Minutes of Meeting CQI Committee

IQBAL MEMORIAL HOSPITAL JHANG

Date: 10 November
Dr Sajjad Ali Akber, Chief Executive Officer, Dr. Beenish, Consultant Gynecologist, Dr.Asif Nadeem, Consultant Anesthestist, Dr. Abdul Wajid, Consultant Orthopedic Surgeon, Dr. Rabia
Participants:
Benazir,General Surgeon, Zulqarnain Haider, Lab Technician, Dr Anum, WMO, Abu Bakar Admin Officer

Agenda KPI Discussion Decision Responsibility Time line Follow up

Support required

Total 08 Emergency
Patients in October
2023 Initial time of Dr. Wajid, Consultant
Maintain Initial Assesment
Orthopedic Surgeon
Time for initial assessment assesment for patient is for Emergency Patient must Receptionist +
Less than 30 minutes Dr. Beenish Fatima, Continues Next
of indoor and emergency be less than 30 minutes and Emergency
(Average Time 14 min) Consultant Process Meeting
patients for indoor patients it must be Record Register
Indoor Total 17 Patient Gynecologist,
less than 45 minutes.
Initial Time OF Dr. Anam, WMO
assesment is less than
45minutes

Dr. Wajid, Consultant

Percentage of cases (in- Reviewed all indoor files and
checked for management plan Orthopedic Surgeon
patients) wherein All consultants
documentation. 100 % all Maintain and seek for Dr. Beenish Fatima, Continues Next
management plan is files have management plan
and Medical
improvement where needed Consultant Process Meeting
documented and counter- documented and counter Officers
Gynecologist,
signed by the clinician signed by the clinician
Dr. Anam, WMO

Reviewed all indoor

Percentage of cases (in- files and checked for Maintain and seek for
All consultants
patients) wherein patients status of discharged Improvement every patient Continues Next
All Medical Officer and Medical
are discharged with patients. 100% patients must be discharged with Process Meeting
Officers
satisfactory condition discharged with satisfactory condition.
satisfactory condition.
Patient
Assessment
 Minutes of Meeting CQI Committee

IQBAL MEMORIAL HOSPITAL JHANG

Date:

Dr. Wajid,
Reviewed all indoor Consultant
Percentage of cases (in- files and checked for Orthopedic Surgeon
patients) wherein the initial patients initial diagnosis Maintain and seek for All consultants and Continues Next CQI
Dr. Beenish Fatima,
clinical impression is same and final diagnosis. improvement where needed Medical Officers Process Meetings
Consultant
as the final diagnosis 100% patients have Gynecologist,
same initial diagnosis Dr. Anam, WMO
and final impression

Number of reporting Total investigation 406 Maintain and seek for Zulqarnain Haider, Continues Next CQI
Lab Technician
errors/1000 investigations 6/406 X 1000 improvement where needed Lab Technician Process Meetings
=14.77%
reported
Reviewed lab record
Maintain and seek for Zulqarnain Haider, Continues Next CQI
Percentage of re-dos register and found 0 %, Lab Technician
improvement where needed Lab Technician Process Meetings
Diagnostic redo occurred
Services Lab Reviewed patient lab
Percentage of reports co-
reports, 100% reports Maintain and seek for Zulqarnain Haider, Continues Next CQI
relating with clinical Lab Technician
co-relate with clinical improvement where needed Lab Technician Process Meetings
diagnosis
diagnosis
100 %
Percentage of adherence to
Observed the staff
safety precautions by Maintain and seek for Zulqarnain Haider, PPE's, and strict Continues Next CQI
regularly adopted safety
employees working in improvement where needed Lab Technician compliance to SOPs Process Meetings
precautions in
diagnostics
laboratory

