Transformational Leadership (TL) SOE
1. Patient Workflow Guide
AIM: Improve Patient Experience in PSCC Outpatient Department
Survey was conducted and result shows that only 74% patient responded YES on the question
“Are you satisfied with the Clinic flow guide on your visit?
OPD Nurses recognize lack of appropriate structure and process.
The UBC escalated to the Nursing Leadership and gained support to conduct a multidisciplinary
Quality Improvement Project.
QI project was created in Dec 2021.
Jan 2022 we created a Guide
February 2022 Educate staff, series of in-services was done
March 2022 Intervention was completed and we launch the project.
Outcome: Post intervention was conducted using the same survey tool.
April – Oct 2022 – We maintain a 100% satisfied and over above 95% for seven consecutive
months.
Structural Empowerment (SE) SOE
1. Anticoagulation QI
AIM: Improve Patient Education related to Anticoagulation Therapy
OPD Nurses in Anticoagulation clinic expressed concern about the knowledge deficit among
patient regarding prescribing warfarin therapy (Some patient is self-medicating, not attending their
appointments, also consume medications and foods that intervene with warfarin) which result of not
achieving INR target.
Clinical Nurse Erica discussed the issue to NQC and MMU committee, then she obtain an
approval to develop improvement plan.
April –May 2023 – Pre Intervention (Data Collection: Survey was done with a Question: Are you
Satisfied with your overall knowledge about anticoagulation therapy?) initially 20% of patient is satisfied
June – August 2023 – Intervention (Provide education, pamphlet, Coagulation workflow was
Implemented, Warfarin Therapy policy created)
Sept – Nov 2023 – Post Intervention (After completion of all intervention, a significant increase
of patient replied YES to the survey, up to 96% in October and November 2023.
2. Patient Experience (Service Excellence in OPD)
Our DON Majed and our CD Maha reviewed the OPD performance and notice a decrease in
Press Ganey patient experience regarding “Friendliness and Courtesy of the nurse”
Maha Received feedback from OPD nurses regarding difficulty in communication in managing
patient frustration.
Maha collaborate with Cristina (Nurse Educator) to develop action plan.
In Nov 2022, Service Excellence Program was completed. Maha disseminate information and
awareness to staff regarding MODHS Principle
