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MEDINOVA DIAGNOSTIC CENTRE Document #:
LABORATORY MDC/LAB/I-001
QUALITY IMPROVEMENT PLAN
Revision #: 2 Page 1 of 11
1. Mission, Vision
VISION:
To become the Diagnostic Centre of choice for those who are seeking high quality and
affordable Medical Diagnostic Services in Dubai.
MISSION:
To provide the highest quality care with outstanding values and superior customer service.
This will be achieved through ongoing development, implementation and evaluation of quality
control methods appropriate to each department; testing performed efficiently and accurately;
and continuous evaluation and revision of current laboratory procedures.
2. Background.
Excellence serves as the guide for our commitment to performance improvement and patient safety.
The Clinical Laboratory Department is committed to the Mission and Vision of Medinova Diagnostic
Centre (MDC).
STRATEGIC DIRECTION:
The strategic direction of the MDC Quality Management Program will be based on accreditation
standards, principles of good quality management practices and the expectations of the Dubai Health
Authority (DHA) in the reporting and the audit/inspection of the quality processes.
Our expectations are well outlined and driven by the expectation of maintaining international
accreditation and the underlying principles as given by our Mission, Vision and Values.
CRITICAL SUCCESS FACTORS:
 The administrative support that will be required to continue to meet the accreditation
expectations.
 The continued fostering of a team approach to continuous improvement.
3. Our Guiding Principles.
 We treat our patients as we would our family members.

 We are prudent, honest, and ethical in all our dealings.
 We work as a team.
 We continually improve the quality of everything we do.
CONTROLLED DOCUMENT
MDC Related forms: Yes [ ] No [ ]
Issue Date: Feb. 2008 Next Review Date: Feb. 2011
Review date: march 2013 Next review Date: March 2015
 We maintain a happy working environment with respect and mutual trust.

 We encourage professional development and innovation through a constant process of
learning.
 We provide efficient services to bring value to our external and internal customers.
4. Quality Philosophy.
MDC believes that the safety and quality of our service delivery is our highest priority. We believe that to
achieve this priority, we must subscribe to a culture of continuous quality improvement through TQM, a
discipline and philosophy of management which institutionalizes planned and continuous improvement,
and assumes that quality is the outcome of all activities that take place within an organization. MDC
further believes that the focus of improvements should be on systems and processes rather than on the
individual that all functions and all employees have to participate in the improvement process, and that
organizations need both quality systems and a quality culture.
5. Scope.
The scope of the Performance Improvement Program includes an overall assessment of the efficacy of
performance improvement activities with a focus on continually improving services provided, and patient
safety practices conducted, throughout the centre.
The program consists of these focus components:
 performance improvement,
 patient safety, and
 quality assessment/improvement and quality control activities.
These indicators are objective, measurable, based on current knowledge and experience and are structured
to produce statistically valid performance measures of care provided. This mechanism also provides for
evaluation of improvements and the stability of the improvement over time.
6. Goals and Objectives.
MDC Quality Management Program Goals.
To support the mission and vision of the centre, the following goals and objectives have been
adopted.
To promote a safe environment for patients and staff
To facilitate a culture of quality throughout the laboratory.
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To provide a systematic approach to performance improvement activities
To promote high quality, cost effective services through the development and implementation of
Policies, Procedures and Guidelines.
Maintain JCI accreditation status.
Promote effective communication.
Foster staff education processes.
Improve employee relations and promote employee satisfaction.
Ensure all DHA and other regulatory requirements are included in performance measures.
Establish priorities for performance improvement activities.
Committees:
To define the centre committee structure to promote effective communication.
In support of the program the centre will have the following committees:
 Senior Management Committee
 Quality Committee
 Safety and Infection Control Committee
JCI Accreditation:
To maintain JCI accreditation status.
Policies and Procedures:

