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Action Plan Development
Action plan for PSFH
improvement
Elements of the action plan
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Define the problem, or the standard
Define steps and procedures ,activities
or action
Define the responsible person
Define the time needed to solve the problem
Develop a monitoring strategy
2
How to develop Patient Safety
Action Plan?
How to comply to standard?
Who will develop it?
When will it be developed?
How will you monitor?
Action Plan
Draft
Responsible person
Actions
Time frame
End time
Monitoring
Strategy
Measures
A. Leadership and Governance
A.1.1.2.Hospital has designated a senior staff member with responsibility,
accountability and authority for patient safety.
PSO
Develop PSO terms of
reference
20.09\2009
A.1.1.3.The leadership conducts regular Patient Safety Executive Walk to
promote patient safety culture, learn about risks in the system, and act on
patient safety improvement opportunities.
Dr.Atef El Nimri
establish a team to plan
the schedule of rounds
and action taken
17.09\2009
A.2.1.2.The hospital conducts regular monthly morbidity and mortality
meetings.
Hospital Director(Dr.Braizate)
Establish a committee
with TOR including the
schedule for meetings
01.10\2009
A.4.1.1.The hospital ensures availability of essential equipment.
Hospital
Director(Dr.Braizate),nursing
manager
Review the list to ensure
that emergency cart are
available in all
departments
30.10\2009
What are the patients identifiers?
How does hospital verify its patients?
How are high risk groups e.g. new born
babies, patients in coma, senile patients
identified?
• HOW?WHO?WHEN?HOW TO
MONITOR?
How does the hospital
maintain clear channels of
communication for urgent
critical results?
How? Who? When?
How does the hospital monitor
and implement guidelines, on
safe blood and blood products?
• WHO?WHEN?HOW?
How does the hospital ensure
availability of life saving
medications at all times?
How to ensure proper segregation of
hospital’s waste?
• WHO?WHEN?HOW?
How does the hospital
conform to guidelines on
management of sharps waste?
Who? When? How?
Thank you for your attention
Injy Khorshid,MBBCh,MPA,FAIHQ,CHS
[email protected]