“ the degree to which health services for individuals and populations increases the likelihood of...

Hospital & Health Care C onsultants

“ 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 qualityStructure

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

OutcomeChanges in health status attributable to

antecedent health care

I Should Quality Initiatives lead to Accreditation

OR

II Should Accreditation lead to quality initiatives

(TAKE YOUR PICK)


• Conformance to standards

• 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

Less mature

More mature


Medical Quality

Quality Assurance

Continuous Quality Improvement

Total Quality Management

Less mature

More mature


The Quality Continuum

Vision Current Strategic Perspective

Involvement Local Global

Focus Niche Processes Complete Processes

Scope Organisation Wide Community Wide

Triggers External Internal

Less mature More mature

Defining Quality

Measuring Quality

Improving Quality

Structural Reorganization

Incentives

Motivation

Standards setting

Monitoring systems

Supervision

Policy Making

Quality Redesigning

Benchmarking

Problem Solving

Management Actions

QualityEvaluation

Regulation

Accreditation

Audit

QUALITYASSURANCE


Effectiveness And

Efficiency

Optimum Utilizationof

Resources

UniformityIn

Processes

Community confidence

Waste Reduction

Safety and risk reduction

ImprovedHealth

Outcomes

Reduced Cost of

Healthcare


An Effective Quality

Improvement Tool

HEALTHCARE ACCREDITATION

A Voluntary Act

Frame work for Quality Assurance

Assessment by External Agency

Organisational Commitment

Unbiased approach

Defined Standards


VOLUNTARY ACT

Vision

Involvement

Focus

Triggers


Structural Standards

Physical facility and spatial associations

Human resource

Equipments

Materials


ProcessStandards

Policies

Programmes/Plans

Processes

Guidelines


Benefits of

Accreditation

A visible commitment by organisation towards quality of patient care

Safe working environment

Resource Optimisation

Benefits all stake holders

Stimulates continuous improvement

Raises community confidence


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

Obtain Standards

Comprehensive Review

Identify Gaps and Bridge it

Is standards Implemented and

Integrated satisfactorily

Is Assessment

Result satisfactory

Apply NABH forAssessment

Assessments by NABH

Receive recommendation& act accordingly

Apply for re-assessment

NABH Accreditation

Yes

No

Yes

No

Process of

AccreditationYES

NO

Decision


Applying Accreditation Standards for Quality Improvement

-A systematic approach

Initiation Documentation

Monitoring Implementation


InitiationInitiation

Sensitization

Constitution of teams

Understanding Standards

Customising Applicability

Action Plan


Documentation

Policies

Processes

Guidelines

Criteria and protocols

Programmes

Roles and Responsibilities

Formats for records and documents

Manuals

Organisational and departmental line of hierarchy


Documentation topics1. Registration policy and procedure2. Admission policy and procedure3. Transfer of unstable patients to

another facility 4. Transfer of stable patients to

another facility 5. Standardized initial assessment of

patients in the OPD, emergency and IPD.

6. Processing and disposal of specimens in laboratory.

7. Handling and disposal of infectious materials

8. Identification and safe transportation of patients to imaging services.

9. Handling and disposal of radio-active and hazardous materials.

10. Safe use of radioactive isotopes for imaging services.

11. Referral of patients to other departments / specialties.

12. Discharge policy and process13. LAMA policy and process14. Informed Consent policy and

process

15. Pricing Policy16. Uniform care policy and

processes17. Emergency care policy and

processes18. Medico-legal cases19. Triaging of patients20. Uniform use of resuscitation 21. Rational use of blood and blood

products22. Care of patients in ICU and HDU23. Situation of bed shortage in

ICU/HDU24. Care of vulnerable patients25. Care of high risk obstetrical

patients26. Care of paediatric patients27. Prevention of child/neonate

abduction or abuse28. Care of patients undergoing

moderate sedation29. Administration of anaesthesia30. Care of patients undergoing

surgical procedures31. Prevention of adverse events


32. Restraints techniques 33. Pain management guidelines34. Rehabilitative services polices35. Research activities policies and

protocols36. Nutritional assessment and

reassessment 37. End of life care38. Procurement, Storage, prescription

and dispensing of Medications39. Administration of medications40. Monitoring of medications41. Patient’s self administration of

medication42. Medication brought from outside the

organisation43. Adverse drug events44. Use of narcotic drugs and

psychotropic substance45. Usage of chemotherapeutic agents46. Usage of radioactive and

investigational drugs47. Safe storage, preparation, handling,

distribution and disposal or radioactive and investigational drugs.

48. Procurement of implantable prosthesis

49. Procurements, handling, storage, distribution, usage and replenishment of medical gases.

50. Antibiotic policy51. Laundry and linen management52. Kitchen sanitation and food handling53. Engineering controls for infection

control54. Mortuary practices an procedures55. Surveillance, data collection and

monitoring of HAI56. Isolation/barrier nursing57. Outbreak control procedures58. Quality control for sterilization59. Handling of bio-medical waste60. Quality assurance programmes61. Operational and maintenance plan62. Smoking policy63. Human resource planning


Committees

Infection control committee

Safety committee Quality assurance committee

Medical audit / death audit committee

Ethics committee

Pharmaco-therapeutic committee

Equipment management committee

Fire and non-fire emergency committee

Sentinel event committee

Resuscitation committee


Training of Staff

Central Vs. Departmental

Internal Vs. External

Theoretical Vs. Practical

Mock drills and Practises

Training Evaluation


Training topics1. Policies and Processes2. Advanced Care of Life Supports / Basic Care of Life Supports3. Disaster management4. Safe practices in laboratory5. Handling of vulnerable patients6. Restraint techniques7. Hand washing 8. End of life care9. Quality assurance10. Handling of hazardous materials11. Fire and non-fire emergencies12. Handling patient in ambulance13. Biomedical waste disposal14. Universal precautions15. Infection control surveillance and monitoring system16. Managing patient during non-availability of beds17. Radiation safety measures


Self Assessments

Intra-departmental

Inter-departmental

Core team assessment

Assessment by ASTRON


Analyzing

assessment results

Identifying weak areas

Improving weak areas

Retraining and/or

reformation of

policy/process

Re-assessment

Continuous Effort


Time Frame

Activities Months

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 171

8

Constitution and initial training ofteams

Preliminary assessment

Understanding standards

Documentation

Implementation and training

Self assessments

Retraining, re-modification

Final self assessments

NABH assessments andAccreditation


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


Improper/Incomplete recordsInadequate training

In-experienced trainersPoor attendanceLack of time and resourcesCommunication barriers

Biased assessmentsIndividual preferencesImproper assessment methodologyImproper assessment framework


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


• Stay informed• Learn to communicate well• Do Quality work• Take risks• Be dependable• Be ethical• Nurture relationships

ABOVE ALL“HAVE A POSITIVE ATTITUDE”

Plan for Personal Excellence -Dianna Boober


“ the degree to which health services for individuals and populations increases the likelihood of...

Documents

quality measuring quality

mature slide

quality assurance assessment

pick slide

decision slide

ishould quality initiatives

accreditation standards

community confidence