To standardize the system for developing, reviewing and communicating policies and procedures.
To facilitate the development of all JCIA, DHA and other regulatory, patient care and operational
policies, procedures, guidelines and plans.
Risk Management:
To establish a risk assessment processes and aggregate data for risk management.
To implement a Risk Program to manage potential risk exposure associated with new or modified
processes/systems/services.
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Client Complaints:
To manage and use client feedback data for continuous quality improvement of delivered services
through client complaints and satisfactory survey processes.
Occurrence Variance:
To implement a standardized monitoring system for untoward occurrences.
Quality Education and Training:

To promote quality education and training initiatives for centre staff
Quality Culture:
To develop a culture of continuous improvement across the organization.
Performance Indicators:
To use performance monitoring and internal and external benchmarking as tools of change for
improvement. (please see attached list of indicators)
7. Quality Model.
The MDC Quality Model focuses on the customer (be they internal or external customers), supported by
structures, processes and outcomes.
STRUCTURES both external and internal form the foundation of the model.
External structures are the organizations and processes which impact on MDC,
and over which MDC have little or no control. Examples of these include DHA, MOH,
accreditation agencies, UAE laws such as building codes, as well as community
expectations.
Internal structures are organizational components over which MDC as an

organization does exert control, such as Vision / Mission , ethics, the various plans we
have in place to guide our documentation requirements such as By-laws, PPG, various
resources be they human, financial, or material; education, leadership and our committee
structure.
MDC Senior Management Committee.
Senior Management Committee is composed of members from the centre and from DM
Healthcare. The committee has ultimate responsibility for the quality and safety of all
services delivered by MDC staff members.
Quality Committee.
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The committee is responsible for developing, implementing, and maintaining a viable

Quality Improvement Plan.
The Quality Information Flow Model:

The model describes how information regarding identified quality improvement
activities can flow upwards from grass roots levels through the appropriate committee
structure to Senior Management Committee, or downwards from Senior Management
Committee through the same channels.
PROCESSES complement structures as the next layer of the quality model, and include
such aspects as written and verbal communication, team work, coordination, training, and
monitoring using FOCUS-PDCA.
OUTCOMES result from structures and process combining together to produce

satisfactory results – such as patient safety, quality care, patient / staff satisfaction, risk
management and utilization management.
8. Document Control.
All documents affecting quality shall be checked, authorized, distributed and administered. The system
ensures that accurate and current documents are available for the employee at the right place at the right
time. The documents can be available in written form or as electronically stored data.
Extra care should be taken to ensure confidentiality of patient information when disposing of information
and charts in line with MDC policies.
9. Methodology.
MDC’s approach to quality improvement and safety:
Find Organize Clarify Uncover Start Plan Do Check Act (FOCUS-PDCA) Model:
Whenever MDC staff are engaged in performance improvement and patient safety initiatives,
they must begin by listening to all customers (the voice of the consumer), focus on the processes
that these customers experience (the voice of the process), and then use statistical process control
methods to evaluate the variation that lives within the processes.
1. Find: a process improvement opportunity.

 Key Performance Monitoring Data
 Day to day observations
 Internal and external customer feedback
2. Organize: a team who understands the process

 Identify Internal/ External customers to the process
 Organize a team that knows the process
 Include technical guidance and support people as required
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3. Clarify: the current knowledge of the process

 Identify customers needs
 Identify boundaries
 Draw the actual flow of the process
 Identify areas and functions that affect the process
 Identify the best way for the current process to work
4. Uncover: the root cause of Variation/ Poor outcome

 Identify the major causes of variation or poor quality
 Identify key measurable characteristics
 Identify the what, where, when and how the data be collected
 Decide on type of causes “common cause versus special cause variation
 Find out which cause of variation can be change to improve the process
5. Select the improvement

 Identify the proposed process portion to be improvement
 Write the mission statement
 Identify the most feasible changes to the process
6. Plan: The Improvement

 Identify what process improvement to be piloted
 Set predictions
 Plan to carry out the cycle (who, what, where, when)
 Plan for data collection
7. Do: Put the plan into action:

 Carry out the plan
 Document problems and unexpected observations
 Do it first on a small scale
8. Check: Evaluate and re-evaluate the effectiveness of the plan:

 Analyze the data
 Compare data to predictions
 Summarize what was learned
 Decide whether the process was improved from the customer’s point of view
9. Act: Determine what the next steps are to improve performance:

 To hold the gain
 Adopt
 Adjust
 Or abandon the change then,
 Modify the plan and retest.
 Standardize parts of the process that improved
 Decide on next steps to continuously improving this process
10. Prioritization Quality Measurement System and Improvement Activities.

