Quality & Patient Safety Department

Patient safety is the absence of preventable harm to a patient during the process of healthcare. At the same time, Healthcare quality refers to the degree to which patient care services increases the probability of desired outcomes and reduce the probability of undesired outcomes, given the current state of knowledge. Thus, it is the mission of the Quality & Patient Safety Department (QPSD) to support and facilitate projects of Shaukat Khanum Memorial Trust (SKMT) in Lahore, Peshawar and Karachi to provide our patients and their families with a safe, appropriate, consistent healthcare in a respectable environment, by innovating strategies, and implementation of system improvement solutions.

The Quality & Patient Safety program primarily focuses on compliance with regulatory requirements, Joint Commission International (JCI) accreditation, ISO certifications, clinical governance, comprehensive risk management and patient safety, performance improvement, clinical performance indicators, patient comments handling, and patient satisfaction and experience surveys.

Accreditation

Accreditation is a process in which an entity, separate and distinct from the health care organization, usually non-governmental, assesses the health care organization to determine if it meets a set of requirements designed to improve the quality of care. QPSD facilitates and supports SKMT to achieve, sustain and exceed international accreditation standards.

SKMT underwent rigorous on-site surveys conducted by teams of Joint Commission International expert surveyors. After completing the surveys, we are proud to have earned Joint Commission International’s Gold Seal of Approval® for enterprise, hospital and ambulatory care accreditations by demonstrating continuous compliance with its internationally recognized standards. The Gold Seal of Approval® is a symbol of quality that reflects an organization’s commitment to providing safe and effective patient care.

Clinical Governance

Clinical governance is a framework through which SKMCH & RC in Lahore, Peshawar, and Karachi are accountable for continuously improving the quality of our services and safeguarding high standards by creating an environment in which excellence in clinical care will flourish. Some of the main ingredients of this framework are as follows:

• Clinical Performance Dashboard (SKMCH&RC, Lahore | SKMCH&RC, Peshawar | KDC&C, Karachi)
• Mortality & Morbidity (M & M) Reviews
• Clinical Audits
• Medical Charts Audit
• Improve Quality through Performance Improvement
• Clinical Risk Management

Patients Comments and Suggestions

The Patients Relations section in QPSD caters to patients and their family comments, appreciations, and suggestions. There is a prescribed process to address and resolve any complaints a patient may have.

Patient Satisfaction & Experience Survey

We conduct patient satisfaction & experience surveys every year for identifying gaps and developing an effective action plan for quality improvement.

Patient Safety Culture Survey

We conduct patient safety culture surveys at all sites of SKMT. These are distributed to nurses, doctors, and other healthcare/allied staff that participate in patient care. Results after tabulation and analysis are presented to the leadership for any necessary action.

Patients’ Rights and Responsibilities

Special care is given to the rights of the patients at all sites of SKMT. Patients are educated and informed about the disease process, and having their informed consent for treatment is of utmost importance. Patient’s privacy and confidentiality is respected.

ISO Certification

ISO 9001 Quality Management System

Scope of ISO 9001:

• Twenty-eight departments at SKMCH&RC, Lahore
• Twenty-three departments at SKMCH&RC, Peshawar
• Shaukat Khanum Diagnostic Centre, Jail Road Lahore
• Shaukat Khanum Diagnostic Centre, Liberty Lahore
• Karachi Diagnostic Centre and Clinics, Karachi

ISO 22000 Food Safety Management System

Scope of ISO 22000:

1. Food and Dietary Services – SKMCH&RC, Lahore
2. Food and Dietary Services – SKMCH&RC, Peshawar

Future Goals

• College of American Pathologists (CAP) Laboratory Accreditation Program
• ANCC Magnet Recognition Program
• Quality Oncology Practice Initiative (QOPI)
• Quality Management Audits in Nuclear Medicine (QUANUM) Programme