accreditation of your hospital
TRANSCRIPT
The presentation is solely meant for Academic purpose
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Regulation is mandatory
Accreditation is voluntary
Accreditation is promoted by way of
incentives and market forces
In order to achieve best of both worlds,
regulation in time to come can simply
rely on accreditation
Regulation Vs. Accreditation
Auditing
Quality System
Standards
Patient Safety
Physician
Surgeon
Nursing / Technician
Paramedical
Logistics
Management
Accreditation
Stimulates continuous improvement
Enables the HCO in demonstrating commitment to quality of care.
Raises community confidence in the services provided.
Provides opportunity to benchmark.
International recognition of services.
Better efficiency and Increase in revenue
Transparency in the overall operations
Provides the framework for an integrated and focused
management structure. Recognition by payers, government and vendors
Benefits to HCO
PATIENTS / ASSOCIATES PATIENT
REGISTRATIO
N
DAY TO DAY
MONITORING
OPD
ADMISSION
OPD
CONSULTATION
DISCHARGE
CERTIFICATE
FEE
COLLECTION
FRONT LINE STAFF
REGISTRATION ,PARAMEDICAL, NURSES, REDSIDENT
CONSULTANT / DOCTORS
CEO/HODs EMPOWERMENT
PATIENT
REGISTRATION
DAY TO DAY
MONITORING
OPD
ADMISSION
OPD
CONSULTATION
DISCHARGE
CERTIFICATE
FEE
COLLECTION
FRONT LINE STAFF
REGISTRATION ,PARAMEDICAL, NURSES, REDSIDENT
CONSULTANT / DOCTORS
CEO/HODs
Accredited hospital provides for effective
governance including structured support
services needed by Clinicians.
It provides for continuous learning
through monitoring of clinical indicators
including opportunity to benchmark.
Improves overall professional
development and provides opportunity
for leadership role in quality
improvement.
Benefits to Clinicians
Percentage of medication errors
Percentage of transfusion reactions
Urinary tract infection rate
Respiratory infection rate
Intra-vascular device infection rate
Surgical site infection rate
Incidence of falls
Incidence of bed sores after admission
Bed occupancy rate and average length of stay
Incidence of needle stick injuries
Systems are checked
Actual practice is not
Safety is given top priority
Measure what you do
Temp PACU arrival
Temp PACU exit
All 34.5 (32.8 – 36.8)
35.7 (34 – 37.2)
Patients with bear hugger
34.8 (34 -36.8)
36 (35- 37.2)
Without bear hugger
34.4 (32.8 – 36.4)
35.7(34 – 36.8)
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Cover preoperative patients
Minimize heat loss before surgery
Monitor temperature/s
Warmer / warm fluids/ early closure/ cover plastic sheet
Cover during transfer
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One of the top priority areas
HAIs
Hand hygiene compliance
Antibiotic use
Antibiogram
Abuse
Prophylactic antibiotic
Resistance pattern
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2005 2010
1 Anesthesia Spinal/epidural
Nerve blocks
2 High risk pts No Yes
3 Mobilization 24- 48 hrs 2-4 hrs
4 Pain relief OK excellent
5 Post op pts Slightly drowsy
Alert, no vomiting
5 Discharge 7 to 10 days 5 days
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2000 2010
1 Ventilator 24 hrs 2 to 3 hrs
2 ICU stay 2- 3 days 18 hours
3 Pain relief (0 to 10) 2 to 4 0 to 2
4 Postop status Slightly drowsy Alert awake
5 Mobilization 3 days Day 0
6 Climbing steps 4 to 5 days 2 to 3 days
7 Blood transfusion 4 to 5 units 0 to 1 unit
8 Infection <5 % <1%
9 Discharge from hospital 12 to 15 days 5 to 6 days
10 Return to work 2 months 2 to 4 weeks
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