Services

 

• Gap analysis, which includes the assessment of AUBMC's baseline compliance with the latest standards (national and international), and setting action plans to achieve and sustain compliance (taskforces, policy review, process revamp) 
  
• Periodic reviews to assess staff compliance with AUBMC's bylaws, policies and procedures, the Joint Commission International (JCI) and the Ministry of Public Health (MOPH) accreditation standards, and setting corrective measures to address deficiencies
  
• Monitoring of accreditation activities throughout the Medical Center, and provision of guidance to departments in the interpretation and implementation of standards 
  
• Revision of AUBMC's processes, policies, and workflows to ensure alignment with standards 
  
• Preparation for the accreditation survey visits, including the compilation of information for the application, required documents, staff education, mock sessions, and the survey's schedule
  
• Maintenance of updated records of accreditation standards, dates and schedules of survey visits, and accreditation reports and certificates
  
• Provision of follow-up reports to accreditation agencies, as needed
  
• Mock surveys and patient tracers
  

Policies and Procedures:

• Preparation, update, indexing, maintenance, and dissemination of multidisciplinary policies and procedures, and departmental manuals
  
• Provision of assistance to departments in the preparation of their policies and procedures manuals
  
• Alignment of AUBMC's policies and procedures with the current standard’s requirements (JCI, MOPH), bylaws, and AUB policies
  
• Cross-referencing of information in policies and manuals across AUBMC

Data Management and Reporting:

• Analysis of data on AUBMC’s PI indicators, PI projects, and quality and compliance reviews​
  
• Provision of data management support to departments, as it relates to sampling, data collection, data management, analysis, and data validation, in line with the JCI requirements
• Design and management of reports, summaries, and dashboards in the electronic health information system

​Patient Safety (under review):

• Review and monitoring of the occurrence reporting system, and identification of trends and patterns
• Review of mortalities with concerned individuals
• Participation in root cause analysis (RCA) teams to investigate sentinel events and near misses
  
• Enhancement of the patient safety culture through safety rounds, campaigns, and briefings
  

Risk Management:

• Risk identification, analysis, reduction, avoidance, and control, through the implementation of preventive and responsive risk management techniques
  
• Handling, review, and analysis of patient occurrences and complaints, in accordance with the AUBMC policy on Patient Safety and Risk Management
• Review of medico-legal matters pertaining to AUBMC services, and estimation of the associated risk
• Coordinating the functions of ad-hoc committees and taskforces in the review of complaints
• Surveillance and assessment of risks by reviewing the policies, procedures, and standards of practice
• Implementation of proactive risk reduction activities, a systematic tracking of identified risks, and root cause analysis (RCA)
• Provision of risk management training to AUBMC staff
  

Utilization Management:

• Planning, organization, direction, and control of resources
• Chart evaluation to ensure a cost-effective utilization of resources, and adherence to the admission, treatment, and length of stay criteria
  
• Development of clinical processes (pathways/standards of care) for procedures or services
• Provision of advice on adequate documentation of active treatment, and the criteria for continued services, according to guidelines
• Analysis of clinical pertinence of charts in terms of quality and appropriateness of care, including adherence to, or deviation from protocols
• Monitoring of PI indicators on the use, patterns of use, and rates of use of specific services
• Selection of targets for utilization review, and development of objective criteria to differentiate between acceptable and questionable care
• Evaluation of specific cases, patterns, and trends, indicating overutilization, underutilization, or misuse
• Identification of pertinent topics and trends that may warrant research or other action​
  

Staff Education: 

• Education provided by QARM covers AUBMC’s staff educational needs, as it relates to:
• Quality management and PI principles
• AUBMC policies and procedures
• Accreditation standards, patient safety
• Occurrence reporting
• Risk management
• Specific issues identified / guidelines received from professional healthcare organizations
  
• ​Education is delivered through orientation, preceptor-ship, grand rounds, campaigns, rounds, lectures, curricula, sessions, workshops, booklets, tip sheets, and online tests. 

Workshops:

• QARM staff conduct 3 to 5-day workshops to participants from diverse healthcare organizations, in coordination with the Continuing Medical Education (CME) Office.
  
• Workshops cover accreditation, quality, patient safety and risk management, and Certified Professional in Healthcare Quality (CPHQ) Reviews​.
  
• QARM staff are ready to prepare custom-made educational programs to meet the needs of participants. 
  
• Educational programs are accredited by authorized agencies, and provide continuing education (CE) credits.