compliance with cpgs-related qi accreditation standards
TRANSCRIPT
![Page 1: Compliance with CPGs-related QI accreditation standards](https://reader036.vdocument.in/reader036/viewer/2022091122/588391901a28ab07628b76b5/html5/thumbnails/1.jpg)
Compliance with CPGs-related
accreditation standards(ACI & CBAHI – 2016/2017)
Dr. Yasser S. AmerQuality Management Department
Medical-City Wide CPGs Steering CommitteeResearch Chair for Evidence-Based Health Care & Knowledge Translation
With gratitude Compiled by Mohammed Hussein, Accreditation Unit
![Page 2: Compliance with CPGs-related QI accreditation standards](https://reader036.vdocument.in/reader036/viewer/2022091122/588391901a28ab07628b76b5/html5/thumbnails/2.jpg)
Current Practice
Best Practice
Clinical Care Gap
![Page 3: Compliance with CPGs-related QI accreditation standards](https://reader036.vdocument.in/reader036/viewer/2022091122/588391901a28ab07628b76b5/html5/thumbnails/3.jpg)
PROVISION OF CARE18. Clinical practice guidelines, pathways, and protocols are developed or adopted to guide priority care services (CBAHI Ref. PC. 18)
18.1 .The hospital implements the national CPGs, pathways, and protocols that are consistent with current EB practice.
18.2 .CPGs, pathways, and protocols are updated at least every two years and as required with emphasis on the most common diagnosis.
18.3 .CPGs, pathways, and protocols are documented in the patient’s medical record.
![Page 4: Compliance with CPGs-related QI accreditation standards](https://reader036.vdocument.in/reader036/viewer/2022091122/588391901a28ab07628b76b5/html5/thumbnails/4.jpg)
CPGs standards in All Accreditation Chapters(PCC-15, ICU-13, Cancer-14, DEM-15, MED/PED-13, OBSGYNE-16, PSYCH-16, OR-27, REHAB-14)The team bases its services on (the latest) research, EB-CPGs, and best practice information to improve quality of its services.
![Page 5: Compliance with CPGs-related QI accreditation standards](https://reader036.vdocument.in/reader036/viewer/2022091122/588391901a28ab07628b76b5/html5/thumbnails/5.jpg)
CPGs’ Sub-standardsEvidence Standard/ sub-standard
• CPG Steering/ dept. committees.
• Adapt/ adopt from int’l CPGs
• Access: printed/ e- (offline/online/eSiHi)
• ICity: Academic digital library
The team has access to EB-CPGs for _________ services.
(AC-Gold)
![Page 6: Compliance with CPGs-related QI accreditation standards](https://reader036.vdocument.in/reader036/viewer/2022091122/588391901a28ab07628b76b5/html5/thumbnails/6.jpg)
CPGs’ Sub-standardsEvidence Standard/ sub-standard
• Policy• AGREE II Instrument
(QA) is a main part of the ADAPTE methods.
The team follows a standardized process to select EB-CPGs for _________ services.
(AC-Platinum)
![Page 7: Compliance with CPGs-related QI accreditation standards](https://reader036.vdocument.in/reader036/viewer/2022091122/588391901a28ab07628b76b5/html5/thumbnails/7.jpg)
CPGs’ Sub-standardsEvidence Standard/ sub-standard
• Policy: (same) AGREE: Domains #3 (methods), #5 (App).
• (Different) (Cochrane)SR/ Evidence synthesis of several specific CPGs?
The team has a detailed process to select between conflicting EBCPGs, multiple Rs, or the app of > CPG for clients with comorbidities. (AC-Diamond)
![Page 8: Compliance with CPGs-related QI accreditation standards](https://reader036.vdocument.in/reader036/viewer/2022091122/588391901a28ab07628b76b5/html5/thumbnails/8.jpg)
CPGs’ Sub-standardsEvidence Standard/ sub-standard
• Disease-specific (Adapted CPG)
The team’s assessment process is based on EB CPGs.
(AC-Diamond)
![Page 9: Compliance with CPGs-related QI accreditation standards](https://reader036.vdocument.in/reader036/viewer/2022091122/588391901a28ab07628b76b5/html5/thumbnails/9.jpg)
CPGs’ Sub-standardsEvidence Standard/ sub-standard
• Or other CPG implementation tools (?)
• Detect/ justify variation in practice + link to clinical outcomes.
The team has care pathways for the common diagnoses that it manages .
(AC-Diamond)
![Page 10: Compliance with CPGs-related QI accreditation standards](https://reader036.vdocument.in/reader036/viewer/2022091122/588391901a28ab07628b76b5/html5/thumbnails/10.jpg)
CPGs’ Sub-standardsEvidence Standard/ sub-standard
• Access: 1. Printed: NSG, Drs.2. Electronic:(offline-PC, online-ICity, eSiHi-PowerPlans/Forms).
The team has access to EB CPGs at the point of care.
