aaahc administration - acha
TRANSCRIPT
AAAHC AdministrationDirector of Student Health
University of North Florida
AAAHC 2018 Core Chapter 3, Administration
An accreditable organization is administered in a manner that ensures the provision of high-quality health services and that fulfills its mission, goals and objectives. (AAAHC, 2018)
A. Administrative policies, procedures and controls adopted by the governing body are implemented to ensure the orderly and efficient management of the organization
In order to meet the elements of compliance for this Chapter, the organization will provide:
“EVIDENCE OF AND WRITTEN POLICIES”
Examples include:
If you say you do “something” here is where
the assessors will find the written evidence.
Administration B. Fiscal controls are in place to protect the assets of the organization:
1. Appropriate and adequate policies and procedures are in place to provide accounting controls over assets, liabilities, revenues, and expenses
EXAMPLES:
(see SHS annual budget, P-card approvals/reconciliations, Processing of Checks Received Policy and other SHS and UNF fiscal policies and procedures);http://www.unf.shs/annual budget.
2. Written P/P are in place for controlling accounts receivable and accounts payable Regulation 6.001: Fiscal Policy, Regulation 6.002: Approval and Execution of Contracts, Regulation 6.008: Purchasing, P-card policies http:.edu/purchasing/purchasingcard/, etc.);
3. Written P/P are in place to control cash payments and credit arrangements (see SHS and UNF fiscal policies and procedures http://www.unf.edu.shsac.
4. Written P/P are in place to manage unpaid accounts and accounts being considerer for transfer to collection Agency. (see Auxiliary Fees and Charge Back Committee); see UNF Controller’s Office Tuition and Fees policies http://www.unf.edu/controller/student)
5. Written P/P are in place to manage the Purchase, receipts, distribution, maintain and security of supplies, equipment and facilities. http://www.unf.edu.shs/pp.
3. The governing body reviews the survey results. http://www.UNF.shs.survey
4. Corrective actions are taken as needed. http://www.UNF.shs.survey.actions.
. Written personnel policies:
1. Specify privileges and responsibilities of employment, including compliance with an adverse incident reporting system, as described in Standard 5.II.B.1-2. (see personnel position descriptions, Organizational Chart, current COOP, Executive Committee responsibilities as set out in the Bylaws of UNF SHS, etc.); certification (see personnel position descriptions, appointment guidelines in UNF Human Resources Policy 7.5, Credentialing and Privileging of Professional Staff Including Ancillary Staff Policy, etc.);
2. Require period appraisal of each person’s job performance, including current competence.
3. Describe incentives and rewards. http://www..edu/hr/e-verify.php)
4. Information is made known to employees at time of employment. See UNF Human Recourses guidelines. http://www..edu/hr/e-verify.php)
hppt://WWW.UNF.HR.GUIDLINES.
5. Comply with prevailing laws and regulations regarding verification of eligibility for employment (I-9 forms) and visas as required. http://www..edu/hr/e-verify.php)
6. Define the status of students and postgraduate trainees. http://www..edu/hr/e-verify.php)
Elements of compliance
1. Documented orientation and training are completed within 30 days of beginning employment.
2. At minimum, orientation and training are provided for the following:
a. Fire safety and the disaster preparedness plan. (Coop plan)
b. The use of emergency, safety, and fire extinguishing equipment. http://www..edu/hr/e-verify.pha
c. The infection prevention and control program, including blood borne pathogen and other training required by OSHA. hppt://www.unf.edu…
d. The safety program, including training in the reporting of adverse incidents. http://www..edu/hr/e- verify.pha
e. The risk management program, including training in the reporting of adverse incidents. http://www..edu/hr/e-verify.pha)
f. Confidentially and privacy training (e.g., HIPAA, FERPA). http://www..edu/hr/e-verify.pa
