Medical Appliances (FMS-SFT-005)

Lina Mekawi, MS Senior Data Analyst

The Joint Commission recommends to minimize (as much as possible) the use of abbreviations and encourages all the accred-

ited organizations to develop and implement “A not to use list of abbreviations”. The Institute for Safe Medication Practices

“ISMP” prepared the list of Error-Prone Abbreviations, Symbols and Dose Designations to prevent frequent misinterpretations that

are known to cause harmful medication errors. ISMP recommends that abbreviations shall not be used when communicating

medical information. The error-prone abbreviations, symbols and dose designations used are: S/C, SQ, Sub Q, S.Q, SC, QD,

QOD, Qd, qd, qD, QHS, μg, mcg, D/C, U, cc, OS, OU, >, / (slash mark), MgSO4 and chemical symbol (NaHCO3) used in drug

name.

A compliance review to check the degree of use of error-prone abbreviations and to ensure compliance with the policy on

abbreviations (MCI-MUL-006) was conducted by the Quality, Accreditation and Risk Management Program on a random sam-

ple of 113 medical records representing (4%) of patients discharged in October 2011. The results showed that in 89% of the re-

viewed medical records one or more error-prone abbreviations (from the above list) were used in the physician orders.

Physicians are urged to avoid the use of the error-prone abbreviations in their orders.

Hayat Al Kai Quality Review Analyst

V OLUM E 6, ISSU E 3 Page 4

Staff Awareness Questionnaire

Questionnaire #31

Dareen Hajj Sleiman Clinical Educator

Diana El Banna Medical Staff Officer

Domna El Zayed Registered Nurse

Mariana Jaafar Research Assistant

http://staff.aub.edu.lb/~webaccrm/

AUBMC Policy and Procedure Manuals Available Online: https://his.aub.edu.lb/

Talented Writer… Send Your

Quality Related Stories to

sa135@aub.edu.lb

Quality, Accreditation and Risk Management Program

Use of Error-Prone Abbreviations, Symbols and Dose Designations in Medication Orders

Have 10 people form a 4-3-2-1 hori-

zontal pyramid (arranged like bowl-

ing pins). Tell them to reverse the

apex and the base of the pyramid

by moving only three people.

Do not give up too easily! Check the

solution in next issue.

The big winners were Joseph NassifJoseph Nassif, MD from the OB/GYN Department and Shawki NassarShawki Nassar, RN from the Nursing Ser-

vices. They received a 220$ worth gift while the other win-ners received various gifts.

Questionnaire #32

Samar Nassif Patient Education Coordinator

Hisham Bawadi Nurse Manager

Hanadi Massalkhi Registered Nurse

Ahmed Kaskas Registered Nurse

List of NEW Policies