Patient Safety, Quality Improvement & Risk Management Project Report

This report details a project focused on enhancing patient safety, quality improvement, and risk management within a healthcare setting, specifically referencing the HSE's initiatives. The project implemented two key systems: a medical e-alert device and a quality assessment and improvement tool. The medical e-alert device aims to streamline the handling of safety notices and hazard alerts, ensuring timely responses and actions. The quality assessment tool, based on eight essential themes, evaluates the management of medical device equipment to improve service quality. The report outlines the project's initiatives, methodologies, and outcomes, including the use of the PDSA cycle for continuous improvement. It analyzes the impact of these tools on service care and patient safety, highlighting the benefits of automated systems and quality assessment in mitigating risks and improving overall healthcare delivery. The report also covers the project's adherence to national guidelines and its contribution to a safer, higher-quality healthcare environment.

PATIENT SAFETY, QUALITY IMPROVEMENT & RISK
MANAGEMENT
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Table of contents
Introduction......................................................................................................................................4
Definition of quality management, service user safety as well as risk management...................4
Findings...........................................................................................................................................5
Demonstration of the project initiative........................................................................................5
Project quality management.........................................................................................................6
Process for quality assessment and improvement tool.................................................................6
Quality tools and techniques........................................................................................................7
Analysis...........................................................................................................................................8
Enhancement of the service care with the aid of project.............................................................8
Safety improved through project..................................................................................................9
Conclusion.....................................................................................................................................10
Reference list.................................................................................................................................12
Appendices....................................................................................................................................14
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Introduction
Safety of the service user is a significant element in terms of conveying efficient healthcare
system. Quality management is an essential aspect of healthcare service to ensure service
efficiency as well as the satisfaction of the service user. Risk management, as well as safety of
service user, is a process of recognizing the associated risk factors which prevent in conveying
effective care. This particular report is aiming to convey the project developed for ensuring the
safety of the service user as well as the quality and risk management. Along with that, this report
will also highlight the project initiatives that are taken such as medical e-alert device and quality
assessment and improvement tool. The medical e-alert device is developed to control as well as
monitor issues associated with the safety responses. In addition to that, quality assessment and
improvement tool are developed to improve the quality of the services following the
management of the medical device system.
Definition of quality management, service user safety as well as risk management
Quality management - Quality management enhances the effectiveness of the treatment which
leads to an increase in the satisfaction of the service user. As mentioned by Mannon (2014, p. 9),
quality components are developed to standardize the work which leads to enhance the quality
care of the service user.
Safety of service user- Safety of the service user is significant as well as effective health care
where quality prevails. As highlighted by Aveling (2016, p. 216), the safety of the service user is
generally the distribution of roles and responsibilities between the system of the organization and
the individual professionals. Potential safety ensures lack of harm as well as it pivots on avoiding
bad events.
Risk management- It is quite necessary for identifying the risk management in the particular
project to obtain the goals of the project considering the planning and preparation of the project.
As stated by Bromiley et al. (2015, p.267), risk management is the culture, process as well as the
structure that is directed towards the development of effective management comprising of
potential opportunities as well as adverse effects. Effective risk management generally
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facilitates in reducing the risk as well as to recognize the factors that are associated with the risk.
Moreover as stated by Griffiths (2016, p.233), risk management is the recognition of the threats
as well as controlling the threats that are associated with the particular project.
Proposed initiative and their importance- The project was aiming to develop medical e-alert
device system as well as quality assessment and improvement tool to convey better health care
and facilitate to enhance the quality and safety of healthcare services. Such tools facilitate in
recognizing the gaps that are present in the recent medical care services as well as mitigating it.
Apart from that, such tools also facilitates in enhancing the quality across the services of the
medical device equipment. These initiatives were also developed to enhance the medical devices
equipment management policy.
The focus of the assignment - This report will highlight the development of the project plan to
convey quality care as well as safety to the service user. In addition to that, it will also
demonstrate the benefits that are conveyed with the aid of these initiatives.
