“ the degree to which health services for individuals and populations increases the likelihood of...
TRANSCRIPT
“ 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
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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)
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• 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
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Medical Quality
Quality Assurance
Continuous Quality Improvement
Total Quality Management
Less mature
More mature
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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
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Effectiveness And
Efficiency
Optimum Utilizationof
Resources
UniformityIn
Processes
Community confidence
Waste Reduction
Safety and risk reduction
ImprovedHealth
Outcomes
Reduced Cost of
Healthcare
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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
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Structural Standards
Physical facility and spatial associations
Human resource
Equipments
Materials
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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
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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*
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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
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Applying Accreditation Standards for Quality Improvement
-A systematic approach
Initiation Documentation
Monitoring Implementation
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InitiationInitiation
Sensitization
Constitution of teams
Understanding Standards
Customising Applicability
Action Plan
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Documentation
Policies
Processes
Guidelines
Criteria and protocols
Programmes
Roles and Responsibilities
Formats for records and documents
Manuals
Organisational and departmental line of hierarchy
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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
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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
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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
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Training of Staff
Central Vs. Departmental
Internal Vs. External
Theoretical Vs. Practical
Mock drills and Practises
Training Evaluation
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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
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Self Assessments
Intra-departmental
Inter-departmental
Core team assessment
Assessment by ASTRON
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Analyzing
assessment results
Identifying weak areas
Improving weak areas
Retraining and/or
reformation of
policy/process
Re-assessment
Continuous Effort
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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
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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
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Improper/Incomplete recordsInadequate training
In-experienced trainersPoor attendanceLack of time and resourcesCommunication barriers
Biased assessmentsIndividual preferencesImproper assessment methodologyImproper assessment framework
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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
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• 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
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