3. The training described in elements 2 is provided annually thereafter.
4. The training described in element 2 is provided when there is an identified need.
5. The delivery of all training is documented. (See staff minutes and employee files).
Achieving Accreditation: Risk and Safety
(AAAHC 2018 Standards: Ch. 3,5,7)
Jackie Hop, RN, MSN, MBA, CPN
Interim Nursing Director, Risk Manager, Infection Prevention
University of Central Florida
Consider investing in a data management and organization program
Designated Risk Manager Part of the Position Description
Maintains risk management program
trends, benchmarking, quality/process improvement
Provides documented risk management education upon hire, annually, and as needed
Safety Plan: Policy and Procedure
Designated Infection Preventionist Highly recommended but not required at this time
Should be in their position description
Can be a person or group
Safety Officer/Manager • Can be the same as the risk manager
• Should be in the
Safety Plan: Risk Assessment
Risk Assessment – Living Document Can use the CDC format and tailor to the facility
Infection prevention
Based on CDC recommendations
Environmental cleaning, including sterilization
Document observations, education, evaluations
Weather events for your area
Safety Plan: Risk Assessment
Supplies Ordering
Data storage
• Centers for Disease Control and Prevention (CDC) (2019). Infection control assessment tools. Retrieved from
Kathy Mosteller, RN, BSN Associate Director of Nursing & Clinical Operations University Health Services The University of Texas at Austin [email protected] / 512-475-8365
An accreditable organization provides health care services while adhering to safe practices for patients, staff, and others. The organization maintains ongoing programs designed to (1) prevent and control infections and
communicable diseases (2) provide a safe and sanitary environment of care
Written Infection
Areas
Areas
Multiple Patients
Common Problem Areas • Program/policies in place but staff not following • Lack of evidence of training/competence of designated leader of
IPC Program • Insufficient or no monitoring and documentation of
cleaning/sterilization • Failure to follow manufacturer’s instructions for use • Lack of adherence to hand hygiene and/or safe injection practices • Lack of written policies re. cleaning of patient treatment/care
areas, or lack of adherence to them • Corrugated cardboard in patient care/supply areas
AAAHC Chapter 7.2 Safety
An accreditable organization provides health care services while adhering to safe practices for patients, staff, and others. The organization maintains ongoing programs designed to (1) prevent and control infections and
communicable diseases (2) provide a safe and sanitary environment of care
Written Safety
for Safety Program
for Safety Program
Personnel Trained in BLS in Facility When Patients are Present
Written Safety
for Safety Program
Personnel Trained in BLS in Facility When Patients are Present
Written Recall Policy
for Safety Program
Personnel Trained in BLS in Facility When Patients are Present
Written Recall Policy
Written Safety
for Safety Program
Personnel Trained in BLS in Facility When Patients are Present
Written Recall Policy
Management of Hazardous
for Safety Program
Personnel Trained in BLS in Facility When Patients are Present
Written Recall Policy
Management of Hazardous
for Safety Program
Personnel Trained in BLS in Facility When Patients are Present
Written Recall Policy
Management of Hazardous
for Safety Program
Personnel Trained in BLS in Facility When Patients are Present
Written Recall Policy
Management of Hazardous
for Safety Program
Personnel Trained in BLS in Facility When Patients are Present
Written Recall Policy
Management of Hazardous
for Safety Program
Personnel Trained in BLS in Facility When Patients are Present
Written Recall Policy
Management of Hazardous
for Safety Program
Personnel Trained in BLS in Facility When Patients are Present
Written Recall Policy
Management of Hazardous
for Safety Program
Personnel Trained in BLS in Facility When Patients are Present
Written Recall Policy
Management of Hazardous
for Safety Program
Personnel Trained in BLS in Facility When Patients are Present
Written Recall Policy
Management of Hazardous
Fire Safety
Worker Protection
Hazardous ChemicalsWork
Injuries & Illnesses
Common Problem Areas • Inadequate documentation of training on conversion to new
Safety Data Sheets • Inadequate documentation of employee immunizations • Lack of active, on-going surveillance of hazards • Lack of awareness of local/state regulations, if any • Ensuring user training on devices or products used in patient care • Monitoring ALL expiration dates • Employee consistent use of PPE • Continuous temperature monitoring
QUESTIONS?
Linda Reid, RN-BC Oregon State University
ACHA May 30, 2019
Four Assessment Areas
Elements of Compliance
The written program: Element 1: Addresses the full scope of the health care services and how they are assessed for quality.
Full scope includes:
Considerations: Sources of ongoing assessment Peer review as Quality Improvement
Element 4: Identifies the programs purposes Element 5: Identifies program’s specific objectives Element 8: Evaluate annually for effectiveness and if program’s purposes and objectives are being met
Address both the purposes and objectives in the Plan Three-year plan to match AAAHC cycle Evaluate Annually
Purposes: ~Quality of care, improve patient outcomes ~Student Learning ~Have a QI Program that is broad-based, active, integrated, organized, and peer-based
~Program uses evidence based medicine/best practices to guide data collection and evaluation
Element 4: Identifies the programs purposes Element 5: Identifies program’s specific objectives Element 8: Evaluate annually for effectiveness and if program’s purposes and objectives are being met
Objectives vs. Goals Objectives
~External benchmarks using national guidelines, AAAHC, ACHA – validate quality or find deficits to improve
~Internal Benchmarks ~AAAHC standards ~Integrate peer review ~Reporting ~Risk management ~Education of staff and patients
Goals
*Specific studies or peer review planned for the coming year *Evaluate monthly/document in minutes *Annual Review of Program and Plan
Element 7: Describe integration of quality improvement, peer review, risk management, infection prevention and control
Considerations:
Peer review using diagnosis can also be or become a quality improvement study
Identify risk management issues through incident reports, safety issues, infection prevention, monitor higher risk processes
Element 9: Describe processes to ensure reporting to governing body and throughout the organization
Considerations:
Use annual report to summarize all activities and program evaluation to present to governing body
Provide access to annual report to all staff
Present results of studies and peer review to appropriate staff following their completion
Quality Improvement Program 5.1.B Ongoing data collection processes in place to measure quality, identify problems or concerns
Elements of Compliance At a minimum, data collection processes include:
Element 1: Analysis of peer review results
Considerations:
Peer review based on a diagnosis may lead to further study
Element 2: Periodic audits of critical processes
Considerations:
Identify and evaluate services/events with high risk potential E.g. anaphylaxis, hospital transfers/911 calls
Element 3: Ongoing monitoring of important processes and outcomes of care
Considerations:
Element 4: Comparison of performance to internal and external benchmarks
Considerations: Internal benchmark: Re-study QI from previous year to evaluate
improvement
External benchmark: AAAHC, ACHA, national standards, literature review
Element 5: Methods to systematically collect information from other pertinent sources Element 6: Ongoing evaluation of the information and data collected to identify unacceptable variation or results needing improvement
Considerations:
Regularly review and evaluate data from incident reports, peer review results, health and safety committee input, infection prevention, satisfaction surveys, NCHA survey, departmental/staff concerns
I’ll be happy to give you innovative thinking. What are the guidelines?
