QI-BD-17. H-D-SP-DPPM – Management Review (Hospital and Department Level)

QI-BD-17. H-D-SP-DPPM – Management Review (Hospital and Department Level)

Posted on April 29, 2012 by

Online Collaboration and Interactive Learning on Hospital and Department Safety Promotion and Disaster Preparedness Program

(OCIL-H-D-SP-DPP)

Question-Issues for Brainstorming and Discussion (April 30, 2012 to May 6, 2012)

QI-BD-17. H-D-SP-DPPM – Management Review (Hospital and Department Level)

We are now drafting /writing an operations manual for the safety promotion and disaster preparedness program of your respective hospital and department.  We started on January 16, 2012.

This operations manual will consist of the manual proper (The Safety Promotion and Disaster Preparedness Program Manual) and a supplemental manual (Supplementary Manual on Implementing Guidelines and Instructions).

I will guide you to the point of holding your hands in drafting / writing the operations manual, both the manual proper and the supplementary manual.

There are so many templates on writing the manual that one can use.  I will be using the template of the Canadian Standards Association (CZA) standards on Emergency Management and Business Continuity as a guide as it follows the template of ISO (International Organization for Standardization).  Below is the outline of the contents paralleling the content-template of ISO.

Contents

Preface

1.  Scope

3.  Definitions

4.  Program Management

5.  Planning

6.  Implementation

7.  Exercises, evaluation and corrective action

8.  Management Review

 

Instructions:

What I will do is to share with you a draft that I will make for each section of the primer using the fictitious ROJ Medical Center (ROJMC) as the name of the hospital. Your task is to adopt or adapt it by changing the name of the fictitious hospital that I created to the name of your hospital or your department.  You can also make refinements, additions and deletions as you deem needed in the context of your hospital or your department.

We are done with Scope and Definition of Terms, Program Management, Planning,  Implementation, and Exercises, Evaluation, and Corrective Action.  We are now in Management Review.

Here is a draft I made for the “Management Review” for ROJMC SPDPPM (Proper) at the hospital and department level.

Now, you make yours.

(We will do the Preface later, most likely when we finish with all the other parts of the manual up to Management Review.)

Dr Rey

April 29, 2012

——————————————–

Hospital Level

8.  Management Review

8.1 The SP-DPP and SP-DPPM shall be continually reviewed and updated at planned intervals at least once every 3 years before and during the strategic planning activity and anytime revision is deemed necessary by the SP-DPC for reasons of

  • improvement because of weaknesses, deficiencies, and flaws detected during exercises; actual emergencies and disaster incident management; self-assessment; and internal and external audits and
  • updating because of changing information and conditions in the hospital and community.

 

8.2 Evaluation of the SP-DPP shall be guided by the formulated vision, mission, and goals.

 

8.3 At the end of each year, the SP-DPC and the SP-DPAC shall assess the implementation of the annual operational plan of the SP-DPC and then submit a report to the governing body and top management.  The SP-DPC shall be asked to present a report of the annual assessment to the governing body and top management with information on outcomes of implementation of annual plan; areas for improvements identified; and recommended action plans for improvement.

 

8.4 At the end of a 3-year cycle, the SP-DPC and the SP-DPAC shall assess the implementation of the 3-year strategic plan of the SP-DPC and then submit a report to the governing body and top management.  The SP-DPC shall be asked to present a report of the assessment to the governing body and top management with information on outcomes of implementation of strategic and the yearly operational plans; areas for improvements identified; recommended action plans for improvement; and recommended changes for the SP-DPP.

 

8.5 For all areas of improvement identified during the yearly assessment and their corresponding recommended corrective and preventive action plans, there shall be end-action evaluation with corresponding reports.  These evaluation reports on continuous improvement of the SP-DPP shall be included in the annual performance reports and in the 3-year strategic performance reports.

——————————————————-

Department Level

8.  Management Review

8.1 The Department SP-DPP and SP-DPPM shall be continually reviewed and updated at planned intervals at least once every 3 years before and during the strategic planning activity and anytime revision is deemed necessary by the Department SP-DPC for reasons of

  • improvement because of weaknesses, deficiencies, and flaws detected during exercises; actual emergencies and disaster incident management; self-assessment; and internal and external audits and
  • updating because of changing information and conditions in the hospital and community.

 

8.2 Evaluation of the Department SP-DPP shall be guided by the formulated vision, mission, and goals.

 

8.3 At the end of each year, the Department SP-DPC and the SP-DPAC shall assess the implementation of the annual operational plan of the Department SP-DPC and then submit a report to the governing body and top management.  The Department SP-DPC shall be asked to present a report of the annual assessment to the governing body and top management with information on outcomes of implementation of annual plan; areas for improvements identified; and recommended action plans for improvement.

 

8.4 At the end of a 3-year cycle, the Department SP-DPC and the SP-DPAC shall assess the implementation of the 3-year strategic plan of the Department SP-DPC and then submit a report to the governing body and top management.  The Department SP-DPC shall be asked to present a report of the assessment to the governing body and top management with information on outcomes of implementation of strategic and the yearly operational plans; areas for improvements identified; recommended action plans for improvement; and recommended changes for the Department SP-DPP.

 

8.5 For all areas of improvement identified during the yearly assessment and their corresponding recommended corrective and preventive action plans, there shall be end-action evaluation with corresponding reports.  These evaluation reports on continuous improvement of the Department SP-DPP shall be included in the annual performance reports and in the 3-year strategic performance reports.

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