2- health care organization management standards

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2 - Health Care Organization Management Standards By Dr.Ashraf AL-Abasiry,MBBCh,MSc Internist,Aramco Unit Saad Specialist Hospital

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1- International Patient Safety Goals 2-Access to Care and Continuity of Care. 3-Patient and Family Rights. 4-Assessment of Patients. 5-Care of Patients. 6-Anesthesia & Surgical Care. 7-Medication Management and Use. 8-Patient and Family Education . Functional Section I: Patient-Centered Standards

Functional Section II: Health Care Organization Management Standards :

Functional Section II : Health Care Organization Management Standards 1-Quality Improvement and Patient Safety. 2-Prevention and Control of Infections. 3-Governance, Leadership, and Direction. 4-Facility Management and Safety. 5-Staff Qualifications and Education. 6-Management of Communication and Information .

1- Quality Improvement and Patient Safety (QPS):

Quality: is meeting the customer's needs in a way that exceeds the customer's expectations at low rates (costs) to the company and achieving employee satisfaction is doing the right things right every time from the first time. 1- Quality Improvement and Patient Safety (QPS)

Quality Improvement & Patient Safety:

Primary Processes: 1-Planning for QI and for patient safety . 2-Design of new processes . 3-Monitoring processes through indicator data collection. 4-Analysis of data. 5-Intense analysis of unexpected events & unfavorable trends. 6-Implementation of changes that result in improvement. 7-Proactive risk assessment. Quality Improvement & Patient Safety

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Quality Improvement and Patient Safety is leadership driven and is deployed by a multidisciplinary team approach. The organization’s leaders : 1- Participate in planning and measuring a quality improvement and patient safety program. 2- Carry out the quality improvement and patient safety program . 3- Prioritize which processes should be measured and which improvement and patient safety activities should be carried out. 4- Provide technological and other support to the quality improvement and patient safety program

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Objectives Function or Process Internal Database Improvement/ Innovation Improvement Priorities Comparative Information Design Measure Analyze Improve Reassess Quality Improvement Circle

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SSH is one of the middleast's premier Hospitals Quality and Patient Safety are our top priorities. We are committed to providing exceptional patient care and customer service throughout all our facilities. From patient satisfaction initiatives to quality improvement, SSH is dedicated to creating and maintaining a culture of operational and service excellence.

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J oint C ommission I nternational QPS standards are incorporated into the daily practice of SSH by: 1- Constant monitoring of our performance by : ▲ The Hospital Management Committee and the standing committee structure (Committee Manual-policies folder). ► Executive Dashboard review of Key performance Measure ( KPMs ) on monthly basis. ► Performance reporting to committees and linkage to executive leadership through Hospital Executive Committee , Hospital Management Committee as well as Hospital Operations Committee.

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▲ - Outside entities such as the multiple accrediting bodies, ( JCI ), ( CCHSA ) and ( ACHSI ), ( CAP ), and American Association of Blood Banks ( AABB ). 2- Individuals with appropriate experience, knowledge and skills, systematically aggregate and analyze data in the organization Example: Laboratory data – Laboratory Quality Coordinator Pharmacy- Pharmacy Quality Coordinator OVRs – RM Department .

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3 – The design of new systems and processes through quality principles. 4 – Use of improvement methodology. The following methodologies are used to measure performance and to identify and act on opportunities for improvement: - FOCUS PDCA of improvement methodology . Two Cycles a Quality Improvement team works through to solve problems and improve processes at SSH. - Root Cause Analysis and Failure Modes Effects Analysis is a systematic method of identifying and preventing product and process problems before they occur.

F-O-C-U-S:

F-O-C-U-S Find a process that needs improvement . Organize a team who is knowledgeable in the process. Clarify the current knowledge of the process . Understand the causes of variation . Select the potential process improvement .