Quality Improvement Program 5.1.C Demonstrate that continuous improvement is occurring by conducting QI studies when data indicates improvement needed
Elements of Compliance Written descriptions of QI studies document each of the following elements:
Element 1 – 10: Describes what is needed in a QI Study
Considerations:
Develop a QI Template with guidelines that incorporate these 10 elements
The organization demonstrates that continuous improvement is occurring by conducting quality improvement studies when the data collection processes described in Standard 5.I.B indicate that improvement is or may be warranted.
Elements of compliance-- Written descriptions of QI studies document each of the following elements, as applicable:14--
A statement of the purpose of the QI study that includes a description of the problem and an explanation of why it is significant to the organization.15--
Identification of the measurable performance goal against which the organization will compare its current performance in the area of study. The goal must be stated in quantitative terms.16--
A description of the data that have been or will be collected to determine the organization's current performance.--
Evidence of data collection.--
Data analysis that describes findings about the frequency, severity, and source(s) of the problem(s).--
A comparison of the organization's current performance in the area of study against the previously identified performance goal.--
Implementation of corrective action(s) to resolve identified problem(s).--
Re-measurement (a second round of data collection and analysis as described in 5.I.C.4-6) to objectively determine whether the corrective actions have achieved and sustained demonstrable improvement.--
If the initial corrective action(s) did not achieve and/or sustain the desired improved performance, implementation of additional corrective action(s) and continued re-measurement until the problem is resolved or is no longer relevant.--
As documented in committee and/or staff meeting minutes, and/or in records of educational activities, the findings of quality improvement activities are communicated:-- To the governing body.--
Throughout the organization, as appropriate.
Title of Study:
1. Purpose and Description of Study:
2. Goal of Study:
6. Conclusion:
2. Goal of Study:
6. Conclusion:
Title of Study: How to Fill Out a QI Report Department: Your department (Nursing, Medical Reception, Lab, etc.) Name: Your name Date of Study: Dates that the study was performed/data collected Date Submitted: Date turned in to QI Committee 1. Purpose and Description of Study:
• Include a statement of the purpose of the QI activity that includes a description of the known or suspected problem, and explain why it is significant for SHS.
• This is the assessment of the issue to be studied. • What is the reason you selected this topic for study? How did you become aware
of the issue? • Is this a new study or a restudy? • Is this a new process, a study of high risk or high volume? Is it a problem prone
area or process? • Has there been any impact on patient outcomes? If so, how severe and how
often?
2. Goal of Study: • Identify the performance goal against which the organization will compare its
current performance in the area of study. The performance goal must be specific, e.g. “90% of time…”, “80% of patients…” etc. What results will you consider to be satisfactory? Provide a specific goal,
• If this is an external benchmark study, what professional guidelines, standards, or organizations are you using to benchmark your results?
• Is this a restudy where you are comparing results from previous year(s)? If so, state it is an “internal benchmark”.
3. Study Methods:
• Describe the data that will be collected in order to determine the current performance.
• Describe the issue in more detail if needed and explain what you did to look at the problem. Some things to consider:
o Do you have any baseline data? o What information collection process did you use to study the issue? (e.g.
chart reviews, surveys, etc.) o What were the key indicators you identified? What criteria did you use?
Was there a data collection tool used? o How many were studied and for how long? (Charts, patients, data tools,
etc.) o What departments were involved and who is participating in the study?
4. Findings:
• Include the evidence of data collection. • What did the data show? What did you find out? • Analyze the data describing findings about the frequency, severity and source(s)
of the problem(s). • Compare the current performance in the area of study against the previously
identified performance goal. (#2 above).
QUALITY IMPROVEMENT REPORT
Title of Study: How to Fill Out a QI Report
Department: Your department (Nursing, Medical Reception, Lab, etc.)
Name: Your name
Date of Study: Dates that the study was performed/data collected
Date Submitted: Date turned in to QI Committee
1. Purpose and Description of Study:
· Include a statement of the purpose of the QI activity that includes a description of the known or suspected problem, and explain why it is significant for SHS.
· This is the assessment of the issue to be studied.
· What is the reason you selected this topic for study? How did you become aware of the issue?
· Is this a new study or a restudy?
· Is this a new process, a study of high risk or high volume? Is it a problem prone area or process?
· Has there been any impact on patient outcomes? If so, how severe and how often?
2. Goal of Study:
· Identify the performance goal against which the organization will compare its current performance in the area of study. The performance goal must be specific, e.g. “90% of time…”, “80% of patients…” etc. What results will you consider to be satisfactory? Provide a specific goal,
· If this is an external benchmark study, what professional guidelines, standards, or organizations are you using to benchmark your results?