(AC-Platinum)
![Page 11: Compliance with CPGs-related QI accreditation standards](https://reader036.vdocument.in/reader036/viewer/2022091122/588391901a28ab07628b76b5/html5/thumbnails/11.jpg)
CPGs’ Sub-standardsEvidence Standard/ sub-standard
• Access: 1. Printed: NSG, Drs.2. Electronic:(offline-PC, online-ICity, eSiHi-PowerPlans/Forms).
The team has uses CPGs (& CPs that are based on CPGs) to standardize the delivery of ____care services.
(AC-Platinum)
![Page 12: Compliance with CPGs-related QI accreditation standards](https://reader036.vdocument.in/reader036/viewer/2022091122/588391901a28ab07628b76b5/html5/thumbnails/12.jpg)
CPGs’ Sub-standardsEvidence Standard/ sub-standard
• Adapted CPG: section for update/ review.
• *2-5 years.• CPG dept.
committee
The team regularly* reviews its CPGs to verify they are up-to-date and reflect current research and best practice info. High priority(AC-Platinum)
![Page 13: Compliance with CPGs-related QI accreditation standards](https://reader036.vdocument.in/reader036/viewer/2022091122/588391901a28ab07628b76b5/html5/thumbnails/13.jpg)
CPGs’ Sub-standardsEvidence Standard/ sub-standard
• Clinical audit, case reviews, clinical rounds & discussions.
The team’s CPG review process includes seeking input from team members about CPG applicability & ease of use .(AC-Platinum)
![Page 14: Compliance with CPGs-related QI accreditation standards](https://reader036.vdocument.in/reader036/viewer/2022091122/588391901a28ab07628b76b5/html5/thumbnails/14.jpg)
CPGs’ Sub-standards (Non-CPG!)Evidence Standard/ sub-standard
• IRB Policy• IRB Approvals for all
research activities available.
The team’s research activities for ____ services meet applicable research and ethics protocols and standards. High priority(AC-Diamond)
![Page 15: Compliance with CPGs-related QI accreditation standards](https://reader036.vdocument.in/reader036/viewer/2022091122/588391901a28ab07628b76b5/html5/thumbnails/15.jpg)
CPGs’ Sub-standardsEvidence Standard/ sub-standard
• Conferences papers.• Full-text publications.• Saudi specialized
Assn's endorsement.• Special collaboration/
communication (?Ext. review)
The team shares research, CPGs and benchmark info with its partners & other similar organizations. Team’s mandate/scope. High priority(AC-Diamond)
![Page 16: Compliance with CPGs-related QI accreditation standards](https://reader036.vdocument.in/reader036/viewer/2022091122/588391901a28ab07628b76b5/html5/thumbnails/16.jpg)
INFECTION PREVENTION & CONTROL(CBAHI Ref. IPC 39-43) * Area for improvement
• 13.2. The hospital implements EB interventions to prevent VAP*.• 13.13. The hospital implements EB interventions to prevent SSI. Two adapted CPGs by SURG SAP (ASHP-13) & NSG SSIP (NICE-11), HW-QIP.• 13.14. The hospital implements EB interventions to prevent
CAUTI*. • 13.15. The hospital implements EB interventions to prevent
CLABSI. Adapted CPG by NSG (CDC-11, INA-11)• 13.16. The hospital implements EB interventions to reduce the
burden of epidemiologically significant organism (MDROs)*
![Page 17: Compliance with CPGs-related QI accreditation standards](https://reader036.vdocument.in/reader036/viewer/2022091122/588391901a28ab07628b76b5/html5/thumbnails/17.jpg)
EMERGENCY STANDARDS•9.8. The team uses EB protocols to select diagnostic
imaging services for pediatric clients (DEM/RADIOLOGY)*.•11.7. The team uses EB care protocols when providing
emergency department services to clients.
![Page 18: Compliance with CPGs-related QI accreditation standards](https://reader036.vdocument.in/reader036/viewer/2022091122/588391901a28ab07628b76b5/html5/thumbnails/18.jpg)
CRITICAL CARE • 7.5. ROP The team identifies medical and surgical clients at risk of
VTE (DVT & PE) and provides appropriate thromboprophylaxis.Adapted CPG by ICU VTEP (ACCP-12), HWPP, HW-QIP, … OBGYNE section for pregnant women (obstetric) not CS*!*MED VTE (T) CPG (ACCP-16) in progress9.5. There are EB criteria for intubation, weaning off ventilator & extubation.9.6. The team follows a protocol when conducting a daily interruption in sedation ICU CPG in progress.
![Page 19: Compliance with CPGs-related QI accreditation standards](https://reader036.vdocument.in/reader036/viewer/2022091122/588391901a28ab07628b76b5/html5/thumbnails/19.jpg)
QMD Priority topics:-Process for Effective identification, assessment & intervention for patients with:-•Risk of Pressure ulcers.•Risk of falling.•Prevent catheter & tubing misconnections.