Shafqat Abbas,
Number of reporting Total investigation 961 Maintain and seek for Radiographer Continues Next CQI
Radiographer
errors/1000 investigations 6/961 X 1000 improvement where needed Technician Process Meetings
Diagnostic Technician
=6.24%
Services
reported.
Radiology
Total investigation 961
Shafqat Abbas,
12/961 X 100 Maintain and seek for Radiographer Continues Next CQI
Percentage of re-dos Radiographer
=1.24% improvement where needed Technician Process Meetings
Technician
reported.
 Minutes of Meeting CQI Committee
Reviewed patient
Percentage of reports co- Shafqat Abbas,
radiology reports, 100% Maintain and seek for Radiographer Continues Next CQI
relating with clinical Radiographer
reports co-relate with improvement where needed Technician Process Meetings
diagnosis Technician
clinical diagnosis
Percentage of adherence to 100 %
safety precautions by Observed the staff 100% SOPs followed Shafqat Abbas,
PPE's, and strict Continues Next CQI
employees working in regularly adopted safety maintain these good lab Radiographer
compliance to SOPs Process Meetings
diagnostics services precautions in practices. Technician
radiology laboratory
Dr. Wajid,
Total 133 Surgeries Consultant Receptionist and
Percentage of unplanned performed and 0% Prepare OT's and Staff for Orthopedic Surgeon WMO to call on Continues Next CQI
invasive procedures unplanned invasive Emergency Surgeries Dr. Beenish Fatima, call Consultant in Process Meetings
procedure Consultant case of emergency
Gynecologist,
Dr. Anam, WMO
 Minutes of Meeting CQI Committee

IQBAL MEMORIAL HOSPITAL JHANG

Date:
Dr. Wajid, Consultant
Orthopedic Surgeon
record if any invasive All consultants
Percentage of rescheduling 0% rescheduling of Dr. Beenish Fatima, Continues Next CQI
procedure rescheduled due to and Medical
of invasive procedures invasive procedures Consultant Process Meetings
any reason Officers
Gynecologist,
Dr. Anam, WMO

Percentage of cases where Dr. Wajid, Consultant

All files checked for
the organization procedures, Orthopedic Surgeon
checklist to prevent Ensure Surgeons that patients All consultants
Invasive to prevent adverse events Dr. Beenish Fatima, Continues Next CQI
wrong patient, wrong safety checklist must be done and Medical
procedures like wrong patient and Consultant Process Meetings
procedure and found then surgery perform Officers
wrong procedure, have been Gynecologist,
100% compliance
adhered to Dr. Anam, WMO

Dr. Wajid, Consultant

Percentage of cases who All files checked for receiving Orthopedic Surgeon
received appropriate appropriate prophylactic All consultants
Maintain and seek for Dr. Beenish Fatima, Continues Next CQI
prophylactic antibiotics antibiotics within the and Medical
specified time frame improvement where needed Consultant Process Meetings
within the specified time Officers
100% compliance Gynecologist,
frame
Dr. Anam, WMO
Dr. Wajid, Consultant
Percentage of medication 0% all files patient Orthopedic Surgeon All consultants
Continues Next CQI
errors (Prescribing, charts reviewed and no Medication must be legible Dr. Beenish Fatima, and Medical
Process Meetings
dispensing, administration) error recorded Consultant Gynecologist, Officers
Dr. Anam, WMO

Any drug reaction Dr. Wajid, Consultant

0% all files reviewed Orthopedic Surgeon All consultants
Incidence of adverse drug immediately reported Dr. Beenish Fatima, Continues Next CQI
and found no drug and Medical
reactions consultant and medical Consultant Gynecologist, Process Meetings
reaction reported Officers
officers Dr. Anam, WMO
Adverse
Drug Dr. Wajid, Consultant
Reactions Percentage of admissions 0% no patient admitted Orthopedic Surgeon All consultants
Maintain and seek for Continues Next CQI
with adverse drug reaction/s with adverse drug Dr. Beenish Fatima, and Medical
improvement where needed Process Meetings
(ADR) reaction Consultant Officers
Gynecologist,
Anam, Consultant
Dr. Wajid, WMO
133 patient files Orthopedic Surgeon
Percentage of medication All consultants
reviewed and 0% of Maintain and seek for Dr. Beenish Fatima, Continues Next CQI
charts with error prone and Medical
medication charts with improvement where needed Consultant Process Meetings
abbreviations Officers
error prone abbreviation Gynecologist,
Dr. Anam, WMO
 Minutes of Meeting CQI Committee