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The PDCA Cycle for Learning and Improvement Act What changes are to be made? Next cycle? Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when ) Do Carry out the plan Document problems and unexpected observations Begin analysis of the data Check Complete the analysis of the data Compare data to predictions Summarize what was learned

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Prevention and Control of Infection (PCI) JCI Standards By Dr. Samer Saad Omar Master Degree of Infection Control & management Alexandria University

Prevention and Control of Infection (PCI):

Prevention and Control of Infection (PCI) The goal of an organization’s infection prevention and control program is to identify and to reduce the risks of acquiring and transmitting infections among patients, staff, health care professionals, contract workers, volunteers, students, and visitors. The infection risks and program activities may differ from organization to organization Effective programs have in common identified leaders, well-trained staff, methods to identify and to proactively address infection risks, appropriate policies and procedures, staff education, and coordination through out the organization.

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Standards Of PCI: A) Program Leadership and Coordination B) Focus of the Program C) Isolation Procedures D) Barrier Techniques and Hand Hygiene E) Integration of the Program with Quality Improvement and Patient Safety F) Education of Staff about the Program

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A) Program Leadership and Coordination: PCI.1 One or more individuals oversee all infection prevention and control activities. This individual (s) is qualified in infection prevention and control practices through education, training, experience, or certification . PCI.2 There is a designated coordination mechanism for all infection prevention and control activities that involves physicians, nurses, and others as based on the size and complexity of the organization. PCI.3 The infection prevention and control program is based on current scientific knowledge, accepted practice guidelines, applicable laws and regulations, and standards for sanitation and cleanliness. PCI.4 The organization’s leaders provide adequate resources to support the infection prevention and control program.

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B) Focus of the Program: PCI.5 The organization designs and implements a comprehensive program to reduce the risks of health care–associated infections in patients and health care workers. PCI.5.1 All patient, staff, and visitor areas of the organization are included in the infection prevention and control program. PCI.6 The organization uses a risk-based approach in establishing the focus of the health care–associated infection prevention and reduction program. PCI.7 The organization identifies the procedures and processes associated with the risk of infection and implements strategies to reduce infection risk.

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PCI.7.1 The organization reduces the risk of infections by ensuring adequate equipment cleaning and sterilization and the proper management of laundry and linen. PCI.7.1.1 There is a policy and procedure in place that identifies the process for managing expired supplies and defines the conditions for reuse of single use devices when laws and regulations permit. PCI.7.2 The organization reduces the risk of infections through proper disposal of waste. PCI.7.3 The organization has a policy and procedure on the disposal of sharps and needles . PCI.7.4 The organization reduces the risk of infections in the facility associated with operations of the food service and of mechanical and engineering controls. PCI.7.5 The organization reduces the risk of infection in the facility during demolition, construction, and renovation.

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C) Isolation Procedures PCI.8 The organization provides barrier precautions and isolation procedures that protect patients, visitors, and staff from communicable diseases and protects immunosuppressed patients from acquiring infections to which they are uniquely prone D) Barrier Techniques and Hand Hygiene PCI.9 Gloves, masks, eye protection, other protective equipment, soap, and disinfectants are available and used correctly when required .

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E) Integration of the Program with Quality Improvement and Patient Safety PCI.10 The infection prevention and control process is integrated with the organization’s overall program for quality improvement and patient safety. PCI.10.1 The organization tracks infection risks, infection rates, and trends in health care–associated infections. PCI.10.2 Quality improvement includes using measures related to infection issues that are epidemiologically important to the organization . PCI.10.3 The organization uses risk, rate, and trend information to design or to modify processes to reduce the risk of health care–associated infections to the lowest possible levels

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PCI.10.4 The organization compares its health care–associated infection rates with other organizations through comparative databases . PCI.10.5 The results of infection prevention and control measurement in the organization are regularly communicated to leaders and staff. PCI.10.6 The organization reports information on infections to appropriate external public health agencies. F) Education of Staff about the Program PCI.11 The organization provides education on infection prevention and control practices to staff, physicians, patients, families, and other caregivers when indicated by their involvement in care.

3-Governance, Leadership and Direction (GLD):

3-Governance, Leadership and Direction (GLD) Providing excellent patient care requires effective leadership. That leadership comes from many sources in a health care organization, including governing leaders (governance), leaders, and others who hold positions of leadership, responsibility, and trust. Each organization must identify these individuals and involve them in ensuring that the organization is an effective, efficient resource for the community and its patients.

