accident emergency care related standards
TRANSCRIPT
-
8/2/2019 Accident Emergency Care Related Standards
1/26
HAADStandards
forLicensureandQuality
Improvement
Dr.David
Matear
ProjectManager
-
8/2/2019 Accident Emergency Care Related Standards
2/26
Agenda
1. BackgroundtotheHAADStandardsproject
2. HAADJCIStandards
3. HospitalStandards
4. Majorstandardschapters
5. Identifiedproblems
6. Relevantstandards
PatientSafetyandQualityImprovement(PCQ)
Communication(CCC)
HighRiskCareProcesses(HRC)
Leadership(LDS)
7. Summary
-
8/2/2019 Accident Emergency Care Related Standards
3/26
BackgroundtotheHAADStandards
project
Facilitieslicensingstandards
Standardsdocumentation
(14
documents)
Inspectionprocess
Internationalstandards
Documentationandstandardsselectionofavarietyofstandards(ISO,JCI,JCAHO,CCHSA,OSHA)
Achievable
in
the
private
sector?
Tawam andRahba achievedJCIin23years
SKMCworkingtowardsJCI(1year+)
RFP Standards
development
and
inspector
training
-
8/2/2019 Accident Emergency Care Related Standards
4/26
HAADJCIStandardsPartnership
Developedandapproved Hospital
Standards
AmbulatoryCareStandards
Continuumof
Care
Standards
Future
MedicalTransport
Laboratories
Ionizingradiation
-
8/2/2019 Accident Emergency Care Related Standards
5/26
HSRCTermsofReferenceAdministrative
Decision
No.26/2007
Administrativedecision MembershipfromHAAD,HealthServicesCompanyand
managementorganizations
Goal Review,amendment,andrecommendationofstandardsforlicensureandinspectionofhealthfacilitiesintheEmirateofAbuDhabi.
Objectives ReviewdraftstandardssubmittedbyJCIintheareasofHospital,
AmbulatoryCare,andContinuumofCare.
Consider
other
developing
and
related
standards. Proposeamendmentstotheproposedstandards.
Recommendtheadoptionofstandardsthatareconsistentwithinternationalstandards.
Developamechanismforannualstandardsreview.
-
8/2/2019 Accident Emergency Care Related Standards
6/26
MajorStandardsChapters
PatientSafetyandQuality
Improvement
Communication
Highrisk
care
processes
Leadership
FacilitySafety
-
8/2/2019 Accident Emergency Care Related Standards
7/26
MandatoryStandards
Representthemostimportant
Basedon
law,
regulatory
policies
SelectedcriticalMeasurableElements(MEs)
orstandards
MUSTbemetforlicensure
-
8/2/2019 Accident Emergency Care Related Standards
8/26
ProblemsIdentified
Patientsafety
Communication
Provisionofhighriskcare
Referralsand
transfers
Documentation
Professionalqualifications
and
skills
-
8/2/2019 Accident Emergency Care Related Standards
9/26
GeneralPrinciples
Ensuretheclinicalandotherprofessionalqualificationsofall
staffaccordingtoHAADlicensingpolicies
Expectationsofinternationalgoodpractice
Maintainsafety
Ensuretheirfacilitiesandequipmentaresufficient
deliversafe,
high
quality
care
in
accordance
with
international
good
practice.
Ensuretherearerobustclinicalandmanagementprocesses
forthe
tracking
of
patient
safety
and
the
effectiveness
of
treatment,includingaccurate,fitforpurposeclinicalrecords.
Reportanyoccurrencethatresultsinarisktopatientsafety
orcompromises
the
delivery
of
high
quality
care
-
8/2/2019 Accident Emergency Care Related Standards
10/26
PatientSafetyGoals
All6PatientSafetyGoalsareMANDATORY
Relevantother
standards
PCQ.1Goal1 Identifypatientscorrectly
ME5Before
treatment
or
procedures
PCQ.2Goal2 Improveeffective
communication
-
8/2/2019 Accident Emergency Care Related Standards
11/26
MonitoringRequirements
PCQ.8 MonitoringofPatientSafetyGoals
PCQ.13 Identificationofkeymeasurestomonitor ME5 Patientassessment ME13 Availability,timeliness,content,anduseof
patientrecords
ME16
Reporting
of
activities
as
required
by
law
and
regulation
ME17 Riskmanagement
ME23 Preventionandcontrolofeventsthatjeopardizethe
safety
of
patients,
families,
and
staff
-
8/2/2019 Accident Emergency Care Related Standards
12/26
InvestigationandReportingofEvents
PCQ.17 Thehospitalusesadefinedprocess
foridentifying
and
managing
sentinel
events
Definitionofeventstobeinvestigated
Rootcause
analysis
within
45
days
Changeprocedures
PCQ.18 Dataareanalyzedwhen
undesirabletrends
and
variation
are
identified
C i i
-
8/2/2019 Accident Emergency Care Related Standards
13/26
Communication
Admission CCC.1 Patientsareadmittedtoreceiveinpatientcare
basedontheiridentifiedhealthcareneedsandthehospitalsmissionandresources. ME
1 Screening
is
initiated
at
the
point
of
first
contact
within
or
outsidethehospital.