Findings
Demonstration of the project initiative
The main purpose of the project was to convey quality assurance to the service user. To develop
the potential quality care to the service user, two systems were developed such as medical e-
alert device system and quality assessment and improvement tool. The main objective of the
medical e- alert device was to convey an easy as well as an efficient method to control and
monitor the issues related to the safety responses. In addition to that, it was also designed to
convey a potential ICT system to manage the medical device safety notice as well as hazard
alerts about any locations. This particular system receives proper notifications from the Health
Product Regulatory Authority (HPRA) regarding the proper safety issue which are distributed
(ehealthireland.ie, 2019). This particular notification is then conveyed to the responsible person
through HSE mail account for the processing the alert within the given time scale. In addition to
that, the responsible person will take the required action that is necessary for the safety issue of
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the service user. This particular action is taken to enhance the safety with the aid of proper
handling of notices or alerts so that proper quality is conveyed (ehealthireland.ie, 2019).
Medical device equipment tool has been designed to enhance the quality of all services
considering the relation to the management of the medical device system. This particular tool is
based on 8 different themes associated with the management of medical device equipment. In
addition to that, the 8 essentials themes convey the vital aspects of quality that the service user
wants (ehealthireland.ie, 2019). Along with that, a total of 277 quality levels guides are provided
in the respective tool to determine the quality test of each theme. The main guiding principle of
this particular device is to enhance the process of continuous quality improvement associated
with the medical device equipment policy. Progression of the level demonstrates that quality
service is improved and becoming sustainable which is leading to proper innovation. Apart from
that, this particular device also provides QA+1 tool which monitors the arrangements that are
present within the quality service of the service user (ehealthireland.ie, 2019).
Project quality management
Steps in medical e- alert device for maintaining a quality management
● This particular system gets a proper notification from the HPRA o all safety devices that
are generated by HSE
● In addition to that, the priority level of all the safety issue is allocated in terms of the
traffic light system such as red, green as well as amber (ehealthireland.ie, 2019)
● After that, a particular notification is conveyed to the responsible person through the HSE
alert to process the issue within the specific period
● The responsible person selects the determined options which are represented as the
Action taken and sends the brief of the particular action in the dropbox
● National Business Administrator then views the responses as well as the issue for
mitigating the particular issue (ehealthireland.ie, 2019)
(Refer to Appendix 1)
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Process for quality assessment and improvement tool
● QA+1 tool consists of 8 central themes which are considered as the essential elements
about the medical device equipment policy
● Essential elements demonstrate the vital aspects of the quality associated with the
medical devices equipment that is required for the service users (ehealthireland.ie, 2019)
● Total 277 guides regarding the quality level are included within the particular tool to
determine the quality level of each status
● Quality level guides illustrate the particular guidelines that demonstrate the service that is
required in each of the service levels
● Proper quality improvement plan, as well as assessment reports, are developed to ensure
the proper quality enhancement plan. Quality improvement plan controls and monitors
the arrangement of the quality service that is required in each level. In addition to that,
assessment reports evaluate the essential elements that are obtained in the quality
improvement process (ehealthireland.ie, 2019).
(Refer to Appendix 2)
Quality tools and techniques
The medical e-alerts device system, as well as quality assessment improvement tool, has
followed the National guidelines regarding the quality of clinical practices in Ireland
(ehealthireland.ie, 2019). The National Clinical Guidelines of Ireland is to convey proper safety
as well as enhancing the quality of standards in the health care services (health.gov.ie, 2019). In
the following context, medical e- alert as well as quality management tool has maintained the
national guidelines in terms of enhancing their process of QA+1 tool to convey potential and
quality services to the service users. Along with that, this project has also followed the respective
guidelines in terms of ensuring proper safety in their medical e- alert device.
The respective project has utilized the Plan Do Act Study model to enhance their process and
maintain the proper quality in the health care service. In the following context, this project was
planned to improve the quality of care that is conveyed to the service user. In addition to that,
this particular step demonstrates the proper methods that are implemented in both the devices to
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get a proper outcome. Along with that, the second step is the do step which it demonstrates the
implementation of the particular action (ahrq.gov, 2019). This particular step also observes the
process of the implementation of the devices as well as observes the reaction of the service user
and service provider. This proper observation helps in redesigning or modifying the devices
considering the needs as well as demands of the service users. As mentioned by Taylor et al.