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The GLD standards are clarified below together with examples of how they are addressed in SSH . The effectiveness of the governance structure is evaluated annually through an Organizational Effectiveness Survey. The Board evaluates governance and the senior leaders. The structure of the organization is displayed in an Organization Chart.

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Those responsible for governance : 1- Approve and make public the organization’s mission statement. 2- Approve the policies and plans to operate the organization. 3 - Approve the budget and allocate the resources required to meet the organization’s mission.

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4 -Appoint the organization’s senior managers or directors. 5 - Collaborate with the organization’s managers. 6 - Approve the organization’s plan for quality and patient safety and regularly receive and act on reports of the quality and patient safety program.

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► A senior manager or director is responsible for operating the organization and complying with the applicable laws and regulations. ► Medical, nursing, and other leaders of clinical services plan and implement an effective organizational structure to support their responsibilities and authority..

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One or more qualified individuals provide direction for each department in the organization. The Directors of each clinical department :  Identify in writing, the services to be provided by the department.  Recommend space, equipment, staffing, and other resources needed by the department or service.  Recommend criteria for selecting the department or services professional staff and choose or recommend individuals who meet those criteria

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 Provide orientation and training for all staff of the department or service appropriate to their responsibilities.  Monitor the departments services performance as well as staff performance. The organization establishes a framework for ethical management that ensures that patient care is provided within business, financial, ethical, and legal norms and that protects patients and their rights.

4-Facility Management and Safety:

4-Facility Management and Safety Health care organizations work to provide a safe, functional, and supportive facilicy for patients, families, staff ,To reach this goal, the physical facility, medical and other equipment, and people must be effectively managed. In particular, management must strive to: *Reduse and control hazards and risks. *Prevent accidents and injuries. *Maintaine safe conditions .

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Effective management includes planning, education, and monitoring. Written plans are developed & consider the following areas when appropriate to the facilitiy& activities of the organization. 1- Safety&security: The organization plans and implements a program to provide a safe and secure physical environment. The organization inspects all patient care buildings and has a plan to reduce evident risks and to provide a safe physical facility for patients, families, staff, and visitors .

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2- Hazardous materials-handling: Storage,use of radioactive materials,hazardous material is safely disposed. Such materials and waste include : chemicals, chemotherapeutic agents,radioactive materials and waste, hazardous gases and vapors, and other regulated medical and infectious waste 3- Emergency management-response: The organization develops and maintains an emergency management plan and program to respond to likely community emergencies, epidemics, and natural or other disasters. The organization tests its response to emergencies, epidemics, and disasters .

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4 - Fire safety: - The organization plans and implements a program to ensure that all occupants are safe from fire, smoke -The plan includes prevention, early detection, suppression, abatement, and safe exit from the facility in response to fires and nonfire emergencies. -The organization regularly tests its fire and smoke safety plan, including any devices related to early detection and suppression, and documents the results -Staff trained to participate in at least one fire/smoke test per year

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5- Medical equipment: Equipment is selected ,maintained,and used in manner to reduse risks. The organization plans and implements a program for inspecting, testing, and maintaining medical equipment and documenting the results . 6- Utility systems: Electrical,water,&other utility systems are maintained to minimize the risks of operating failure. Potable water and electrical power are available 24 hours a day, seven days a week, through regular or alternate sources, to meet essential patient care needs. The organization has emergency processes to protect facility occupants in the event of water or electrical system disruption, contamination, or failure.

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7- Staff Education The organization educates and trains all staff members about their roles in providing a safe and effective patient care facility. Staff members are trained and knowledgeable about their roles in the organization’s plans for fire safety, security,hazardous materials, and emergencies. Staff are trained to operate and to maintain medical equipment and utility systems. The organization periodically tests staff knowledge through demonstrations, mock events, and other suitable methods. This testing is then documented

5- Staff Qualifications and Education (SQE):

5- Staff Qualifications and Education (SQE) A health care organization needs an appropriate variety of skilled, qualified people to fulfill its mission and to meet patient needs. The organization’s leaders work together to identify the number and types of staff needed based on the recommendations from department and service directors. .