CCC.3 Patientswithemergencyorimmediateneedsaregivenpriorityforassessmentandtreatment. ME
1 The
hospital
has
established
criteria
to
prioritize
patients
withimmediateneeds.
CCC.6 Admissionortransfertoorfromunitsprovidingintensiveorspecializedservicesisdeterminedby
establishedcriteria.
ME1 Thehospitalhasestablishedentryand/ortransfercriteriaforitsintensiveandspecializedservicesorunits.
ME5 Patientstransferredoradmittedtointensiveandspecialized
units/services
meet
the
criteria
and
this
is
documented
in
the
patientsrecord.
-
8/2/2019 Accident Emergency Care Related Standards
14/26
Discharge,Referral,Followup
CCC.8 Thereisapolicyguidingtheappropriatereferralordischargeofpatients
ME1 Thereisapolicyguidingtheappropriatereferraland/ordischargeofpatients
ME2 Thereferraland/ordischargeisbasedonthe
patientsneeds
for
continuing
care
CCC.9 Patientrecordscontainacopyofthedischargesummary
ME4 A
copy
of
the
discharge
summary
is
provided
to
thepractitionerresponsibleforthepatientscontinuingorfollowupcare
-
8/2/2019 Accident Emergency Care Related Standards
15/26
TransferofPatients
CCC.10 Thereisapolicyguidingtheappropriatetransferofpatientstoanotherhospitalororganizationtomeettheir
continuingcare
needs
ME2 Theprocessaddressesthetransferofresponsibilitytoanotherproviderorsetting
ME5 Theprocessaddresseswhoisresponsibleduringtransfer
ME
7
Patients
are
appropriately
transferred
to
other
hospitals
or
organizations
CCC.11 Thereferringhospitalorganizationdeterminesthatthereceivinghospitalcanmeetthepatientscontinuingcare
needs ME1 Thereferringhospitaldeterminesthatthereceivinghospitalcanmeettheneedsofthepatienttobetransferred
ME2 Patientclinicalinformationoraclinicalsummaryistransferredwiththepatient
-
8/2/2019 Accident Emergency Care Related Standards
16/26
TransferofPatients
CCC.12 Duringdirecttransfer,aqualifiedstaffmembermonitorsthepatientscondition
ME1 All
patients
are
monitored
during
direct
transfer
to
another
hospital
CCC.13 Thetransferprocessisdocumentedinthepatientsrecord
ME1 The
records
of
transferred
patients
note
the
name
of
the
hospitalandnameoftheindividualagreeingtoreceivethepatient
ME2 Therecordsoftransferredpatientsnotethereason(s)fortransfer
ME3 Therecordsoftransferredpatientsnoteanyspecialconditions
related
to
transfer
ME4 Therecordsoftransferredpatientsnoteanychangeofpatientconditionorstatusduringtransfer
-
8/2/2019 Accident Emergency Care Related Standards
17/26
Transportation
CCC.14 Theprocessforreferring,
transferring,or
discharging
the
patient
considerstransportationneeds
ME1 Theprocessforreferringpatients
considerstransportation
needs
ME4 Transportationisappropriatetothe
patientsneeds
-
8/2/2019 Accident Emergency Care Related Standards
18/26
HighRiskCare
Assessmentsand
Care
HRC11 Qualifiedindividualsconducttheassessmentsandreassessments
ME2 Onlythoseindividualspermittedbylicensure,applicablelawsandregulations,orcertificationperformpatientassessments
ME3 Emergency
assessments
are
conducted
by
individualsqualifiedtodoso
HRC16 Policiesandproceduresguidethecareof
highrisk
patients
and
the
provision
of
high
risk
services
ME1 (a)Careofemergencypatients
-
8/2/2019 Accident Emergency Care Related Standards
19/26
Leadership
Ethics LDS.3 Thehospitalestablishesaframeworkfor
ethical
management
that
ensures
that
patient
care
isprovidedwithinbusiness,financial,ethical,and
