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Services
Both accreditation and risk management are two
functions assumed by AUBMC. The Accreditation and Risk Management Office
is entrusted to perform these two functions.
Accreditation and Compliance
The Accreditation and Risk Management Office coordinates the Medical
Center accreditation activities to ensure compliance with the required
accreditation standards both at the national and the international
levels. The main functions performed in this regard are:
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 Preparation and update of policies and
procedures and maintenance of multidisciplinary policy manuals (both
in hard and soft copies)
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Conducting staff education and awareness
programs to keep the Medical Center staff informed about changes in
the policies and standards
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Monitoring of a set of performance indicators
at the Medical Center level
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Participating in performance improvement
projects and task-forces
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Provision of follow-up reports to accreditation
agencies
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Oversight of other accreditation activities
through out the Medical Center
The Accreditation Office is charged with the
responsibility of tracking and monitoring the accreditation activities
of all facilities / services / programs in the Medical Center. The
Accreditation Office maintains updated records pertaining to
accreditation activities of other services in the Medical Center. These
records include:
The Accreditation Office conducts periodic reviews
to assess the level of compliance of the Medical Center services /
departments with the accreditation standards. For this purpose, the
actual performance of AUBMC staff is reviewed to assess the degree of
compliance with the established policies and procedures. The findings
are reported to the Medical Center leadership and governance through the
established organization structure.
Compliance review is conducted according to a set
schedule for the whole year. This schedule is amended as the need
arises.
Preparation of Policies and Procedures
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Medical
Data Analysis
 The services provided by the Medical Data Analyst
include:
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Database entry from several data sources,
updating the data on an ongoing basis
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Monitoring of Medical Center-wide indicators,
analysis, benchmarking, and reporting
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Provision of medical data analysis support to
other Medical Center services / departments
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Patient-Related Risk
Management
The Accreditation and Risk Management Office aims to promote the
patient safety throughout the Medical Center by implementing preventive
and responsive risk management techniques.
The Patient-Related Risk Management Plan at AUBMC
is a systematic, coordinated and continuous approach to risk
identification, analysis, reduction, avoidance, loss prevention and
control. In this regard, the following functions are carried by the
office:
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Management of patient-care complaints
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Provision of risk management training to the
Medical Center staff
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Handling of patient related occurrences
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Analysis of patient occurrences
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Benchmarking with available sources
The Accreditation and Risk Management Office
coordinates its activities with the Quality Management and Utilization
Review Program, Infection Control and Prevention Program, Safety Office
and the Medical Staff Office.
The Accreditation and Risk Management Office staff
conduct their review of patient-related occurrences in accordance with
the AUBMC policy on Patient-Related Occurrence Reporting and Management.
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Educational
Programs
 The
Accreditation and Risk Management Office provides staff education on
newly developed or revised policies and procedures to the concerned
AUBMC medical, nursing and other healthcare professional staff.
Other educational activities are also conducted on
specific patient care issues that are identified as a result of
root-cause analysis or upon receipt of new patient safety guidelines
from professional healthcare organizations.
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