IQBAL MEMORIAL HOSPITAL JHANG

Date:
Dr. Wajid, Consultant
0% All patient files
Percentage of patients Orthopedic Surgeon
reviewed and checked All consultants
receiving high risk Maintain and seek for Dr. Beenish Fatima, Continues Next CQI
for receiving high risk and Medical
medications developing improvement where needed Consultant Process Meetings
medications developing Officers
adverse drug event Gynecologist,
adverse drug event.
Dr. Anam, WMO
0%. all patient files
checked and reviewed
Percentage of modification Pre-anesthesia assessment Dr. Asif Nadeem, Consultant Continues Next CQI
anesthesia plan no
of anesthesia plan must be carefully Consultant Anesthetist Anesthetist Process Meetings
change in anesthesia
plan recorded
Percentage of unplanned 0% no patient
Maintain and seek for Dr. Asif Nadeem, Consultant Continues Next CQI
ventilation following undergoes ventilation
improvement where needed Consultant Anesthetist Anesthetist Process Meetings
Anesthesia anesthesia following anesthesia
Total 133 Surgeries
Percentage of adverse 1/133 x 100 Maintain and seek for Dr. Asif Nadeem, Consultant Continues Next CQI
anesthesia events =0.75% improvement where needed Consultant Anesthetist Anesthetist Process Meetings
reported
0% No anesthesia
Anesthesia-related mortality record if any anesthesia Dr. Asif Nadeem, Consultant Continues Next CQI
related mortality
rate related mortality reported Consultant Anesthetist Anesthetist Process Meetings
reported
Dr. Wajid, Consultant
Total 4 patients were Orthopedic Surgeon All consultants
Percentage of transfusion transfused blood and Maintain and seek for Dr. Beenish Fatima, Continues Next CQI
Consultant Gynecologist,
and Medical
reactions 0% transfusion reaction improvement where needed Process Meetings
Dr. Anam, WMO Officers
reported
Zulqarnain
Dr. Wajid, Consultant
Total 4 patients were Orthopedic Surgeon
All consultants
Percentage of wastage of transfused blood and Maintain and seek for Dr. Beenish Fatima, Continues Next CQI
and Medical
blood and blood products 0% wastage of blood or improvement where needed Consultant Process Meetings
Officers
blood product reported Gynecologist,
Dr. Anam, WMO
 Minutes of Meeting CQI Committee

IQBAL MEMORIAL HOSPITAL JHANG

Date:
Blood & Dr. Wajid, Consultant
Blood Orthopedic Surgeon
All consultants
products Percentage of blood 0% no Blood Maintain and seek for Dr. Beenish Fatima, Continues Next CQI
and Medical
component usage Component transfused improvement where needed Consultant Process Meetings
Officers
Gynecologist,
Dr. Anam, WMO
Dr. Wajid, Consultant
4 Patients were
Orthopedic Surgeon
transfused blood, and All consultants
Turnaround time for issue of Maintain and seek for Dr. Beenish Fatima, Continues Next CQI
average time of and Medical
blood and blood components improvement where needed Consultant Process Meetings
Issuance of blood is less Officers
Gynecologist,
than 1/2 hour
Dr. Anam, WMO

Percentage of medical 100% all patient files Dr. Anam, WMO All consultants
Maintain and seek for Continues Next CQI
records not having discharge have discharged Asifa Amin, Staff and Medical
improvement where needed Process Meetings
summary summary Nurse Officers

Percentage of medical 100% patient files have Dr. Anam, WMO All consultants
Maintain and seek for Continues Next CQI
records not having timed named and timed Asifa Amin, Staff and Medical
improvement where needed Process Meetings
and named entries entries. Nurse Officers
Medical
Records
Percentage of medical Dr. Anam, WMO All consultants
0% all patients files Maintain and seek for Continues Next CQI
records having incomplete Asifa Amin, Staff and Medical
consent are complete improvement where needed Process Meetings
and/or improper consent Nurse Officers

Dr. Anam, WMO All consultants

Percentage of missing Maintain and seek for Continues Next CQI
0% no missing record Asifa Amin, Staff and Medical
records improvement where needed Process Meetings
Nurse Officers