· Is this a restudy where you are comparing results from previous year(s)? If so, state it is an “internal benchmark”.
3. Study Methods:
· Describe the data that will be collected in order to determine the current performance.
· Describe the issue in more detail if needed and explain what you did to look at the problem. Some things to consider:
· Do you have any baseline data?
· What information collection process did you use to study the issue? (e.g. chart reviews, surveys, etc.)
· What were the key indicators you identified? What criteria did you use? Was there a data collection tool used?
· How many were studied and for how long? (Charts, patients, data tools, etc.)
· What departments were involved and who is participating in the study?
4. Findings:
· What did the data show? What did you find out?
· Analyze the data describing findings about the frequency, severity and source(s) of the problem(s).
· Compare the current performance in the area of study against the previously identified performance goal. (#2 above).
5. Analysis and Recommendations:
· Describe what corrective actions have been implemented to resolve identified problem(s), if any.
· This may include new or revised policies or procedures, education, staffing changes, equipment or supply changes, environmental changes, or other adjustments.
· How and why did you make these changes?
· Plan for restudying the issue to objectively determine whether the corrective actions have achieved and sustained demonstrable improvement.
· Analyze strengths and weaknesses of the study; recommendations to improve the study process.
· What conclusions can be drawn from the data, and do those result in any process recommendations/changes?
6. Conclusion:
· Was your goal reached?
· How will you monitor the corrective studies that have been implemented? Does it need to be restudied? If so, when?
· If this is a restudy, evaluate if the initial corrective action achieved and/or sustained the desired improved performance. If not, implementation of additional corrective actions and continued re-measurement will be needed until the problem is resolved or is no longer relevant.
· The findings should be communicated to the Direct Reports Team and throughout SHS, as appropriate.
· Whom do you need to inform and how will you inform them of the results and/or changes that are necessary?
· The findings should be incorporated into the organization’s educational activities as needed.
Quality Improvement Program 5.1.D
Elements of Compliance At a minimum, external benchmarking activities include:
Elements: 1. Performance measures for improving processes or patient outcomes
2. Collection/analysis of data related to performance measures
3. Comparing internal performance to external benchmarks
4. Tracking changes in performance
5. Incorporation of benchmark results into other QI activities
6. Results of benchmarking activities are reported
Considerations:
Use a diagnosis seen frequently, choose a performance measure (specific goal), collect data, compare to national guidelines
Benchmark against current national guidelines CDC, U.S. Preventive Services Task Force, Evidence-based medical resource
software
Let results of benchmark spark other Quality Improvement ideas
Re-study if results do not meet the performance measure to track improvement
Choose to study what is important to you and your organization
Incorporate key recommendations of the Accrediting organization:
AAAHC = Patient Outcomes, Clinical Care, Administrative, Cost of Care (many studies can cover more than one of these areas)
Have a specific, measureable goal for the study
Have a template with guidelines that include the 10 elements required in a QI Report
Interventions and Recommendations
“As you can see we have thought carefully about ways of improving staff productivity.”
Linda Reid Director of Nursing Services Oregon State University Student Health Services [email protected] 541-737-5582
AAAHC 2018 Core Chapter 3, Administration
A. Administrative policies, procedures and controls adopted by the governing body are implemented to ensure the orderly and efficient management of the organization
AdministrationB. Fiscal controls are in place to protect the assets of the organization:
Administrationc. Patient satisfaction with services and facilities provided is periodically assessed.
D. Written Personnel policies are established and implemented to facilitate attainment of the mission, goals, and objectives of SHS
AdmirationE. Orientation and training, according to position description, are provided to all
Continue E.
Achieving Accreditation:Risk and Safety (AAAHC 2018 Standards: Ch. 3,5,7)
Safety Plan: Policy and Procedure
Safety Plan: Policy and Procedure
Safety Plan: Risk Assessment
Safety Plan: Risk Assessment
Safety Plan: Risk Assessment
Safety Plan: Risk Assessment
Safety Plan: Risk Assessment
Safety Plan: Risk Assessment
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Common Problem Areas
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Four Assessment Areas
Elements of Compliance
Element 4: Identifies the programs purposesElement 5: Identifies program’s specific objectivesElement 8: Evaluate annually for effectiveness and if program’s purposes and objectives are being met
Element 4: Identifies the programs purposesElement 5: Identifies program’s specific objectivesElement 8: Evaluate annually for effectiveness and if program’s purposes and objectives are being met
Element 7: Describe integration of quality improvement, peer review, risk management, infection prevention and control
Element 9: Describe processes to ensure reporting to governing body and throughout the organization
Quality Improvement Program5.1.BOngoing data collection processes in place to measure quality, identify problems or concerns
Element 2: Periodic audits of critical processesConsiderations:
Element 4: Comparison of performance to internal and external benchmarksConsiderations:
I’ll be happy to give you innovative thinking. What are the guidelines?