(2014, p.291), PDSA cycle is implemented to develop the plan to change the existing plan. Apart
from that, in the next step, the members of the project have evaluated the responses that are
conveyed from the service user as well as the service provider. This has also facilitated them in
enhancing their devices in terms of designing their devices according to the needs of the service
user. Along with that, according to the next step, the members of the project have acted properly
in terms of recording their project work as well as the feedback from the service user. This has
facilitated them in designing their devices by their needs in the future (ahrq.gov, 2019).
Figure 1: Plan Do Act Study Cycle
(Source: Taylor et al., 2019, p.293)
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PlaDoAcStud

Analysis
Enhancement of the service care with the aid of the project
Medical e- alert device has facilitated in tackling or handling the medical safety notices as well
as the hazard alerts within the HSE organisation. This particular device has enabled the
organisation to get the proper notification regarding the safety issue of the medical devices. In
addition to that, this has also facilitated the members within the organisation to take proper
actions to mitigate the safety issues (ehealthireland.ie, 2019). Along with that, this particular
notification is delivered within the closed-loop which facilitates the designated person to take
potential actions regarding the particular issue. With the aid of the automated system
implemented within the device, safety hazard notice is closed automatically which illustrates that
the responsible person has completed the details of the issue. Moreover, this particular device
also conveys the statistical as well as management reports regarding the actions of the issue. An
automated email is also generated if the responses are not answered properly (ehealthireland.ie,
2019).
Medical device equipment tool facilitates in enhancing the quality of the services in terms of
enhancing the management of the medical devices. This particular process also facilitates in
identifying the gaps that are present in the current situation of the medical services. The
respective tool facilitates in mitigating the gaps that are associated with the medical services so
that the service user can receive the quality care that they deserve. 8 central themes are
considered as the necessary elements of the respective tool that facilitates the service user to
select the effective level that is necessary for them. Moreover, this particular assessment tool also
facilitates in developing the improvement plan to mitigate the gaps that are present in the current
management of the medical devices as well as quality care. In addition to that, this particular tool
also conveys the accomplishments that are obtained in terms of managing the medical device
equipment (ehealthireland.ie, 2019).
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Safety improved through the project
The medical e- alert system also ensures safety with the aid of proper handling of notices as
well as alerts. This facilitates the organization to prioritise the work according to the notice or
the alerts of the respective system (ehealthireland.ie, 2019). In addition to that, this also helps the
service user to remain safe regarding the management of the medical devices. With the aid of
this particular device service, the user can also handle the hazards or mitigate it properly. Apart
from that, the respective devices also facilitate proper monitoring and control that helps to keep
a proper track regarding the usage of proper medication at the proper time. The respective device
also permits the service user to remain independent in terms of conveying quality care to the
service user (ehealthireland.ie, 2019).
Apart from that, medical device equipment tools convey different quality levels to the service
user so that they can select the level of services they require. Proper completion of the medical
device assessments conveys the evidence in support with the National Standard For Safer Better
Healthcare. This particular tool also provides the collaboration of the information that is
demonstrated from the assessment tool. This particular demonstration facilitates in monitoring
the progression of the quality improvement plan following the HIQA standards
(ehealthireland.ie, 2019). Moreover, such monitoring helps in overviewing the process of quality
management so that they can ensure that all the HIQA standards are maintained properly. This
particular tool is also significant for ensuring safe and effective quality care that is conveyed to
the service user.
Conclusion
Thus it can be concluded that this particular project initiative included the development of
medical e- alert device as well as the medical device equipment tool. These particular devices
facilitated in conveying potential care or effective quality care to the service user. In addition to
that, the medical e- alert device facilitates in conveying easy as well as an efficient way of
controlling and monitoring the safety issues that are associated with the medical equipment.
