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Hospital & Health Care Consultants
Hospital & Health Care Consultants
Hospital & Health Care Consultants
“ The degree to which health services for
individuals and populations increases the
likelihood of desired outcomes and are
consistent with current professional
knowledge”
Institute of Medicine
Medical Quality
(Avedis Donabedian1970’s)
Measurement of quality
Structure
Stable characteristics of the providers of care,
tools and resources at their disposal
Process
Activities that go on between and within the
practitioners and patients
Outcome
Changes in health status attributable to
antecedent health care
Hospital & Health Care Consultants
I Should Quality Initiatives lead to Accreditation
OR
II Should Accreditation lead to quality initiatives
(TAKE YOUR PICK)
Hospital & Health Care Consultants
• Conformance to standards
Less mature
• An ongoing process of building and
sustaining relationships and properties of
deliverables by assessing, anticipating and
fulfilling stated and implied needs
• Error-free, value added care that meets or
exceeds the needs and legitimate expectations of
the served and serving
More mature
Hospital & Health Care Consultants
Medical Quality
Less mature
Quality Assurance
Continuous Quality Improvement
Total Quality Management
More mature
The Quality Continuum
Vision
Involvement
Focus
Scope
Triggers
Less mature
Current
Local
Niche Processes
Organisation Wide
External
Strategic Perspective
Global
Complete Processes
Community Wide
Internal
More mature
Defining
Quality
Hospital & Health Care Consultants
Policy Making
Structural Reorganization
Incentives
Quality Redesigning
Motivation
Benchmarking
QUALITY
ASSURANCE
Problem Solving
Management Actions
Standards setting
Monitoring systems
Supervision
Improving
Quality
Measuring
Quality
Quality
Evaluation
Regulation
Audit
Accreditation
Hospital & Health Care Consultants
Effectiveness
And
Efficiency
Optimum Utilization
of
Resources
Uniformity
In
Processes
Community
confidence
Improved
Health
Outcomes
Waste
Reduction
Reduced
Cost of
Healthcare
Safety and
risk reduction
Hospital & Health Care Consultants
A Voluntary Act
HEALTHCARE
ACCREDITATION
Defined Standards
Assessment by External Agency
An Effective
Quality
Improvement Tool
Organisational Commitment
Frame work for Quality
Assurance
Unbiased approach
Hospital & Health Care Consultants
Vision
Involvement
VOLUNTARY
ACT
Focus
Triggers
Hospital & Health Care Consultants
Physical facility and spatial associations
Equipments
Structural
Standards
Materials
Human resource
Hospital & Health Care Consultants
Policies
Process
Standards
Processes
Guidelines
Programmes/Plans
Hospital & Health Care Consultants
A visible commitment by organisation
towards quality of patient care
Safe working environment
Benefits
of
Accreditation
Resource Optimisation
Stimulates continuous improvement
Benefits all stake holders
Raises community confidence
Hospital & Health Care Consultants
I
Quality initiatives should lead to Accreditation
(Philosophy leading to the goals)
II Accreditation should lead to Quality initiatives
(The goal prompting and directing philosophy)
*NOW MAKE YOUR CHOICES*
Quality Improvement
Process
of
Accreditation
Hospital & Health Care Consultants
NO
Decision
YES
Obtain Standards
Comprehensive Review
Identify Gaps and Bridge it
Yes
Apply NABH for
Assessment
Is standards
Implemented and
Integrated
satisfactorily
No
Apply for re-assessment
Assessments by NABH
Is Assessment
Result satisfactory
Yes
NABH Accreditation
No
Receive recommendation
& act accordingly
Hospital & Health Care Consultants
Applying Accreditation Standards for Quality
Improvement
A systematic approach
Initiation
Documentation
Implementation
Monitoring
Hospital & Health Care Consultants
Sensitization
Constitution of teams
Initiation
Initiation
Understanding Standards
Customising Applicability
Action Plan
Hospital & Health Care Consultants
Policies
Processes
Guidelines
Criteria and protocols
Documentation
Programmes
Roles and Responsibilities
Formats for records and documents
Manuals
Organisational and departmental line of hierarchy
Hospital & Health Care Consultants
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Documentation topics
Registration policy and procedure
Admission policy and procedure
Transfer of unstable patients to
another facility
Transfer of stable patients to
another facility
Standardized initial assessment of
patients in the OPD, emergency
and IPD.
Processing and disposal of
specimens in laboratory.
Handling and disposal of
infectious materials
Identification and safe
transportation of patients to
imaging services.
