JOBDESK

QUALITY AND PATIENT SAFETY COMMITTEE

1. Ensure reliability of quality planning and patient safety with techniques and tools in carrying out
such activities;

2. Ensure the improvement of the quality and safety of patients through socialization, facilitation and
audit activities involving the participation of the parties in based on their respective accountability;

3. Ensuring the implementation of risk management effectiveness, especially service and

management activities to reduce the number of risks and affect the quality improvement and patient
safety;

4. Ensure good communication and relationships with partners related to quality accreditation and
patient safety;

5. Conducting data validation to ensure reliability of information on achievement of quality indicators

and patient safety;

6. Carry out counseling and coordination with the accreditation supervisor in doing surveillance in
realizing the fulfillment of the quality standard and patient safety that have been established;

7. Set policies, strategies and procedures of quality management;

8. Collate the quality indicators and patient safety;

9. Collate a quality improvement program and patient safety;

10. Monitor and evaluate all of patient quality improvement and safety programs;

11. Socialize the achievement of quality and patient safety programs;

12. Coordinate the implementation of internal quality audits;

13. Coordinate the plan and schedule activities related to quality accreditation;

14. Facilitate internal and external counselors related to the implementation of quality accreditation;

15. Facilitate activities related to internal and external quality innovations;

16. Collecting data and analyze it, related to the achievement of quality and patient safety indicators;

17. Doing consultation with all units related to the implementation of quality improvement and patient
safety.

SECRETARY OF QUALITY AND PATIENT SAFETY COMMITTEE

1. Doing administrative activities of the quality improvement and patient safety program;

2. Collect and properly save data of quality indicators and patient safety every units;
 3. Schedule meetings, both routine and incidental;

4. Arrange patient safety round schedule to units;

5. Make a schedule of clinical quality data validation;

6. Prepare external and internal incident reports and periodic reports of KPRS Team activities;

7. Prepare quarterly and annual reports based on patient quality improvement and safety program;

8. Represents the leader of the KPRS Team if he/she is absent;

9. Coordinate the activities of all coordinators in patient safety unit and quality assurance unit;

10. Coordinate committee / team activities related to quality improvement and patient safety program;

11. Monitor and evaluate activities about the programs in committees / teams / units related to the
quality improvement and patient safety program;

1) QUALITY IMPROVEMENT TEAM

1. Collate policies and strategies for quality management;

2. Collate the quality indicator programs;

3. Coordinate with related units to collate other quality improvement programs;

4. Coordinate with the SPI (Internal Supervisory Staff) for the preparation of internal quality audit
tools;

5. Monitor the implementation of all quality improvement programs;

6. Evaluate the implementation of all quality improvement programs;

7. Collate the report about achievement of indicators;

8. Socialize the achievement of quality improvement program;

9. Facilitating the follow-up of recommendation results;

10. Make the schedule of national accreditation activities;

11. Coordinate the plans of national accreditation activities;

12. Facilitate the meetings related to the implementation of national accreditation;

13. Facilitate the internal and external mentor regarding the implementation of national accreditation;

14. Coordinate with patient safety team and all unit to making RCA (Root Case Analysis) and FMEA
(Failure Mode and Effect Analysis) ;

15. Coordinate with patient safety team and related units with quality and patient safety mentor;
 16. Facilitate activities related to the implementation of innovation development and quality control
cluster;

17. Facilitate monthly meetings with directors and related units;

18. Coordinate to related committees / units about the implementation of patient-focused service
standards and management;

19. Attend meetings, workshops, and seminars related to the development of internal and external
clinical quality.

COORDINATOR OF CLINICAL QUALITY

1. Create a strategic plan for clinical quality improvement program;

2. Collate monitoring guidelines for clinical quality indicators;

3. Establish technical matrix and monitoring methodology of clinical quality indicator;

4. Prepare the measuring instruments for monitoring clinical quality indicators;

5. Coordinate with related units in monitoring of clinical quality indicators;

6. Analyzing the outcomes of clinical quality indicators;

7. Comparing the monitoring results of clinical quality indicators periodically with national standards
and other similar hospitals;

