finalization of hospital accreditation standards
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Finalization of Hospital Accreditation Standards
Workshop on
Directorate General of Health Services (DGHS)Government of the People’s Republic of Bangladesh
September 08, 2012
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Draft | Hospital Standards
• The hospital standards are first divided into two major sections:
1. Patient-Focused Standards [5 chapters]
2. Hospital-Focused Standards [5 chapters]
Directorate General of Health Services (DGHS)Government of the People’s Republic of Bangladesh
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Draft | Patient Focus Standards | 5 Chapters
• Patient-focused standards section is extended into 5 chapters:
1. Patient Safety Goals [PSG]
2. Total Patient Management [TPM]
3. Critical Care Management [CCM]
4. Total Medication Management [TMM]
5. Patient and Family, Rights and Education [PFRE]
Directorate General of Health Services (DGHS)Government of the People’s Republic of Bangladesh
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Draft | Hospital-Focused Standards | 5 Chapters
• Hospital-focused standards section is further extended into another 5 chapters:
1. Quality and Risk Management [QRM]
2. Infections Control and Prevention [ICP]
3. Facility Safety and Equipment Management [FSEM]
4. Governance and HR Management [GHM]
5. Information and Communication [IAC]
Directorate General of Health Services (DGHS)Government of the People’s Republic of Bangladesh
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Patient Focus Standards| Chapter 1
PSG.1 Identify Patients CorrectlyPSG.2 Improve Effective CommunicationPSG.3 Improve the Safety of High-Alert MedicationsPSG.4 Ensure Correct-Site, Correct-Procedure, Correct-
Patient SurgeryPSG.5 Reduce the Risk of Hospital–Associated InfectionsPSG.6 Reduce the Risk of Patient’s Falls
Directorate General of Health Services (DGHS)Government of the People’s Republic of Bangladesh
6 (six) Patient Safety [PSG] Goals
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Patient Focus Standards| Chapter 2
Directorate General of Health Services (DGHS)Government of the People’s Republic of Bangladesh
Total Patient Management [TPM]
• Admission to the Hospital• Continuity of Care• Assessment of patient• Laboratory Services• Radiology and Diagnostic Imaging Services• Uniform Care Delivery• Care of High-Risk Patients and Provision of High-Risk Services• Food and Nutrition Therapy• End-of-Life Care• Discharge, Referral, and Follow-Up• Transfer of Patients | Transportation
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Patient Focus Standards| Chapter 3
Directorate General of Health Services (DGHS)Government of the People’s Republic of Bangladesh
Critical Care Management [CCM]
• Management Responsibility• Sedation Care• Anesthesia Care• Surgical Care
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Patient Focus Standards| Chapter 4
Directorate General of Health Services (DGHS)Government of the People’s Republic of Bangladesh
Total Medication Management [TMM]
• Management Responsibility• Selection and Procurement• Storage• Ordering and Transcribing• Preparing and Dispensing• Administration• Monitoring
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Patient Focus Standards| Chapter 5
Directorate General of Health Services (DGHS)Government of the People’s Republic of Bangladesh
Patient & Family, Rights & Education [PFRE]
• Patient and Family Rights• Informed Consent• Research• Organ Donation• Patient and Family Education
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Hospital-Focused Standards| Section 2 | Chapter 1
Directorate General of Health Services (DGHS)Government of the People’s Republic of Bangladesh
Quality and Risk Management [QRM]
• Leadership and planning• Design of Clinical and Managerial Processes• Data Collection for Quality Measurement• Analysis of Measurement Data• Gaining and Sustaining Improvement
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Hospital-Focused Standards| Section 2 | Chapter 2
Directorate General of Health Services (DGHS)Government of the People’s Republic of Bangladesh
Infection Control and Prevention [ICP]
• Leadership and Coordination• Focus of the Program• Isolation Procedures• Barrier Techniques and Hand Hygiene• Integration of the Program with Quality Improvement and Patient
Safety• Education of Staff about the Program
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Hospital-Focused Standards| Section 2 | Chapter 3
Directorate General of Health Services (DGHS)Government of the People’s Republic of Bangladesh
Facility Safety and Equipment Management [FSME]
• Leadership and Coordination• Safety and Security• Hazardous Materials• Disaster Readiness• Fire Safety• Medical Equipment• Utility Systems• Staff Education
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Hospital-Focused Standards| Section 2 | Chapter 4
Directorate General of Health Services (DGHS)Government of the People’s Republic of Bangladesh
Governance & HR Management [GHM]
• Governance of the Organization• Leadership of the Organization• Direction of Departments and Services• Organizational Ethics• HR Planning• Orientation and Education• Medical Staff Credentials | Clinical Privileging • Ongoing Monitoring and Evaluation of Medical Staff • Nursing Staff Credentials• Other Health Care Practitioners Credentials
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Hospital-Focused Standards| Section 2 | Chapter 5
Directorate General of Health Services (DGHS)Government of the People’s Republic of Bangladesh
Information and Communication [IAC]
• Communication with the Community• Communication with Patients and Families• Communication between Practitioners within and outside of the
Organization• Leadership and Planning• Patient Clinical Record• Aggregate Data and Information
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