Quality Improvement Program5.1.CDemonstrate that continuous improvement is occurring by conducting QI studies when data indicates improvement needed
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Quality Improvement Program
Elements of Compliance
Interventions and Recommendations
University of North Florida
AAAHC 2018 Core Chapter 3, Administration
An accreditable organization is administered in a manner that ensures the provision of high-quality health services and that fulfills its mission, goals and objectives. (AAAHC, 2018)
A. Administrative policies, procedures and controls adopted by the governing body are implemented to ensure the orderly and efficient management of the organization
In order to meet the elements of compliance for this Chapter, the organization will provide:
“EVIDENCE OF AND WRITTEN POLICIES”
Examples include:
If you say you do “something” here is where
the assessors will find the written evidence.
Administration B. Fiscal controls are in place to protect the assets of the organization:
1. Appropriate and adequate policies and procedures are in place to provide accounting controls over assets, liabilities, revenues, and expenses
EXAMPLES:
(see SHS annual budget, P-card approvals/reconciliations, Processing of Checks Received Policy and other SHS and UNF fiscal policies and procedures);http://www.unf.shs/annual budget.
2. Written P/P are in place for controlling accounts receivable and accounts payable Regulation 6.001: Fiscal Policy, Regulation 6.002: Approval and Execution of Contracts, Regulation 6.008: Purchasing, P-card policies http:.edu/purchasing/purchasingcard/, etc.);
3. Written P/P are in place to control cash payments and credit arrangements (see SHS and UNF fiscal policies and procedures http://www.unf.edu.shsac.
4. Written P/P are in place to manage unpaid accounts and accounts being considerer for transfer to collection Agency. (see Auxiliary Fees and Charge Back Committee); see UNF Controller’s Office Tuition and Fees policies http://www.unf.edu/controller/student)
5. Written P/P are in place to manage the Purchase, receipts, distribution, maintain and security of supplies, equipment and facilities. http://www.unf.edu.shs/pp.
3. The governing body reviews the survey results. http://www.UNF.shs.survey
4. Corrective actions are taken as needed. http://www.UNF.shs.survey.actions.
. Written personnel policies:
1. Specify privileges and responsibilities of employment, including compliance with an adverse incident reporting system, as described in Standard 5.II.B.1-2. (see personnel position descriptions, Organizational Chart, current COOP, Executive Committee responsibilities as set out in the Bylaws of UNF SHS, etc.); certification (see personnel position descriptions, appointment guidelines in UNF Human Resources Policy 7.5, Credentialing and Privileging of Professional Staff Including Ancillary Staff Policy, etc.);
2. Require period appraisal of each person’s job performance, including current competence.
3. Describe incentives and rewards. http://www..edu/hr/e-verify.php)
4. Information is made known to employees at time of employment. See UNF Human Recourses guidelines. http://www..edu/hr/e-verify.php)
hppt://WWW.UNF.HR.GUIDLINES.
5. Comply with prevailing laws and regulations regarding verification of eligibility for employment (I-9 forms) and visas as required. http://www..edu/hr/e-verify.php)
6. Define the status of students and postgraduate trainees. http://www..edu/hr/e-verify.php)
Elements of compliance
1. Documented orientation and training are completed within 30 days of beginning employment.
2. At minimum, orientation and training are provided for the following:
a. Fire safety and the disaster preparedness plan. (Coop plan)
b. The use of emergency, safety, and fire extinguishing equipment. http://www..edu/hr/e-verify.pha
c. The infection prevention and control program, including blood borne pathogen and other training required by OSHA. hppt://www.unf.edu…
d. The safety program, including training in the reporting of adverse incidents. http://www..edu/hr/e- verify.pha
e. The risk management program, including training in the reporting of adverse incidents. http://www..edu/hr/e-verify.pha)
f. Confidentially and privacy training (e.g., HIPAA, FERPA). http://www..edu/hr/e-verify.pa
