Clinical Governance

Mortality & Morbidity (M & M) Reviews

Healthcare organizations must systematically identify and mitigate patient safety risks and hazards with an integrated approach in order to continuously drive down preventable patient harm. Structured, multidisciplinary review is required to identify system processes that may result in failures in care, adverse events, and mortality. The M & M committee meets on a monthly basis. The objectives are to learn from complications and errors, to modify behavior and judgment based on previous experiences, and to prevent repetition of errors leading to complications.

Clinical Audits

Clinical audit is a Quality improvement process and an important mechanism for providing assurance in relation to the provision of safe and effective patient care. QPSD is committed to assist in delivering effective clinical audit in all the clinical services.

Medical Charts Audit

There is a multi-disciplinary approach in conducting review of patient clinical record content, quality and the completeness of patient clinical records, and the results are incorporated into the hospital’s quality over sight mechanism.

Improve Quality through Performance Improvement

Performance improvement monitoring and evaluation standards are system-wide and comprehensive. Hospital leadership sets hospital wide measurement and improvement activities. These are measurement and improvement efforts that impact or reflect activities in multiple departments and services. Hospital leadership provides focus for the hospital’s quality measurement and improvement activities, including measurement and activities regarding the hospital’s full compliance with the International Patient Safety Goals. QPSD supports and facilitates all improvement activities conducted throughout SKMCH & RC by providing expertise in planning, execution, monitoring and education. SKMCH & RC has adopted FOCUS PDCA methodology for Improvement.

Clinical Risk Management

Clinical Risk Management is an approach to improving quality in healthcare which places special emphasis on identifying circumstances which put patients at risk of harm, and then acting to prevent or control those risks. The aim is to both improve quality of care for patients and to reduce the costs of such risks for healthcare providers. SKMCH & RC has a robust electronic Incident Reporting System (IRS). Root cause analysis (RCA) is conducted for sentinel events, retrospectively. Failure Mode Effect Analysis (FMEA) is a systematic method of identifying and preventing product and process problems before they occur. QPSD is mandated to conduct FMEA for atleast one process, each year. QPSD has also initiated maintaining a Risk Register, which is a database that enables standardized, efficient, and effective implementation of a proactive risk management. Based on Risk Management principles, it provides a platform to systematically identify, assess, manage and monitor key organization risks.