Handling and disposal of radioactive and hazardous materials.
Safe use of radioactive isotopes
for imaging services.
Referral of patients to other
departments / specialties.
Discharge policy and process
LAMA policy and process
Informed Consent policy and
process
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Pricing Policy
Uniform care policy and
processes
Emergency care policy and
processes
Medico-legal cases
Triaging of patients
Uniform use of resuscitation
Rational use of blood and blood
products
Care of patients in ICU and HDU
Situation of bed shortage in
ICU/HDU
Care of vulnerable patients
Care of high risk obstetrical
patients
Care of paediatric patients
Prevention of child/neonate
abduction or abuse
Care of patients undergoing
moderate sedation
Administration of anaesthesia
Care of patients undergoing
surgical procedures
Prevention of adverse events
Hospital & Health Care Consultants
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Restraints techniques
Pain management guidelines
Rehabilitative services polices
Research activities policies and
protocols
Nutritional assessment and
reassessment
End of life care
Procurement, Storage, prescription
and dispensing of Medications
Administration of medications
Monitoring of medications
Patient’s self administration of
medication
Medication brought from outside the
organisation
Adverse drug events
Use of narcotic drugs and
psychotropic substance
Usage of chemotherapeutic agents
Usage of radioactive and
investigational drugs
Safe storage, preparation, handling,
distribution and disposal or
radioactive and investigational drugs.
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Procurement of implantable
prosthesis
Procurements, handling, storage,
distribution, usage and
replenishment of medical gases.
Antibiotic policy
Laundry and linen management
Kitchen sanitation and food handling
Engineering controls for infection
control
Mortuary practices an procedures
Surveillance, data collection and
monitoring of HAI
Isolation/barrier nursing
Outbreak control procedures
Quality control for sterilization
Handling of bio-medical waste
Quality assurance programmes
Operational and maintenance plan
Smoking policy
Human resource planning
Hospital & Health Care Consultants
Medical audit / death audit committee
Infection control committee
Resuscitation committee
Sentinel event committee
Committees
Fire and non-fire emergency committee
Equipment management committee
Pharmaco-therapeutic committee
Ethics committee
Safety committee
Quality assurance committee
Hospital & Health Care Consultants
Central Vs. Departmental
Internal Vs. External
Training
of Staff
Theoretical Vs. Practical
Mock drills and Practises
Training Evaluation
Hospital & Health Care Consultants
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Training topics
Policies and Processes
Advanced Care of Life Supports / Basic Care of Life Supports
Disaster management
Safe practices in laboratory
Handling of vulnerable patients
Restraint techniques
Hand washing
End of life care
Quality assurance
Handling of hazardous materials
Fire and non-fire emergencies
Handling patient in ambulance
Biomedical waste disposal
Universal precautions
Infection control surveillance and monitoring system
Managing patient during non-availability of beds
Radiation safety measures
Hospital & Health Care Consultants
Intra-departmental
Self
Assessments
Inter-departmental
Core team assessment
Assessment by ASTRON
Hospital & Health Care Consultants
Analyzing
assessment results
Re-assessment
Identifying
weak areas
Continuous
Effort
Retraining and/or
reformation of
policy/process
Improving
weak areas
Hospital & Health Care Consultants
Time Frame
Activities
Months
1
1
Constitution and initial training of
teams
Preliminary assessment
Understanding standards
Documentation
Implementation and training
Self assessments
Retraining, re-modification
Final self assessments
NABH assessments and
Accreditation
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Hospital & Health Care Consultants
Lack of commitment
Lack of time
Lack of clarity on roles of team, team
members
Difference of opinion on policy, procedures
and standards
Unavailability of adequate information
Improper/Incomplete documentation
Hospital & Health Care Consultants
Improper/Incomplete records
Inadequate training
In-experienced trainers
Poor attendance
Lack of time and resources
Communication barriers
Biased assessments
Individual preferences
Improper assessment methodology
Improper assessment framework
Hospital & Health Care Consultants
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Plan for Personal Excellence
-Dianna Boober
Define success in your own terms
Assess your strengths
Set goals with deadlines
Develop discipline and be willing to pay
the price
• Use time wisely
• Ask for advice
• Be receptive to feed back
Hospital & Health Care Consultants
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Plan for Personal Excellence
-Dianna Boober
Stay informed
Learn to communicate well
Do Quality work
Take risks
Be dependable
Be ethical
Nurture relationships
ABOVE ALL
“HAVE A POSITIVE ATTITUDE”
Hospital & Health Care Consultants
Hospital & Health Care Consultants