3. The training described in elements 2 is provided annually thereafter.
4. The training described in element 2 is provided when there is an identified need.
5. The delivery of all training is documented. (See staff minutes and employee files).
Achieving Accreditation: Risk and Safety
(AAAHC 2018 Standards: Ch. 3,5,7)
Jackie Hop, RN, MSN, MBA, CPN
Interim Nursing Director, Risk Manager, Infection Prevention
University of Central Florida
Consider investing in a data management and organization program
Designated Risk Manager Part of the Position Description
Maintains risk management program
trends, benchmarking, quality/process improvement
Provides documented risk management education upon hire, annually, and as needed
Safety Plan: Policy and Procedure
Designated Infection Preventionist Highly recommended but not required at this time
Should be in their position description
Can be a person or group
Safety Officer/Manager • Can be the same as the risk manager
• Should be in the
Safety Plan: Risk Assessment
Risk Assessment – Living Document Can use the CDC format and tailor to the facility
Infection prevention
Based on CDC recommendations
Environmental cleaning, including sterilization
Document observations, education, evaluations
Weather events for your area
Safety Plan: Risk Assessment
Supplies Ordering
Data storage
• Centers for Disease Control and Prevention (CDC) (2019). Infection control assessment tools. Retrieved from
Kathy Mosteller, RN, BSN Associate Director of Nursing & Clinical Operations University Health Services The University of Texas at Austin [email protected] / 512-475-8365
An accreditable organization provides health care services while adhering to safe practices for patients, staff, and others. The organization maintains ongoing programs designed to (1) prevent and control infections and
communicable diseases (2) provide a safe and sanitary environment of care
Written Infection
Areas
Areas
Multiple Patients
Common Problem Areas • Program/policies in place but staff not following • Lack of evidence of training/competence of designated leader of
IPC Program • Insufficient or no monitoring and documentation of
cleaning/sterilization • Failure to follow manufacturer’s instructions for use • Lack of adherence to hand hygiene and/or safe injection practices • Lack of written policies re. cleaning of patient treatment/care
areas, or lack of adherence to them • Corrugated cardboard in patient care/supply areas
AAAHC Chapter 7.2 Safety
An accreditable organization provides health care services while adhering to safe practices for patients, staff, and others. The organization maintains ongoing programs designed to (1) prevent and control infections and
communicable diseases (2) provide a safe and sanitary environment of care
Written Safety
for Safety Program
for Safety Program
Personnel Trained in BLS in Facility When Patients are Present
Written Safety
for Safety Program
Personnel Trained in BLS in Facility When Patients are Present
Written Recall Policy
for Safety Program
Personnel Trained in BLS in Facility When Patients are Present
Written Recall Policy
Written Safety
for Safety Program
Personnel Trained in BLS in Facility When Patients are Present
Written Recall Policy
Management of Hazardous
for Safety Program
Personnel Trained in BLS in Facility When Patients are Present
Written Recall Policy
Management of Hazardous
for Safety Program
Personnel Trained in BLS in Facility When Patients are Present
Written Recall Policy
Management of Hazardous
for Safety Program
Personnel Trained in BLS in Facility When Patients are Present
Written Recall Policy
Management of Hazardous
for Safety Program
Personnel Trained in BLS in Facility When Patients are Present
Written Recall Policy
Management of Hazardous
for Safety Program
Personnel Trained in BLS in Facility When Patients are Present
Written Recall Policy
Management of Hazardous
for Safety Program
Personnel Trained in BLS in Facility When Patients are Present
Written Recall Policy
Management of Hazardous
for Safety Program
Personnel Trained in BLS in Facility When Patients are Present
Written Recall Policy
Management of Hazardous
for Safety Program
Personnel Trained in BLS in Facility When Patients are Present
Written Recall Policy
Management of Hazardous
Fire Safety
Worker Protection
Hazardous ChemicalsWork
Injuries & Illnesses
Common Problem Areas • Inadequate documentation of training on conversion to new
Safety Data Sheets • Inadequate documentation of employee immunizations • Lack of active, on-going surveillance of hazards • Lack of awareness of local/state regulations, if any • Ensuring user training on devices or products used in patient care • Monitoring ALL expiration dates • Employee consistent use of PPE • Continuous temperature monitoring
QUESTIONS?
Linda Reid, RN-BC Oregon State University
ACHA May 30, 2019
Four Assessment Areas
Elements of Compliance
The written program: Element 1: Addresses the full scope of the health care services and how they are assessed for quality.
Full scope includes:
Considerations: Sources of ongoing assessment Peer review as Quality Improvement
Element 4: Identifies the programs purposes Element 5: Identifies program’s specific objectives Element 8: Evaluate annually for effectiveness and if program’s purposes and objectives are being met
Address both the purposes and objectives in the Plan Three-year plan to match AAAHC cycle Evaluate Annually
Purposes: ~Quality of care, improve patient outcomes ~Student Learning ~Have a QI Program that is broad-based, active, integrated, organized, and peer-based
~Program uses evidence based medicine/best practices to guide data collection and evaluation
Element 4: Identifies the programs purposes Element 5: Identifies program’s specific objectives Element 8: Evaluate annually for effectiveness and if program’s purposes and objectives are being met
Objectives vs. Goals Objectives
~External benchmarks using national guidelines, AAAHC, ACHA – validate quality or find deficits to improve
~Internal Benchmarks ~AAAHC standards ~Integrate peer review ~Reporting ~Risk management ~Education of staff and patients
Goals
*Specific studies or peer review planned for the coming year *Evaluate monthly/document in minutes *Annual Review of Program and Plan
Element 7: Describe integration of quality improvement, peer review, risk management, infection prevention and control
Considerations:
Peer review using diagnosis can also be or become a quality improvement study
Identify risk management issues through incident reports, safety issues, infection prevention, monitor higher risk processes
Element 9: Describe processes to ensure reporting to governing body and throughout the organization
Considerations:
Use annual report to summarize all activities and program evaluation to present to governing body
Provide access to annual report to all staff
Present results of studies and peer review to appropriate staff following their completion
Quality Improvement Program 5.1.B Ongoing data collection processes in place to measure quality, identify problems or concerns
Elements of Compliance At a minimum, data collection processes include:
Element 1: Analysis of peer review results
Considerations:
Peer review based on a diagnosis may lead to further study
Element 2: Periodic audits of critical processes
Considerations:
Identify and evaluate services/events with high risk potential E.g. anaphylaxis, hospital transfers/911 calls
Element 3: Ongoing monitoring of important processes and outcomes of care
Considerations:
Element 4: Comparison of performance to internal and external benchmarks
Considerations: Internal benchmark: Re-study QI from previous year to evaluate
improvement
External benchmark: AAAHC, ACHA, national standards, literature review
Element 5: Methods to systematically collect information from other pertinent sources Element 6: Ongoing evaluation of the information and data collected to identify unacceptable variation or results needing improvement
Considerations:
Regularly review and evaluate data from incident reports, peer review results, health and safety committee input, infection prevention, satisfaction surveys, NCHA survey, departmental/staff concerns
I’ll be happy to give you innovative thinking. What are the guidelines?
