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“ The degree to which health services for individuals and populations increases the likelihood of desired outcomes and are consistent with current professional knowledge” Institute of Medicine Medical Quality (Avedis Donabedian1970’s) Measurement of quality Structure Stable characteristics of the providers of care, tools and resources at their disposal Process Activities that go on between and within the practitioners and patients Outcome Changes in health status attributable to antecedent health care I Should Quality Initiatives lead to Accreditation OR II Should Accreditation lead to quality initiatives (TAKE YOUR PICK) • Conformance to standards Less mature • An ongoing process of building and sustaining relationships and properties of deliverables by assessing, anticipating and fulfilling stated and implied needs • Error-free, value added care that meets or exceeds the needs and legitimate expectations of the served and serving More mature Medical Quality Less mature Quality Assurance Continuous Quality Improvement Total Quality Management More mature The Quality Continuum Vision Involvement Focus Scope Triggers Less mature Current Local Niche Processes Organisation Wide External Strategic Perspective Global Complete Processes Community Wide Internal More mature Defining Quality Policy Making Structural Reorganization Incentives Quality Redesigning Motivation Benchmarking QUALITY ASSURANCE Problem Solving Management Actions Standards setting Monitoring systems Supervision Improving Quality Measuring Quality Quality Evaluation Regulation Audit Accreditation Effectiveness And Efficiency Optimum Utilization of Resources Uniformity In Processes Community confidence Improved Health Outcomes Waste Reduction Reduced Cost of Healthcare Safety and risk reduction A Voluntary Act HEALTHCARE ACCREDITATION Defined Standards Assessment by External Agency An Effective Quality Improvement Tool Organisational Commitment Frame work for Quality Assurance Unbiased approach Vision Involvement VOLUNTARY ACT Focus Triggers Physical facility and spatial associations Equipments Structural Standards Materials Human resource Policies Process Standards Processes Guidelines Programmes/Plans A visible commitment by organisation towards quality of patient care Safe working environment Benefits of Accreditation Resource Optimisation Stimulates continuous improvement Benefits all stake holders Raises community confidence I Quality initiatives should lead to Accreditation (Philosophy leading to the goals) II Accreditation should lead to Quality initiatives (The goal prompting and directing philosophy) *NOW MAKE YOUR CHOICES* Quality Improvement Process of Accreditation NO Decision YES Obtain Standards Comprehensive Review Identify Gaps and Bridge it Yes Apply NABH for Assessment Is standards Implemented and Integrated satisfactorily No Apply for re-assessment Assessments by NABH Is Assessment Result satisfactory Yes NABH Accreditation No Receive recommendation & act accordingly Applying Accreditation Standards for Quality Improvement A systematic approach Initiation Documentation Implementation Monitoring Sensitization Constitution of teams Initiation Initiation Understanding Standards Customising Applicability Action Plan Policies Processes Guidelines Criteria and protocols Documentation Programmes Roles and Responsibilities Formats for records and documents Manuals Organisational and departmental line of hierarchy Documentation topics 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Registration policy and procedure Admission policy and procedure Transfer of unstable patients to another facility Transfer of stable patients to another facility Standardized initial assessment of patients in the OPD, emergency and IPD. Processing and disposal of specimens in laboratory. Handling and disposal of infectious materials Identification and safe transportation of patients to imaging services. Handling and disposal of radioactive and hazardous materials. Safe use of radioactive isotopes for imaging services. Referral of patients to other departments / specialties. Discharge policy and process LAMA policy and process Informed Consent policy and process 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. Pricing Policy Uniform care policy and processes Emergency care policy and processes Medico-legal cases Triaging of patients Uniform use of resuscitation Rational use of blood and blood products Care of patients in ICU and HDU Situation of bed shortage in ICU/HDU Care of vulnerable patients Care of high risk obstetrical patients Care of paediatric patients Prevention of child/neonate abduction or abuse Care of patients undergoing moderate sedation Administration of anaesthesia Care of patients undergoing surgical procedures Prevention of adverse events 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. Restraints techniques Pain management guidelines Rehabilitative services polices Research activities policies and protocols Nutritional assessment and reassessment End of life care Procurement, Storage, prescription and dispensing of Medications Administration of medications Monitoring of medications Patient’s self administration of medication Medication brought from outside the organisation Adverse drug events Use of narcotic drugs and psychotropic substance Usage of chemotherapeutic agents Usage of radioactive and investigational drugs Safe storage, preparation, handling, distribution and disposal or radioactive and investigational drugs. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. Procurement of implantable prosthesis Procurements, handling, storage, distribution, usage and replenishment of medical gases. Antibiotic policy Laundry and linen management Kitchen sanitation and food handling Engineering controls for infection control Mortuary practices an procedures Surveillance, data collection and monitoring of HAI Isolation/barrier nursing Outbreak control procedures Quality control for sterilization Handling of bio-medical waste Quality assurance programmes Operational and maintenance plan Smoking policy Human resource planning Medical audit / death audit committee Infection control committee Resuscitation committee Sentinel event committee Committees Fire and non-fire emergency committee Equipment management committee Pharmaco-therapeutic committee Ethics committee Safety committee Quality assurance committee Central Vs. Departmental Internal Vs. External Training of Staff Theoretical Vs. Practical Mock drills and Practises Training Evaluation Training topics 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. Policies and Processes Advanced Care of Life Supports / Basic Care of Life Supports Disaster management Safe practices in laboratory Handling of vulnerable patients Restraint techniques Hand washing End of life care Quality assurance Handling of hazardous materials Fire and non-fire emergencies Handling patient in ambulance Biomedical waste disposal Universal precautions Infection control surveillance and monitoring system Managing patient during non-availability of beds Radiation safety measures Intra-departmental Self Assessments Inter-departmental Core team assessment Assessment by ASTRON Analyzing assessment results Re-assessment Identifying weak areas Continuous Effort Retraining and/or reformation of policy/process Improving weak areas Time Frame Activities Months 1 1 Constitution and initial training of teams Preliminary assessment Understanding standards Documentation Implementation and training Self assessments Retraining, re-modification Final self assessments NABH assessments and Accreditation 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 8 Lack of commitment Lack of time Lack of clarity on roles of team, team members Difference of opinion on policy, procedures and standards Unavailability of adequate information Improper/Incomplete documentation Improper/Incomplete records Inadequate training In-experienced trainers Poor attendance Lack of time and resources Communication barriers Biased assessments Individual preferences Improper assessment methodology Improper assessment framework • • • • Plan for Personal Excellence -Dianna Boober Define success in your own terms Assess your strengths Set goals with deadlines Develop discipline and be willing to pay the price • Use time wisely • Ask for advice • Be receptive to feed back Plan for Personal Excellence -Dianna Boober • • • • • • • Stay informed Learn to communicate well Do Quality work Take risks Be dependable Be ethical Nurture relationships ABOVE ALL “HAVE A POSITIVE ATTITUDE”