legalnormsandthatprotectspatientsandtheir
rights ME4 Thehospitalprovidesclearadmission,transfer,and
dischargepolicies
ME6 The
hospital
discloses
and
resolves
conflicts
when
financialincentivesandpaymentarrangements
compromisepatientcare
-
8/2/2019 Accident Emergency Care Related Standards
20/26
DepartmentalLeadership
LDS.8 Oneormorequalifiedindividuals
providedirection
for
each
department
or
serviceinthehospital
ME1 Anindividualwithappropriatetraining,education,
andexperience
directs
each
department
or
service
in
the
hospital
-
8/2/2019 Accident Emergency Care Related Standards
21/26
StaffEducation
LDS.17 Staffmemberswhoprovidedirectcareandservicesandotherstaffidentifiedbythehospitalareannually
trainedin
basic
or
advanced
cardiac
life
support
ME1 Staffmemberstobetrainedincardiaclifesupportareidentifiedbythedevelopmentofalist. Thelist
includes
at
least
all
direct
care
givers
ME2 Theappropriateleveloftrainingisprovided(e.g.,basiclifesupport(BLS),advancedlifesupport(ALS),pediatricadvancedlifesupport(PALS))
ME3 Staff
members
are
retrained
every
two
years
ME4 Thereisevidencetoshowifastaffmemberpassedthetrainingwhichincludesbothawrittentestandreturn
demonstration
-
8/2/2019 Accident Emergency Care Related Standards
22/26
MedicalStaffing
LDS.18 Thehospitalhasaneffectiveprocessforgathering,verifying,andevaluatingthecredentials(license,education,
training,and
experience)
of
those
medical
staff
permitted
to
providecareandservicestoindividualswithoutsupervision
ME1 Thosepermittedbylawsandregulationsandby
the
hospital
to
provide
care
and
services
to
individuals
withoutsupervisionareidentified
ME2 Currentlicensure,education,training,andexperiencearedocumentedfortheseprofessionals
ME3 Such
information
is
verified
from
the
original
source
-
8/2/2019 Accident Emergency Care Related Standards
23/26
MedicalStaffing
LDS.19 Thehospitalmaintainsforeverymedical
staff
member
a
record
of
the
current
professional
license,certificate,orregistrationwhenrequiredby
lawsorregulationsorbytheorganization
ME
2(c)
Current
list
of
privileges
LDS.20 Thecredentialsofmedicalstaffmembers
arereevaluatedatleastevery3yearstodetermine
theirqualifications
to
continue
to
provide
care
and
servicesintheorganization
ME1 Thereisaprocesstoevaluateeachmedicalstaff
memberevery
three
years
-
8/2/2019 Accident Emergency Care Related Standards
24/26
MedicalStaffing
LDS.21 Thehospitalhasastandardized,objective,
evidencebasedproceduretoauthorizeallmedical
staffmemberstoadmitandtreatpatientsand
provideotherclinicalservicesconsistentwiththeir
qualifications ME1 Thereisastandardizedproceduretogrant
privilegestopractitionersoninitialappointmentandon
reappointment
every
three
years ME5 Theaggregationoftheannualdataisusedinthe
evaluationforreappointmentwhichoccurseverythree
years
S
-
8/2/2019 Accident Emergency Care Related Standards
25/26
Summary
Approved
licensing
standards
govern
health
care
Mandatorystandardsmustbemet
Theproblemsidentifiedarecoveredinthestandards
Patientsafety
Communication
Provisionofhighriskcare
Referralsandtransfers
Documentation
Professionalqualificationsandskills
Relevantstandardstoidentifiedproblems
PatientSafety
and
Quality
Improvement
(PCQ)
Communication(CCC)
HighRiskCareProcesses(HRC)
Leadership
(LDS) Inspectorswillenforcethatstandardsaremet
-
8/2/2019 Accident Emergency Care Related Standards
26/26
QUESTIONS?