Quality Improvement Program 5.1.C Demonstrate that continuous improvement is occurring by conducting QI studies when data indicates improvement needed
Elements of Compliance Written descriptions of QI studies document each of the following elements:
Element 1 – 10: Describes what is needed in a QI Study
Considerations:
Develop a QI Template with guidelines that incorporate these 10 elements
The organization demonstrates that continuous improvement is occurring by conducting quality improvement studies when the data collection processes described in Standard 5.I.B indicate that improvement is or may be warranted.
Elements of compliance-- Written descriptions of QI studies document each of the following elements, as applicable:14--
A statement of the purpose of the QI study that includes a description of the problem and an explanation of why it is significant to the organization.15--
Identification of the measurable performance goal against which the organization will compare its current performance in the area of study. The goal must be stated in quantitative terms.16--
A description of the data that have been or will be collected to determine the organization's current performance.--
Evidence of data collection.--
Data analysis that describes findings about the frequency, severity, and source(s) of the problem(s).--
A comparison of the organization's current performance in the area of study against the previously identified performance goal.--
Implementation of corrective action(s) to resolve identified problem(s).--
Re-measurement (a second round of data collection and analysis as described in 5.I.C.4-6) to objectively determine whether the corrective actions have achieved and sustained demonstrable improvement.--
If the initial corrective action(s) did not achieve and/or sustain the desired improved performance, implementation of additional corrective action(s) and continued re-measurement until the problem is resolved or is no longer relevant.--
As documented in committee and/or staff meeting minutes, and/or in records of educational activities, the findings of quality improvement activities are communicated:-- To the governing body.--
Throughout the organization, as appropriate.
Title of Study:
1. Purpose and Description of Study:
2. Goal of Study:
6. Conclusion:
2. Goal of Study:
6. Conclusion:
Title of Study: How to Fill Out a QI Report Department: Your department (Nursing, Medical Reception, Lab, etc.) Name: Your name Date of Study: Dates that the study was performed/data collected Date Submitted: Date turned in to QI Committee 1. Purpose and Description of Study:
• Include a statement of the purpose of the QI activity that includes a description of the known or suspected problem, and explain why it is significant for SHS.
• This is the assessment of the issue to be studied. • What is the reason you selected this topic for study? How did you become aware
of the issue? • Is this a new study or a restudy? • Is this a new process, a study of high risk or high volume? Is it a problem prone
area or process? • Has there been any impact on patient outcomes? If so, how severe and how
often?
2. Goal of Study: • Identify the performance goal against which the organization will compare its
current performance in the area of study. The performance goal must be specific, e.g. “90% of time…”, “80% of patients…” etc. What results will you consider to be satisfactory? Provide a specific goal,
• If this is an external benchmark study, what professional guidelines, standards, or organizations are you using to benchmark your results?
• Is this a restudy where you are comparing results from previous year(s)? If so, state it is an “internal benchmark”.
3. Study Methods:
• Describe the data that will be collected in order to determine the current performance.
• Describe the issue in more detail if needed and explain what you did to look at the problem. Some things to consider:
o Do you have any baseline data? o What information collection process did you use to study the issue? (e.g.
chart reviews, surveys, etc.) o What were the key indicators you identified? What criteria did you use?
Was there a data collection tool used? o How many were studied and for how long? (Charts, patients, data tools,
etc.) o What departments were involved and who is participating in the study?
4. Findings:
• Include the evidence of data collection. • What did the data show? What did you find out? • Analyze the data describing findings about the frequency, severity and source(s)
of the problem(s). • Compare the current performance in the area of study against the previously
identified performance goal. (#2 above).
QUALITY IMPROVEMENT REPORT
Title of Study: How to Fill Out a QI Report
Department: Your department (Nursing, Medical Reception, Lab, etc.)
Name: Your name
Date of Study: Dates that the study was performed/data collected
Date Submitted: Date turned in to QI Committee
1. Purpose and Description of Study:
· Include a statement of the purpose of the QI activity that includes a description of the known or suspected problem, and explain why it is significant for SHS.
· This is the assessment of the issue to be studied.
· What is the reason you selected this topic for study? How did you become aware of the issue?
· Is this a new study or a restudy?
· Is this a new process, a study of high risk or high volume? Is it a problem prone area or process?
· Has there been any impact on patient outcomes? If so, how severe and how often?
2. Goal of Study:
· Identify the performance goal against which the organization will compare its current performance in the area of study. The performance goal must be specific, e.g. “90% of time…”, “80% of patients…” etc. What results will you consider to be satisfactory? Provide a specific goal,
· If this is an external benchmark study, what professional guidelines, standards, or organizations are you using to benchmark your results?
