6.

QUALITY MANAGEMENT REVIEW SYSTEM

A. Quality Management Program

Introduction:
The Novo Eye Care Clinic Inc. is an ambulatory surgical clinic providing
comprehensive care to patients of all ages. Our scope of care encompasses
medically stable patients, chronic illness management, health education, and both
individual and family counseling. Our operations are designed to coordinate the
management of high-quality, integrated healthcare services for individuals and
the communities we serve. We ensure this coordination through our core values:
leadership, respect, excellence, integrity, stewardship, compassion, and service.

Purpose:
The Quality Management Program aims to describe how we monitor the care
provided to our patients, ensuring alignment with our mission. It also outlines the
components of the program that contribute to the ongoing improvement of care
quality.

Goals and Objectives:

The primary objective is to continuously monitor the quality of healthcare
provided to all patients. Specific goals include, but are not limited to:

1. Maintaining an effective Quality Management Program through annual

evaluations.
2. Ensuring high levels of patient satisfaction and access to appropriate
healthcare services by:
o Continuously monitoring complaints, grievances, and appeals to
identify improvement opportunities.
o Tracking patient satisfaction and needs to drive service
enhancements.
o Implementing and evaluating interventions when patient satisfaction
or access issues are identified.
o Reporting monitoring results to management for review and action.
Scope of the Quality Management Program:

1. Individual performance plays a key role in achieving our mission, with the
greatest advancements stemming from collaborative improvements in
service processes.
2. Prioritizing organizational monitoring and reporting.
3. Focusing on key areas such as:
o Service utilization
o Patient satisfaction
o Clinical services, including behavioral health, case management,
member education, and quality improvement initiatives.

Principles of the Quality Management Program:

 Teamwork:
Process improvements, new process designs, and problem-solving are
driven by both individual and team efforts. A structured continuous
improvement methodology guides our solutions.
o Provide education and implement improved processes.
o Foster direct communication between nursing staff, doctors, medical
records, and administrative areas.
o Monitor improvements for continued enhancement.
o Keep records of meetings and decisions.
 Patient/Client Awareness:
We actively listen to our patients and clients—both internal and external—
to measure our service quality against their expectations. We are
committed to objectively measuring all service system aspects and
addressing any variances from expected performance. Our challenge is to
balance these expectations with the reality of limited resources.
Communication occurs through emails, posted memos, management
notices, and direct communication with senior and medical staff.
 Fact-Based Decision Making:
Decisions are based on reliable and valid data, not personal preference or
instinct. We share data resources across the organization while respecting
confidentiality and appropriate distribution.
Reporting of Quality Management Program Activities:
The Quality Management Program involves all practicing ophthalmologists and
regular staff, each of whom holds accountability for quality-related activities.
These members work closely to oversee daily operations in each department. The
program monitors its effectiveness and provides regular reports to the Chief
Executive Officer, including findings, actions, and recommendations. Management
meets at least monthly to review data, evaluate program effectiveness, and
propose improvements. Members include ophthalmologists from the ambulatory
eye center.

Quality Management Program Evaluation:

The Management Committee reviews the Quality Management Program monthly
to assess its effectiveness and make necessary revisions. Evaluation summaries
are provided to the Chief Executive Officer. The formal evaluation covers the
impact and effectiveness of the following:

 Quality Management Program

 Utilization Management Program
 Special Needs Plan Care Management

B. Procedure For Handling Complaints

Definition:
A "Complaint" is a statement made by a patient, client, or staff member that indicates
dissatisfaction with the safety, quality, or overall service provided. It reflects that something was
unsatisfactory or substandard in the care or services delivered.

Policy:

The organization is committed to providing a fair, consistent, and transparent

process for handling complaints and aims to:

 Establish an open and transparent complaint-handling system.

 Define key performance indicators for which the organization is
accountable.
 Set specific timeframes for the resolution of complaints.
  Clarify staff roles and responsibilities in managing complaints.
 Ensure complaints are handled fairly and objectively.
 Record and analyze complaint data to identify opportunities for service
improvement.

Purpose:

The purpose of this policy is to outline an organizational approach to handling

complaints that empowers staff to facilitate and resolve them efficiently. The
policy also holds the management accountable both internally and externally for
decision-making and complaint-handling performance.

Principles:

Complaints will be addressed based on the following principles:

1. Commitment: A dedicated approach to resolving complaints promptly.

2. Accessibility: Ensure that the complaints process is easy for all patients,
clients, and staff to access.
3. Transparency: The process should be open, with clear communication
about the complaint's progress.
4. Objectivity and Fairness: Complaints will be handled impartially, without
bias or favoritism.
5. Confidentiality: All complaints and investigations will be kept confidential,
protecting patient and staff privacy.
6. Accountability: The organization takes responsibility for its actions and
decisions in managing complaints.
7. Continuous Improvement: The complaint-handling process will be
continuously reviewed to improve services.

