7-8 september 2016 | sheraton hotel & towers | ho chi minh ... · hospital management asia ho...
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7-8 September 2016 | Sheraton Hotel & Towers | Ho Chi Minh City, Vietnamwww.hospitalmanagementasia.com
QUALITY IMPROVEMENT PROCESS through ACCREDITATION
Juan Lucas Rosas, MDQuality Assurance Director
FV Hospital7 September 2016
Hospital Management AsiaHo Chi Minh City, Vietnam
I. Define the Need for Quality Improvement II. Team Building and Group ActivitiesIII. Create a Time LineIV. Prepare Documentation and Implementation PlanV. Facilitate Learning and TrainingVI. Audit, Tracers, MeasuresVII. Feedback and Action PlanningVIII.Validation through Accreditation
CREATE CULTURE of SAFETY and QUALITY of CARE
How to Drive Quality Improvement Process through Accreditation
Deaths:
-Medical Errors (98,000) > Vehicle Accidents(43,000),
Breast Cancer (42,000)
AIDS (16,000).
-Medication Errors > Workplace Injuries
IOM REPORT: “TO ERR IS HUMAN”
IOM REPORT: “TO ERR IS HUMAN”
Less deaths from adverse events occurring in
nuclear reactors and the airline industry
than the Hospital Industry
Mission:“Provide World‐Class Medical Expertise People Trust”
Values
Quality of CarePatient Safety Practices
CompetenciesBehaviour
Alignment to the Mission/Vision/ Core Values of the HospitalFull Support of the Top Management
Define the need.
JCI accredited organizations have all demonstrated:• A deep commitment to high-quality care• A culture of safety for patients, visitors, and staff• A willingness to undergo rigorous preparation and a survey• Care delivery based on leading, evidence-based practices• Leadership in continuous compliance with exacting standards
Advantages and Benefits of Accreditation:
• Helps organize and strengthen patient safety efforts
• Strengthens community confidence in the quality and safety of care, treatment and services
• Provides a competitive edge in the marketplace• Improves risk management and risk reduction • May reduce liability insurance costs• Provides education to improve business
operations• Provides professional advice and counsel,
enhancing staff education
Advantages and Benefits of Accreditation:
• Provides a customized, intensive review • Enhances staff recruitment and development • Recognized by insurers • Provides a framework for organizational structure
and management • May fulfill regulatory requirements in select
countries .• Provides practical tools to strengthen or maintain
performance excellence • Aligns health care organizations with one of the
most respected names in health care
The Dangers of Self Regulation:• Complacency• “Reinventing the Wheel”• Inherent Bias• Credibility and Difficulty within the ranks• Resistance and Refusal to change
II.
“ All change is hard at the beginning, messy in the middle and beautiful at the end.”
Challenges:• Resistance to change• Working in Silos• “What is there for me?”
Team Building and Group Activities
“BEGIN with the END in MIND.”Steven Covey
5th Edition: JCI standards
•16 Chapters
•287 standards
•1,146 Measurable elements
IV.
Chapter Code of Standards Required Hospital Programs by JCI Relevant FVH programs / plans Code of documentSent to
Compliance Team
Check Approved by PRC/CEO
AOPAOP.5.3
Laboratory quality and safety programLaboratory Quality Management Program LAB-PRG-008-2015 26/5/2015 Y 24/6/2015
AOP.5.9 Laboratory Biosafety Programme LAB-PLA-015-2014 26/5/2015 Y 4/6/2015
AOP
AOP.6.3
Radiation quality and safety program
Radiation Safety Policy of Imaging Department RSC-POP-348-2013
AOP.6.7
Radiation safety and mobile radiography RSC-POP-040-2014
Radiology quality program 04-01-2015 Y
MMU MMU.1 Medication management and use program Medication Management & Use Program 26/3/2015 Y 9/4/2015
QPSGLDPCI
QPS.1GLD.4PCI.10
Quality improvement and patient safety program Quality Improvement and Patient Safety Program QAD-PRG-004-2015 26/5/2015
QPS QPS.11 Risk management program FVH Risk Management Programme QAD-PRG-013-2015 13/7/2015 Y 22/7/2015
PCI PCI.5 Infection prevention and control program Infection Prevention and Control Programme 2015 IPCC-PRG-012-2015 26/5/2015 Y
GLDSQE
GLD.3.3SQE.2SQE.8
Programs for the recruitment, retention, development, and continuing education of all staff
Recruitment Policy HRD-POP-095-2012
Employment Policy HRD-POP-275-2013
Training and Development Policy and Procedure HRD-POP-384-2014
GLD GLD.13 Culture of safety program Culture of safety program MED-PRG-018-2015 15/6/2015 Y
FMS FMS.2 Program to provide a safe physical facility Safety and Security Plan FAC-PLA-011-2014
Program to provide a secure environment for patients, families, staff, and visitors Safety and Security Plan FAC-PLA-011-2014
Hazardous materials and waste program
Hazardous Material and Waste Management Program (HMWP) 06-07-2015 Y
Waste Management Plan FAC-PLA-003-2011
Emergency management program Disaster Management Plan FAC-POP-094-2011
Fire and smoke safety program Fire Safety Management Plan FAC-PLA-010-2014
Program for inspecting, testing, and maintaining medical technology
Biomedical Equipment Management Program (MEMP) 14/8/2015
Hospital utility systems program Utility Management Plan FAC-POP-220-2012 04-06-2015 Y
SQE SQE.8.2 Staff health and safety program Staff Health Check Policy
MPE Medical professional education program
HRP Research program
HRP Program for the protection of human subjects
Documentation and Implementation
Learning and Training to Improve Compliance:• Online JCI Training Course• Coaching Rounds – Culture of Safety, PDCA for PIs• Weekly JCI short informational notes on FVH Intranet
screen saver – Tip/s of the Day• Handbook on JCI Standards• Intra –Departmental Review of FVH Policies• Awareness Week Celebration• Environment of Care Rounds• Mock Surveys and Tracers• JCI Task Force
Coaching Sessions on
Patient Safety
Incident Management
Culture of Safety
Programme
Implementation of Just Culture Decision Chart
CULTURE OF SAFETY Coaching:
Measures:• Quality Indicators• Performance Improvement Projects• CPGs• Programs – QIPS, IPC, FMS• Patient Satisfaction Survey• Culture of Safety Survey• Open and Close Medical Records Review
Beginning of an End:Pledge to continue the Culture of Safety and Quality of Care
Quality Improvements never cease even to the best of hospitals in the world !