Goal 1: Promote A Culture of Safety "Zero Harm"
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Objective 1.1 Effective Programme of Infection Prevention and Control (IPC).
Objective 1.1 Effective Programme of Infection Prevention and Control (IPC).
Hand Hygiene policy & procedures (Evidence Based Practice (EBP) Guidelines, Staff training documents, and Reports of tracking).
Staff training documents, and Reports of tracking
-There are 10 IPC certification has been taken for nurses (2023)
-Next year plan, IPC certification retake for all the staff
-There are two lectures about ipc Guidelines updates, PPE, for the SN
(2023)
-Next year plan, to arrange six lectures, one lecture every two months, for the Staff nurses.
-There are one lectures about ipc Guidelines ,PPE, has been conducted for the nurse aid(2023)
-Next year plan, to arrange four lectures, one lecture every quarter, for the nurse aid.
Hand Hygiene policy & procedures
-Hand hygiene compliance is 80 %
-The target benchmark is 90%
Evidence-Based sterile technique and aseptic technique guidelines (Scrubs- Prevention of Surgical Site Infections-CCI).
Evidence-Based sterile technique and aseptic technique guidelines (Scrubs- Prevention of Surgical Site Infections-CCI).
-Surgical site infection for permanent pacemaker cases is 2 infected pocket due to skin erosion
-Surgical site infection for permanent pacemaker cases is 2 infected pocket due to skin erosion
-The target benchmark for pocket
-The target benchmark for pocket
infection is zero
infection is zero
Objective 1.2 Effective Inter-Professional Communication: Safe Patient Flow
Objective 1.2 Effective Inter-Professional Communication: Safe Patient Flow
Patient Identification Policy & Procedures (NSR.01)
-The patient identification kpis is measured to ensure the commitment of the correct patient identification policy has been conducting.
-For the statistics press the below
link.
Fall Screening and prevention Policy & Procedures (NSR.05) & related forms.
-The fall down patient for (2023) is zero
-The measurements is to keep the percentage at the zero level
Quality control documents,Data collection and analysis documents & reports.
-The Radiation Protection and Safety QIPs is to ensure the International Safety Standards for the staff and patients has been meet and improved.
-For the statistics press the below
link.
Goal 2: Exemplary Professional Practice
G 2.2 Consistently Delivering Integrated Care
G 2.2 Consistently Delivering Integrated Care
Time-Out Policy & Procedures (NSR.19).
-The Time out Audit is measured to ensure the Accuracy of the Time out policy has been Accomplished.
-For the statistics press the below
link.
Goal 3: Structural Empowerment
G 3.2 Effective Program of Staff Safety & Health.
G 3.2 Effective Program of Staff Safety & Health.
Increase in safe practice, safety-focused environment noted by reduction in needle sticks, staff injuries.
The needle sticks, staff injuries is only one staff and has been reported to the IPC department (2023)
Goal 4: Transformational Leadership: Supporting
Growth
G 4.1 Effective Nursing Leadership
G 4.1 Effective Nursing Leadership
Average of Nursing staff Absenteeism per unit.
-The Nursing staff Absenteeism for (2023) is zero
-The measurements is to keep the percentage at the zero level
Staff performance and competency are regularly evaluated (annually).
Staff performance and competency are regularly monitored by the unit manager the results collected at the AMBER model, Appraisal forms.
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