8. Make periodic reports of monitoring results of clinical quality indicators;

9. Completed and prepared internal hospital socialization activities on the achievement of clinical
quality indicator;

10. Collate recommendation matter on the achievement of clinical quality indicators;

11. Distribute recommendation matter about monitoring results of clinical quality indicators to related
units;

12. Make recaps and follow-up evaluation reports of recommendations from related units;

13. Doing internal and external communications about the achievement of the quality & patient safety
program to related units within internal and external hospitals by mail/ email / phone;

14. Assisting coordination in internal and external activities of the quality improvement team program;

15. Attend meetings, workshops, and seminars related to clinical quality development both internal
and external hospitals;

16. Collate internal data validation guidelines for clinical quality indicator;

17. Establish a validation tool for specific clinical quality indicators;

 18. Doing validation activity of clinical quality indicator achievement result in coordination with related
units;

19. Doing comparative analysis of internal validation results with data of related unit;

20. Create a report of internal validation results of clinical quality indicator;

21. Creating innovation programs and internal quality control groups;

22. Coordinate the implementation of development, innovation and quality control cluster;

23. Coordinate refreshment programs and training of quality control clusters;

24. Make the reports of innovation development activities and quality control clusters;

25. Coordinate to relevant departments/units related to the implementation of patient-focused service

standards.

COORDINATOR OF MANAGEMENT QUALITY

1. Create a strategic plan of management quality program;

2. Collate monitoring guidelines for management quality indicators;

3. Create technical matrix and monitoring methodology of management quality indicator;

4. Collate measuring tools for monitoring of management quality indicators;

5. Coordinate with related units to monitoring of management quality indicators;

6. Analyzing the results of management quality indicators achievement;

7. Comparing of monitoring results of clinical quality indicators periodically with national standards
and other similar hospitals;

8. Make periodic reports of monitoring results of management quality indicators;

9. Completed and prepared internal socialization activities of the hospital about the achievement of
management quality indicators;

10. Collate recommendation matter about the achievement of management quality indicators;

11. Distribute recommendation matter about the monitoring results of management quality indicators
to related units;

12. Make recaps and follow-up evaluation reports of recommendations from related units;

13. Doing internal and external communications about the achievement of the PMKP program to
related units within the internal and external environment by mail/ phone;

14. Assisting coordination in internal and external activities of the quality improvement team program;
 15. Attend meetings, workshops and seminars related to the development of internal and external
management quality of the hospital;

16. Collate internal data management validation guidelines for quality management indicators;

17. Establish a validation tool for specific quality management indicators;

18. Doing validation activity of clinical quality indicator achievement result by coordination with related
unit;

19. Doing comparative analysis of internal validation results with related unit data;

20. Make specific internal validation outcome report of the quality management indicators;

21. Creating innovation programs and internal quality control groups;

22. Coordinate the implementation of development, innovation and quality control cluster;

23. Coordinate refreshment programs and training of quality control clusters;

24. Make the reports of innovation development activities and quality control clusters;

25. Coordinate to related departments/units on the implementation of patient-focused service

standards.

2) PATIENT SAFETY TEAM

1. Establish a patient safety target policy;

2. Responsible to the Director of Hospital for the implementation of hospital patient safety activities;

3. Establish policies related to hospital patient safety program;

4. Establish a hospital patient safety program;

5. Planning the training of KPRS members;

6. Coordinate with other units to implement the KPRS program;

7. Monitoring and evaluate the activities of all members of KPRS;

8. Give recommendation to resolve patient safety issue to the Director of Hospital for follow-up.

COORDINATOR OF INVESTIGATION

1. Accept and re-analyze any event;

2. Give the solution of the problem submitted to the KPRS Team Leader;

3. Monitoring and evaluate to every units about the implementation of the patient safety program
related to the investigation; and
 4. Create periodic reports and specific reports of investigative activities.

COORDINATOR OF REPORTING

1. Receiving and recording all data of events by the unit;

2. Categorize the types of reports received;

3. monitoring and evaluate the implementation of patient safety programs related to incident
reporting;

4. Prepare periodic and specific reports with reporting activities.

COORDINATOR OF EDUCATION AND TRAINING

1. Establish training programs for members of the KPRS Team;

2. Establish an orientation program for new staff;

3. Establish patient safety awareness programs for all staffs;

4. Create an internal training schedule;

5. Monitoring and evaluate about the patient's safety culture to staffs; and

6. Create periodic reports and specific reports about the implementation of patient safety related
training programs.

COORDINATOR OF PATIENT SAFETY OFFICER

1. Doing the patient's safety target;

2. Socializing the patient's safety target in every unit;

3. Make a patient safety incident report;

4.Doing Simple investigation of patient safety incidents;