· Is this a restudy where you are comparing results from previous year(s)? If so, state it is an “internal benchmark”.
3. Study Methods:
· Describe the data that will be collected in order to determine the current performance.
· Describe the issue in more detail if needed and explain what you did to look at the problem. Some things to consider:
· Do you have any baseline data?
· What information collection process did you use to study the issue? (e.g. chart reviews, surveys, etc.)
· What were the key indicators you identified? What criteria did you use? Was there a data collection tool used?
· How many were studied and for how long? (Charts, patients, data tools, etc.)
· What departments were involved and who is participating in the study?
4. Findings:
· What did the data show? What did you find out?
· Analyze the data describing findings about the frequency, severity and source(s) of the problem(s).
· Compare the current performance in the area of study against the previously identified performance goal. (#2 above).
5. Analysis and Recommendations:
· Describe what corrective actions have been implemented to resolve identified problem(s), if any.
· This may include new or revised policies or procedures, education, staffing changes, equipment or supply changes, environmental changes, or other adjustments.
· How and why did you make these changes?
· Plan for restudying the issue to objectively determine whether the corrective actions have achieved and sustained demonstrable improvement.
· Analyze strengths and weaknesses of the study; recommendations to improve the study process.
· What conclusions can be drawn from the data, and do those result in any process recommendations/changes?
6. Conclusion:
· Was your goal reached?
· How will you monitor the corrective studies that have been implemented? Does it need to be restudied? If so, when?
· If this is a restudy, evaluate if the initial corrective action achieved and/or sustained the desired improved performance. If not, implementation of additional corrective actions and continued re-measurement will be needed until the problem is resolved or is no longer relevant.
· The findings should be communicated to the Direct Reports Team and throughout SHS, as appropriate.
· Whom do you need to inform and how will you inform them of the results and/or changes that are necessary?
· The findings should be incorporated into the organization’s educational activities as needed.
Quality Improvement Program 5.1.D
Elements of Compliance At a minimum, external benchmarking activities include:
Elements: 1. Performance measures for improving processes or patient outcomes
2. Collection/analysis of data related to performance measures
3. Comparing internal performance to external benchmarks
4. Tracking changes in performance
5. Incorporation of benchmark results into other QI activities
6. Results of benchmarking activities are reported
Considerations:
Use a diagnosis seen frequently, choose a performance measure (specific goal), collect data, compare to national guidelines
Benchmark against current national guidelines CDC, U.S. Preventive Services Task Force, Evidence-based medical resource
software
Let results of benchmark spark other Quality Improvement ideas
Re-study if results do not meet the performance measure to track improvement
Choose to study what is important to you and your organization
Incorporate key recommendations of the Accrediting organization:
AAAHC = Patient Outcomes, Clinical Care, Administrative, Cost of Care (many studies can cover more than one of these areas)
Have a specific, measureable goal for the study
Have a template with guidelines that include the 10 elements required in a QI Report
Interventions and Recommendations
“As you can see we have thought carefully about ways of improving staff productivity.”
Linda Reid Director of Nursing Services Oregon State University Student Health Services [email protected] 541-737-5582
AAAHC 2018 Core Chapter 3, Administration
A. Administrative policies, procedures and controls adopted by the governing body are implemented to ensure the orderly and efficient management of the organization
AdministrationB. Fiscal controls are in place to protect the assets of the organization:
Administrationc. Patient satisfaction with services and facilities provided is periodically assessed.
D. Written Personnel policies are established and implemented to facilitate attainment of the mission, goals, and objectives of SHS
AdmirationE. Orientation and training, according to position description, are provided to all
Continue E.
Achieving Accreditation:Risk and Safety (AAAHC 2018 Standards: Ch. 3,5,7)
Safety Plan: Policy and Procedure
Safety Plan: Policy and Procedure
Safety Plan: Risk Assessment
Safety Plan: Risk Assessment
Safety Plan: Risk Assessment
Safety Plan: Risk Assessment
Safety Plan: Risk Assessment
Safety Plan: Risk Assessment
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Common Problem Areas
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Four Assessment Areas
Elements of Compliance
Element 4: Identifies the programs purposesElement 5: Identifies program’s specific objectivesElement 8: Evaluate annually for effectiveness and if program’s purposes and objectives are being met
Element 4: Identifies the programs purposesElement 5: Identifies program’s specific objectivesElement 8: Evaluate annually for effectiveness and if program’s purposes and objectives are being met
Element 7: Describe integration of quality improvement, peer review, risk management, infection prevention and control
Element 9: Describe processes to ensure reporting to governing body and throughout the organization
Quality Improvement Program5.1.BOngoing data collection processes in place to measure quality, identify problems or concerns
Element 2: Periodic audits of critical processesConsiderations:
Element 4: Comparison of performance to internal and external benchmarksConsiderations:
I’ll be happy to give you innovative thinking. What are the guidelines?
Quality Improvement Program5.1.CDemonstrate that continuous improvement is occurring by conducting QI studies when data indicates improvement needed
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Quality Improvement Program
Elements of Compliance
Interventions and Recommendations