Policy for quality and risk management

1. The Establishment’s Medical Commission (CME) which validates annual targets for deploying the quality and risk management policy

2. A Quality Steering Committee / department managers

It is composed of all department managers (representative from radiotherapy, hospitalisation, radiophysics, pharmacy, admissions, and administration departments), meeting every month to develop quality and treatment safety in every sector.

The Quality Steering Committee meets at least every month and sometimes more often, depending on the projects underway; it ensures the management of ongoing quality improvement within the scope of its missions to:

• Define Quality Assurance priorities (audits, assessments) and coordinate actions to be implemented.
• Ensure management of HAS Certification process with allocation of themes per manager
• Ensure the coordination and monitoring of action plans
• Organise the setting up of working groups
• Validate all the steps and processes

3. COVIRIS

3.1 This committee is tasked with defining priorities with regards to risk management and coordinating the different resources involved in the prevention and management of risks:

• Patient risks (major risks linked to treatments)
• Establishment risks (linked to equipment, infrastructure, etc.)
• Professional risks

3.2 Its operation is based on:

• a specific consultant, Dr. Assouline, who provides information and coordinates the management of clinical risks for patients as well as heading the management of the medical staff.
• monthly meetings to ensure that declarations of undesirable events are processed.
• CREX: permenant working groups in radiotherapy and medication circuit which meets every two months.
• the Mortality and Morbidity Review: set up for hospitalisation in 2010, in addition to the CREX.

3.3 Priorities defined by COVIRIS:

• Make the medication circuit secure
• Make computerised patient files secure
• Reinforce patient identity vigilance, especially in radiotherapy
• Promote a culture of treatment safety
• Monitor indicators and dashboards

4. Coordination

Coordination between the Steering Committee and COVIRIS is ensured by a core of professionals participating in both committees who are involved in the development of quality and management policy.

Coordination is also ensured with the CME for managing EPP processes under the supervision of the Chairman of the CME, who deploys evaluations of professional practices in every Clinic sector in line with the quality and risk management programme.

Different aspects of quality management have been assigned to managers sitting on the Steering Committee who are tasked to work with their teams and resource persons on the identification of risks and feeding the quality account which is validated by the Executive Committee and the CME.

The Center’s quality and treatment safety policy is defined around 5 development priorities:

1. Organise, steer and coordinate Quality and Treatment Safety management based on the process management and ISO Certification. This especially includes coordination of healthcare vigilance and monitoring undesirable events, FSEI, CREX and patient complaints by involving service users in these processes.
2. Computerising document management: Updating procedures with regards to frames of reference for best practices.
3. Communicating and handling information: ensure that quality procedures are generally adopted and that each professional embraces the policy by developing a culture of treatment safety.
4. Encourage the policy for evaluations of professional practices
   The “Centre de Cancérologie de la Porte de Saint-Cloud” has integrated its procedures for the Evaluation of Professional Practices (EPP) in its quality and treatment safety policy. It is also taken into account in treatment and medical projects.
   The EPP programme is discussed and validated by the extended CME under the aegis of the CME Chairman, selected as the EPP correspondent. The choice of EPPs takes into account strategic guidelines, PAQSS (programmes for quality and treatment safety actions), the concerns of professionals with regard to quality and patient safety, and requirements of the HAS, INCA and ASN, etc.
5. Draw up, implement and monitor the annual quality improvement programme through an efficient, dashboard driven policy. This process can be part of a Benchmarking approach with other structures.

The choice of EPP themes reflects the Center’s desire to deploy evaluations in all activity sectors and for healthcare and specific practices at the establishment as well as meeting the requirements of supervisory bodies: ARS, INCA, HAS, etc.

A medical manager was appointed for each EPP. Depending on the theme, different professionals joined in to successfully complete these evaluations.

The Chairman of the CME is designated as the EPP correspondent. He ensures the coordination and monitoring of processes undertaking in association with colleagues for medical EPPS and with the health executive in medical oncology and chemotherapy and the radiotherapy executive for paramedical EPPs.

The state of progress is regularly monitored and reported back to the Steering Committee and EPP correspondent. Re-evaluation is made according to studies carried out or scheduled in the aim of measuring the impact of improvement actions ensuing from various implemented studies.

Clinical practice indicators are integrated in the EPP programme and will be reinforced with the development of dashboards at the “Centre de Cancérologie de la Porte de Saint-Cloud”.

Information is given to professionals via a letter, or by the institutional bodies or through their participation in working groups. Depending of the state of progress of each study, the results are then disseminated.

EPP development strategy is reviewed every year by the CME in line with challenges faced by the Center and issues regarding the patient experience.