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 

I.

PRIMUM NON NOCERE First Do No Harm

Define the Need

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

Team Building and Group Activities

Group and Individual Recognitions:

Driving Commitment for Quality Improvement

We can do the seemingly impossible –bridge the gaps if we work together!

“BEGIN with the END in MIND.”Steven Covey

5th Edition: JCI standards

•16 Chapters

•287  standards

•1,146 Measurable elements

III. Create a Time Line

JCI Accreditation Preparation

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

V. Learning and Training

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:

VI. Audits, Tracers, Measures

Audits, Tracers, Measures

MAIN ACTIVITIES IN TRACER

• Review Documentation

• Talk & Listen

• Observe

• Record

Measures:• Quality Indicators• Performance Improvement Projects• CPGs• Programs – QIPS, IPC, FMS• Patient Satisfaction Survey• Culture of Safety Survey• Open and Close Medical Records Review

VII. Feedback and Action Plans

VIII. Actual Accreditation

CREATE a CULTURE of SAFETY and QUALITY of CARE

Celebrate Success!

CONCLUSION: 

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 !