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 (QPS) program strives to foster high reliability in healthcare, defined as consistent excellence in quality and safety over extended periods of time, across all services and settings. QPS program focuses on compliance with regulatory requirements, Joint Commission International (JCI) accreditation, QOPI certification, CAP 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 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 recognised standards. It is worth noting that we are the first and only organisation in Pakistan to receive enterprise recognition. The Gold Seal of Approval® is a symbol of quality that reflects an organisation’s commitment to providing safe and effective patient care.

Clinical Governance & Patient Safety

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. This framework consists of plans, policies and procedures used to identify and reduce adverse events and other safety risks to patients, visitors and staff. Some of the main ingredients of this framework are as follows:

Patients Comments & 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 to identify gaps and develop 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 has been implemented at SKMCH&RC since 2001, ensuring consistent quality and continuous improvement in healthcare services.

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

Quality Oncology Practice Initiative (QOPI)

The QOPI Certification Program, which is based on the American Society of Clinical Oncology, Inc.’s (“ASCO”) Quality Oncology Practice Initiative (“QOPI”), enables haematology-oncology practices to demonstrate their commitment to excellence and ongoing quality improvement.

SKMT underwent a remote survey in August 2023, conducted by an ASCO surveyor. After completing the survey, we are proud to have earned QOPI certification.

Scope of QOPI certification:

  1. SKMCH&RC, Lahore
  2. SKMCH&RC, Peshawar

College of American Pathologists (CAP) Laboratory Accreditation Program

Shaukat Khanum Memorial Cancer Hospital & Research Centre (SKMCH&RC) in Lahore received accreditation from the College of American Pathologists (CAP) in October 2024, recognising its commitment to excellence in laboratory medicine. This accreditation is a significant milestone for the SKMCH&RC, reflecting its dedication to maintaining high standards in laboratory testing and patient care.

Future Goals

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