Process for Handling Complaints:

 1. Committee Creation:
A dedicated Complaint Investigation Committee will be formed to handle
and investigate complaints following the organization's policy.
2. Issuance of Notice to Explain:
Once a complaint is filed, a formal memo titled "Notice to Explain" is issued
to the involved personnel. They are required to submit an explanation of
the incident or complaint within 24 hours of receiving the notice.
3. Hearing/Investigation:
A formal meeting or hearing is organized with the Management Committee,
the complainant, and the concerned staff. Each party has the opportunity
to present their perspective on the complaint or incident.
4. Committee Review and Findings:
The Management Committee will review the findings from the
investigation, analyze the event, and discuss potential preventative
measures that could have mitigated the incident.
5. Recommendations Submission:
The Committee submits its findings, insights, and recommendations to the
Chief Executive Officer for evaluation and final decision-making, including
the application of disciplinary action, if necessary.

Incident Reporting and Analysis of Adverse Events:

Definition:
An "Incident" refers to any occurrence that may have compromised patient
safety, service quality, or operational integrity. An "Adverse Event" is an
unintended injury or complication resulting from medical care.

Policy:

The organization is dedicated to proactively identifying, reporting, and analyzing

incidents and adverse events to improve safety and service quality. All incidents,
near misses, and adverse events are recorded and reported promptly to the
Quality Management Committee.

Process for Reporting Incidents and Adverse Events:

 1. Immediate Reporting:
Staff members are required to report incidents or adverse events to the
supervisor or directly to the Quality Management Committee within 24
hours.
2. Documentation of Incidents:
A detailed Incident Report Form will be completed, documenting the
nature of the incident, those involved, the potential cause, and the
immediate actions taken.
3. Investigation:
The Quality Management Committee will conduct a thorough investigation
of the incident or adverse event. This includes interviews with relevant
personnel, reviewing medical records, and analyzing procedural gaps.
4. Root Cause Analysis:
A root cause analysis (RCA) will be performed to determine the underlying
factors that contributed to the incident. The RCA will focus on system-
based solutions rather than individual blame.
5. Recommendations and Corrective Actions:
Based on the investigation findings, recommendations will be made to
prevent recurrence. This may involve process improvements, staff
retraining, or changes in protocols.
6. Reporting to Leadership:
Findings and recommendations are reported to the Chief Executive Officer
and the Management Committee. Regular updates and final resolutions are
discussed in monthly quality review meetings.

Monitoring and Continuous Improvement:

 Incident and complaint data will be regularly reviewed to identify trends or

recurring issues.
 Feedback from patients and staff will be incorporated into improvement
plans.
 All processes related to incident reporting, adverse event management,
and complaints will be evaluated and updated as necessary to ensure
ongoing service improvement.
C. Reporting System for Adverse, Unplanned or Untoward Events
POLICY
To report, document and monitor adverse drug reaction that occur within the
facility population
PURPOSE
To establish a mechanism that adverse drug reaction are systematically reported
and reviewed.

RESPONSIBILITY
Nurses, Ophthalmic Technicians, Physician

PROCEDURE
1. Any staffs who witness a suspected drug reaction will notify nurse on
duty.
2. The nurse on duty will immediately contact the attending physician and
Charge nurse to report the possibility of an adverse drug reaction.
3. The nurse on duty will complete the nursing section of the Adverse Drug
Reaction Report.
4. The physician will examine the individual, order necessary intervention, if
needed and will complete the medical section of the Adverse Drug
Reaction Report.
5. The report will be kept for evaluation by the management and will be
discussed and presented on a scheduled meeting
6. The management will evaluate each report and when appropriate will
make recommendations for further evaluation and submit to DOH
 ADVERSE DRUG REACTION REPORT

PART 1 (To be completed by Nurse on Duty)

PATIENTS NAME:________________________________________
DATE OF ADR:________________

Description of Reaction:

Current and Recent Medication (include dose and frequency)

1.__________________________________________________________

2.__________________________________________________________

3.__________________________________________________________

Signature of Nurse on Duty: Date:

___________________________ ______________

Page 2 ADVERSE DRUG REACTION REPORT

PART II (To be completed by Physician)

Summary of Clinical conclusions (include relevant medical and laboratory data)

Specify implicated suspected drug:

Recommendations/ Action taken

Signature of Nurse on Duty: Date:

___________________________ ______________
Page 3 ADVERSE DRUG REACTION REPORT

PART III (To be completed by CEO/MANAGEMENT HEAD)

ASSESSMENT OF ADR
1. TYPE (check one)
A.__________Type A reactions are result of an exaggerated, but otherwise
normal pharmacological action of a drug given in the usual therapeutic closes.

B.___________ Type B reactions are totally aberrant effects that are not to be
expected form known pharmacological actions of a drug when given in the
usual therapeutic doses to a patient whose body handles the drug in the
normal way.

Reactions was responded to appropriate? [ ] YES [ ] NO

Management Review and Recommendations:

Refer to Medical Director [ ] YES [ ] NO

Report to DOH [ ] YES [ ] NO

Report to Manufacturer [ ] YES [ ] NO
_______________________________________
Signature of CEO / Date