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The criteria used to prioritize quality measurement and opportunities for improvement include:
 High risk
 Problem prone
 Government requirements
 High volume
 High cost
Quality improvement and safety activities may be reprioritized based on significant organizational
performance findings or changes in regulatory requirements, patient population, environment of care, and
expectations and needs of patients, staff, or the community.
The outcome measure/ indicators of any quality improvement activity should reflect improvement in
one or more of the following:
 Efficacy
 Appropriateness.
 Availability.
 Timeliness.
 Effectiveness.
 Continuity.
 Safety.
 Efficiency.
 Respect and caring.
11. Confidentiality Statement
All information, reports, minutes, statements or other memoranda or data which serve or are the outcome
of the quality assessment and improvement process shall be considered privileged and strictly confidential
in their entirety. Such material shall be used only for the evaluation and improvement of patient care.
12. Periodic Review of the Plan.
A review every 2 years will be completed by the Senior Management Committee to determine the success
in the implementation of the plan. Results will be utilized in revising the plan.
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Revision #:2 Page 8 of 11
APPENDIX 1
2007 International Patient Safety Goals
MDC promotes the following patient safety goals
Medinova Diagnostic Centre (MDC)
At MDC we promote the following International Patient Safety Goals
Goal 1. Identify Patients Correctly

1a. Use at least two (2) ways to identify a patient when giving medicines, blood, or
blood products; taking blood samples and other specimens for clinical testing; or
providing any other treatments or procedures. To meet this goal MDC Laboratory
staff are expected to use 2 patient identifiers before specimen collection:
Identifier 1: Patient Name
Identifier 2: laboratory number
All samples will bear bar coded labels.
Goal 2. Improve Effective Communication

2a. Implement a process/procedure for taking verbal or telephone orders, or for the
reporting of critical test results, that requires a verification “read-back” of the
complete order or test result by the person receiving the information.
To meet this goal when giving results on the phone MDC laboratory staff will
require the receiver of the results to read back the results provided on the phone.
Goal 5. Reduce the risk of health care–associated infections.

5a. Comply with current published and generally accepted hand hygiene
guidelines.
To meet this goal, MDC staff are required to follow hand hygiene guidelines
CONTROLLED DOCUMENT
Revision Date: March 2013 Next Review date: March 2015
Revision Date: April 2014 Next Review Date: April 2016
Quality Improvement Indicators list
1 MGT.4.2.1 (A) Blood culture contamination

2 MGT.4.2.1 (A) Hand washing observation
3 MGT.4.2.1 (A) Hand washing facility
4 MGT.4.2.1 (A) Needlestick injury
5 MGT.4.2.1 (B) Refrigerator teperature check
6 MGT.4.2.1 (B) Internal QC completion rate
Sysmex
Biorad D10
Alera
Alfa 600
Axsym
Architect
Starlyte
7 MGT.4.2.1 (B) Out of control rate
Sysmex
Biorad D10^
Alera
Alfa 600
Axsym
Architect
Starlyte
8 MGT.4.2.1 (B) Timeliness of corrective action
9 MGT.4.2.1 (C1) Pre-procedure requirement
10 MGT.4.2.1 (C2) Rejected samples
11 MGT.4.2.1 (C3) Completeness of requisition
12 MGT.4.2.1 (C3) Order entry errors
13 MGT.4.2.1 (D1) Panic values
Turn around time
Documentation of read back
14 MGT.4.2.1 (D2) TAT Urgent / Stat
TAT for RBS
15 MGT.4.2.1 (D2) TAT for Potassium^^
16 MGT.4.2.1 (D2) TAT for Troponin I
MGT.4.2.1 (D3) Documentation of read back
17 MGT.4.2.1 (D1) Adequacy of documentation
18 Rerun log % of Total tests
Rerun % of Total
MGT.4.2.1 (D4) No. of significant differences (%)
19 MGT.4.2.2 (A) Patient satisfaction survey
20 MGT.4.2.2 (A) Doctor's satisfaction survey
21 MGT.4.2.2 (A) Client complaint rate
22 MGT.4.2.2 (B) Tests sent out rate
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23 MGT.4.2.2 (B) Type of tests sent out