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J oint C ommission I nternational SQE standards are incorporated into the daily practice of SSH by each of the examples stated below, which follow each Standard. 1-Organization leaders define the desired education, skills, knowledge, and other requirements of all staff members . Leaders use the following factors to project staffing needs: ► The organization’s mission. ► The mix of patients served by the organization and the complexity and severity of their needs. ► The services provided by the organization. ► The technology used in patient care. .

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2 - Each staff member's responsibilities are defined in a current job description. 3 -Organization leaders develop and implement processes for recruiting, evaluating, and appointing staff as well as other related procedures identified by the organization 4 - The organization uses a defined process to ensure that clinical staff knowledge and skills are consistent with patient needs. Examples : Staffing Plans, Scopes of Service, and Duty Rosters are used in conjunction with the Employee Performance Appraisal Program (EPAP), and identified hospital needs.

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5 - There is documented personnel information for each staff member. 6 - A staffing plan for the organization, developed by the leaders, identifies the number, types, and desired qualifications of staff. reviewed and updated as necessary. Examples: Senior Management regularly reviews Staffing Plans, in particular in conjunction with Plans for new services. 7 -All clinical and nonclinical staff members are oriented to the organization, the department or unit.

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8 - Health care provider staff are trained in resuscitative techniques. 9 -The organization provides facilities and time for staff education and training. 10 -The organization provides a staff health and safety program.

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11 -The organization has an effective process for gathering, verifying, and evaluating the credentials (license, education, training, and experience) of those medical staff permitted to provide patient care without supervision. Examples : Established process through the Saudi Council for Health Specialties (MOH

6-Management of Communication and Information (MCI):

6-Management of Communication and Information (MCI) Providing patient care is a complex process that is highly dependent on the communication of information. This communication is : To and with the community, To patients and their families, and to other health professionals. Failures in communication are one of the most common root causes of patient safety incidents .

Policy and Planning:

Policy and Planning Communications plans should identify: What information is essential and can be shared. Who . . . Needs the information. Has the information. How . . . Information will flow. Information is coordinated for public and media release. Communications systems will be used.

Flexible Communications and Information Systems:

Flexible Communications and Information Systems Accurate Information Communications Flow Effective Decision making + =

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The organization communicates with its community to facilitate access to care and access to information about its patient care services. The types of information communicated include: ♦ Information on services, ♦ hours of operation, and the process to obtain care ♦ Information on the quality of services, which is provided to the public and to referral sources. Patient and family communication and education are provided in an understandable format and language .

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Communication is effective throughout the organization ►Information Planning should ensure that the organization’s information needs are met, including: ♦ Computer systems ♦ Mail ♦ Movement of materials / records ♦ Printed products ♦ Clinical records ►The leaders ensure that there is effective communication and coordination among those individuals and departments responsible for providing clinical services.

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► The organization plans and designs information management processes to meet internal and external information needs. ♦ Information privacy and confidentiality are maintained. ♦ Information security, including data integrity, is maintained. ♦ The organization has a policy on the retention time of records, data, and information. ♦ The organization uses standardized diagnosis codes, procedure codes, symbols, abbreviations, and definitions. ♦ Records and information are protected from loss, destruction, tampering, and unauthorized access or use.

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►Information about the patient’s care and response to care is communicated among medical, nursing, and other care providers during each staffing shift, and between shifts. ► The patient’s record(s) is available to the health care practitioners to facilitate the communication of essential information. Information related to the patient’s care is transferred with the patient

Patient Clinical Record:

Patient Clinical Record The clinical record contains sufficient information to ♦ identify the patient ♦ support the diagnosis ♦ justify the treatment ♦ document the course & results of treatment ♦ promote continuity of care Emergency Records include ♦ Arrival time ♦ Conclusions at end of treatment ♦ Patient condition at discharge ♦ Follow up instructions The organization initiates and maintains a clinical record for every patient assessed or treated.

Aggregate Data and Information:

Aggregate Data and Information Data is aggregated for clinical, managerial, and quality analysis; and outside agencies. Timely information from external sources (i.e. library function) available For patient care, clinical education, research, & management Participation in external databases Confidentiality is maintained