5. Recording Incidents of Patient Safety;

6. Report all patient safety incidents to the leader of KPRS Team.

3) RISK MANAGEMENT TEAM

1. Establish a risk management program based on the organization's mission and plans, as well as
the needs of patients, communities, and staff;
 2. Carry out management processes using current practice guidelines, medical service standards,
scientific literature and other information based on practicum, as well as in accordance with sound
business practices and relevant to current information;

3. Coordinate the identification processes of risk;

4. Make scoring and risk-priority setting for every units;

5. Coordinate with Patient Safety team in case of KTD (not desirable incident) response;

6. Evaluate KNC (almost injured incident) and high risk process which can change it being sentinel
incident;

7. Doing RCA and /or FMEA activities for an incident that leads to high and sentinel risk;

8. Monitoring and evaluate to every units about the implementation of risk management program of
hospital and management of related matters;

9. Monitoring and make specific reports on risk management activities including RCA and FMEA
reports

COORDINATOR OF CLINICAL RISK

1. Establish a risk management program based on organization's mission and plans, as well as the
needs of patients, communities, and staff;

2. Carry out management processes using current practice guidelines, medical service standards,
scientific literature and other information based on practicum, as well as in accordance with business
practices and relevant to current information;

3. Ensuring the identification of clinical risks;

4. Ensuring the scoring and priority setting in every unit;

5. As counselor and coordinate with the patient safety team in case of KTD's response;

6. Monitor and evaluate KNC (almost injured incident) and other high processes that may change it
being sentinel incident;

7. Coordinate the implementation of RCA and/or FMEA activities for an incident that leads to high risk
and sentinel;

8. Coordinate monitoring and evaluation of every units about the implementation of risk management
programs of hospitals and management from other related matters;

9. Prepare periodic and specific reports on risk management activities including RCA and FMEA
reports
COORDINATOR OF NON-CLINICAL RISK

1. Establish of non-clinical risk management program based the organization's mission and plan, and
meet the needs of patients, communities and staff;

2. Doing non-clinical risk management processes using current practice guidelines, medical service
standards, scientific literature and other information based on clinical practice design, and in
accordance with business practices relevant to current information;

3. Doing identification processes of non-clinical risks;

4. Doing scoring and establish non-clinical risk priorities across units / installations / sections;

5. Coordinate with patient safety team in case of KTD investigation;

6. Evaluate KNC and other high risk processes that may change it being sentinel events;

7. Doing RCA and / or FMEA activities for an event that leads to high and sentinel risk;

8. Monitoring and evaluate to every units about the implementation of non-clinical risk management
program of the hospital and management from other related matters;

9. Prepare periodic and specific reports on non-clinical risk management activities including RCA and
FMEA reports

PIC

1. Establish PMKP(Quality & Patient safety Committee) Program

2. Collecting quality data from monthly data collectors;

3. Analyze the quality data collected in the unit every month;

4. Report quality data that has been analyzed every month to the Person in charge;

5. Prepare FOCUS PDSA if indicator is not reached;

6. Reporting the Patient Safety Incident to the KPRS Reporting Coordinator;

7. Doing regular meetings related to Quality and Patient Safety;

8. Applying the quality improvement and patient safety plan;

9. Doing identifying risk process in every unit;

10. Doing a simple analysis of existing risks;

11. Monitoring and evaluate of risk programs in the units under its responsibility;

12. Periodically report the results of the risk management program evaluation to the risk manager
ACTIVITIES OF QUALITY & PATIENT SAFETY PROGRAM IN HOSPITAL

1. Establish the priority activities which will be evaluated

2. Share the activities result of PMKP program

3. Education & Learning program of PMKP – or it can be combined with Education & learning
program of hospital

4. Implement of Clinical Practice Guidelines – Clinical Pathway in priority areas

5. Establish the Key of Quality Indicator – Clinical Area Indicator (11 Clinical area), Management
Area Indicator (9 Management Area), Patient Safety Area Indicator (6 Patient Safety Target)

6. Quality Indicator of unit – PMKP program in every unit

7. Assessment of clinical staffs & hospital staffs

8. Monitoring the implementation of PPI