24 MGT.4.2.2 C Out of stock rate
Reagents
Controls
Other supplies
25 MGT.4.2.2 D Staff satisfaction rate
26 MGT.4.2.2 D Staff turnover rate
27 MGT.4.2.2 E Statistics
Total no. of requests
28 MGT.4.2.2 E Monthly lab revenue
29 MGT.4.2.2 E Annual profit growth rate
30 MGT.4.2.2 F Laboratory Chemical spill incidents
31 MGT.4.2.2 F OVR
32 MGT.4.2.2 F Use of one identifier
33 MGT.4.2.1 D1 Transcription errors
NEW KPIs
Time lag between billing & bar coding

TAT before & at Jubilee complex
Temperature monitoring of sample boxes
APPENDIX
Committee Structure
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DM healthcare
MDC Senior Management Committee

Members:
1. Ms. Alisha Moopen
2. Dr. Junaid Khan
3. Dr. Sunita Vaidya
4. Dr. Kulothungan
Meetings: Every 2 months
Quality Committee Infection Control and Safety

Committee
Members: Members:
1. Dr. Sunita Vaidya 1. Dr. Sunita Vaidya
2. Dr. Kulothungan 2. Dr. Kulothungan
3. Ms. Kriti Mankotia 3. Ms. Nazira Begum
4. Ms. Nazira Begum 4. Mr. Rahul
Technician
Meetings: Quarterly Meetings: Quarterly
APPROVAL
Name Signature Date
Prepared by: Nazira Begum, Assistant manager
Approved By: Sunita Vaidya, Laboratory Director
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MEDINOVA DIAGNOSTIC CENTRE Document #:

CRITICAL SUCCESS FACTORS:

3. Our Guiding Principles.

 We treat our patients as we would our family members.

 We maintain a happy working environment with respect and mutual trust.

6. Goals and Objectives.

MDC Quality Management Program Goals.

To promote a safe environment for patients and staff

To facilitate a culture of quality throughout the laboratory.

To provide a systematic approach to performance improvement activities

Maintain JCI accreditation status.

Promote effective communication.

Foster staff education processes.

Improve employee relations and promote employee satisfaction.

Establish priorities for performance improvement activities.

Policies and Procedures:

Quality Education and Training:

Internal structures are organizational components over which MDC as an

MDC Senior Management Committee.

The committee is responsible for developing, implementing, and maintaining a viable

The Quality Information Flow Model:

OUTCOMES result from structures and process combining together to produce

MDC’s approach to quality improvement and safety:

1. Find: a process improvement opportunity.

2. Organize: a team who understands the process

3. Clarify: the current knowledge of the process

4. Uncover: the root cause of Variation/ Poor outcome

5. Select the improvement

6. Plan: The Improvement

7. Do: Put the plan into action:

8. Check: Evaluate and re-evaluate the effectiveness of the plan:

9. Act: Determine what the next steps are to improve performance:

10. Prioritization Quality Measurement System and Improvement Activities.

11. Confidentiality Statement

12. Periodic Review of the Plan.

Medinova Diagnostic Centre (MDC)

At MDC we promote the following International Patient Safety Goals

Goal 1. Identify Patients Correctly

Goal 2. Improve Effective Communication

Goal 5. Reduce the risk of health care–associated infections.

Quality Improvement Indicators list

1 MGT.4.2.1 (A) Blood culture contamination

23 MGT.4.2.2 (B) Type of tests sent out

Time lag between billing & bar coding

MDC Senior Management Committee

Meetings: Every 2 months

Quality Committee Infection Control and Safety

Approved By: Sunita Vaidya, Laboratory Director

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