Continuous Performance Improvement Department

• Aims to ensure that all the services that the Children’s Cancer Hospital 57357 provides concentrate on boosting and improving patient safety results and implementing effective safety measures in all aspects of care through the following:
  • Spreading and activating the patient safety culture in the Hospital depends on safety and prevention of mistakes.
  • Concentrating on performance improvement instead of blaming the employees
  • Encouraging the employees to be knowledgeable about safety, risks, and prevention of mistakes.
  • Encouraging the employees to report mistakes and risks that affect patient care safety.
• Incident reporting system
  • The primary purpose is to obtain information about the facts that lead to damage, learn from them, and avoid them.
  • Proactively reporting and analyzing these facts enhances safety plans in all stages of care.
  • The goal of analyzing events is to determine ways to improve healthcare.
  • Using a preventive system to help employees report any incident through an electronic system or a hard copy.
• Patient safety culture
  • Safety culture is an integrated pattern of individual and organizational behavior that aims to reduce the damages patients may face due to healthcare provision.
  • The Hospital plans to establish, support, implement, monitor, and improve safety culture in line with the Hospital’s vision, mission, quality standards, and accreditation requirements.

• Quality specialists in 57357 perform daily follow up on all kinds of services provided to patients in all the units according to best international practices and standards and the Hospital’s policies to identify procedures/processes at risk.
• The internal audit is the proactive monitoring of these procedures or processes to spot any mistakes in the care procedure effectively; it is designed to cover all aspects of patient safety, such as:
  • National and International patient safety standards.
  • Medication safety.
  • Environmental safety.
  • Medical documentation.
  • Evaluating awareness of policies and general procedures.
  • All the specified results are collected and analyzed and then presented to the head of the concerned department and upper management for correction.

• Risk management is the systematic process of identifying, evaluating, and handling potential and actual risks.
• Risk management is a proactive job involving the application of procedures to reduce the repetition and intensity of unexpected accidents.
• Risk management is an approach to improve the quality and safety of provided healthcare by identifying the circumstances that would expose patients to risk and working on preventing or controlling these risks.

• Performance improvement is one of the essential pillars for improving and developing work operations.
• The performance improvement unit directs plans, supports, and follows up on quality improvement projects in the hospital.
  • PDCA.
  • FMEA.
  • 6 Sigma (DMAIC, DMADV, DOE).
  • Lean (Gemba Kaizen, 6-S, Value Stream Mapping).
  • Business Process Re-engineering (BPR).
  • Agile, Scrum.

The unit aligns quality processes with international guidelines; our robust research foundation depends on two pillars:

• Testing and implementing different medical and nonmedical activities through an evidence-based research framework.
• We are employing evidence to serve the application.

• The data management unit collects and validates the hospital’s performance data through performance indicators aligned with strategic objectives.
• The document management system is an electronic system used to receive, follow up, and save documents consistently and uniformly and reduce paper use.
• Electronic health records, IT accreditation, increased availability of electronic health data, and improved data analysis technology lead to improving healthcare services provision.
• The goal of informatics is to collect adequate data about healthcare quality, analyze these data, and apply the results to quality improvement programs.
• A clinical documentation improvement program is designed to obtain precise and comprehensive documentation for medical records.
• The informatics quality uses digital transformation to reach the highest degree of quality, for example (process mining, Auditing automation, and dashboard)
• Revealed information from analyzing the Hospital’s indicators helps make the ideal decision on the medical, administrational and strategic levels
• A large amount of healthcare data leads to the emergence of the idea of “big data” in the field of healthcare; with the collection of more data, the upgrading of tools required to support the analysis and preparation of reports continues, which enables us to gain more wisdom in decision making.

A. Internal training

• Program of directing newly hired employees
  • The department participates in presenting two lectures: the first is about the national and international standards of patient safety as a general direction to help employees improve patient safety and care quality and reduce risks of medical mistakes, and the second is about quality concepts in CCHE 57357

• The Hospital’s quality courses
  • The quality department coordinates with the nursing continuous education department for 30 hours of quality courses, including improving patient safety, data management, accreditations (the Joint Commission International JCI and the national accreditation GAHAR), healthcare quality basic concepts, facility management safety, tracking, auditing, and project improvement tools.

• The department’s quality training program
• On-the-job training on tracking activities

B. External Training

• JCI program for quality and patient safety

CCHE 57357 was selected to be the only training site for the JCI program for quality and patient safety for 3 cycles with the Joint Commission International to offer training certificates in quality and patient safety

• Applying quality and medical processes through programs geared to visiting Hospitals of renowned universities, such as the American University in Cairo and Badr University

Short courses

1. Preparation course, CPHQ
2. Risk management course
3. Data management course
4. Patients safety course
5. Quality implementation in healthcare facilities

For registration in the JCI program and Quality short course:

Please visit CCHE 57357 Continuous Education & Development Department 

Click on Short Courses