Along with that, this respective device also facilitates in prioritizing the safety issue in terms of
developing the signals that are necessary for the respective issues. With the aid of the automated
system, the responsible person of the organisation overview the requirements of the issues as
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well as take proper action to mitigate the concerned issue. In addition to that, this respective
device also helps to maintain the safety of the service users in terms of handling the notices or
alerts of the medical devices. This also helps the service user to remain independent in terms of
tackling the hazards of the medical devices.
Apart from that, the medical device equipment tool is also necessary to assess the quality
improvement of medical devices. The concerned tool facilitates in maintaining the safety of the
medical devices in terms of conducting a proper assessment of the particular devices. In addition
to that, this particular tool also helps the service user to select the level of quality management
that is required as this tool conveys 8 different themes for selection. Along with that, the
concerned tool also helps in controlling the process of the quality enhancement plan. This
monitoring or controlling facilitates in demonstrating that the respective tool in maintaining the
HIQA standards properly. Moreover, the completion of the assessment process provides the
proper evidence following the National Healthcare Standards. This particular project also
maintains the National Healthcare Guidelines of Ireland in terms of providing quality services to
the concerned service user. Moreover, maintaining the Plan Do Act Study model also facilitated
in implementing the plan as well as designing their devices according to the necessities of the
service users.
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Reference list
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https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-
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accountability in patient safety? A multi‐site ethnographic study. Sociology of health &
illness, 38(2), pp.216-232.
Bromiley, P., McShane, M., Nair, A. and Rustambekov, E., (2015). Enterprise risk management:
Review, critique, and research directions. Long range planning, 48(4), pp.265-276.
ehealthireland.ie (2019). HSE National Medical Device Alert System. Available at:
ehealthireland.ie (2019). Medical Device Equipment Quality Assessment & Improvement Tool.
Available at: https://www.ehealthireland.ie/Case%20Studies/Quality-Patient-Safety/Medical-
Device-Equipment-Quality-Assessment-Improvement-Tool/ [accessed on: 28/8/19]
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https://www.ehealthireland.ie/Case%20Studies/Quality-Patient-Safety/ [accessed on: 23/8/19]
Griffiths, P., (2016). Risk-based auditing. Routledge: Abingdon
health.gov.ie (2019). National Clinical Guidelines. Available at: https://health.gov.ie/national-
patient-safety-office/ncec/national-clinical-guidelines/ [accessed on:28/8/19]
health.gov.ie (2019). National Quality Assurance Criteria for Clinical Guidelines Version 2 .
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Assurance-Criteria-NCG-v2-April-2015.pdf [accessed on: 24/8/19]
hiqa.ie (2019). Draft National Quality Assurance Criteria for Clinical Guidelines . Available at:
https://www.hiqa.ie/sites/default/files/2017-01/Draft-National-Quality-Assurance-Criteria.pdf
[accessed on: 26/8/19]
hiqa.ie (2019). National Quality Assurance Criteria for Clinical Guidelines . Available at:
https://www.hiqa.ie/sites/default/files/2017-01/National-Quality-Assurance-Criteria.pdf
[accessed on: 25/8/19]
hse.ie (2019). Health Service Executive. Available at: https://www.hse.ie/eng/ [accessed on:
26/8/19]
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hse.ie (2019). Patient Safety Strategy 2019-2024 . Available at:
https://www.hse.ie/eng/about/qavd/draft-hse-patient-safety-strategy-28th-feb-2019-for-
consultation.pdf [accessed on: 24/8/19]
https://www.ehealthireland.ie/Case%20Studies/Quality-Patient-Safety/National-Medical-Device-
Alert-System/ [accessed on: 26/8/19]
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Ross, J.E., (2017). Total quality management: Text, cases, and readings. Routledge: Abingdon
Taylor, M.J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D. and Reed, J.E., (2014). Systematic
review of the application of the plan–do–study–act method to improve quality in healthcare. BMJ
Qual Saf, 23(4), pp.290-298.
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internal medicine, 160(9), pp.642-643.
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