Transcript Slide 1

4.0 Quality Management System
4.1
4.2
4.1 General (4.2)
4.1.f Continual Improvement*
4.2 Document requirements
4.2.2 Quality Manual (4.2) Justification & process flow diagram*
4.2.3 Documentation (4.5)
4.2.4 Records (4.16)
5.0 Management responsibility
5.1 5.2 5.3 5.4 5.5 5.6
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6.0 Resource management
6.1
6.2
6.3
6.4
6.1 Resources (4.1)
6.2 Human Resources (4.18)
6.3 Infrastructure (4.9)
6.4 Work environment (4.9)
INPUT
© Det Norske Veritas AS. All rights reserved
5.1 Management commitment (4.1)
5.2 Customer focus*
5.3 Quality Policy (4.1)*
5.4 Planning (objectives)
5.5 Responsibility & authority (4.1)
5.5.3 Internal Communication*
5.6 Management review (4.1)
8.0 Measurement, analysis
and improvement
8.1
7.0 Product realization
7.1 7.2 7.3 7.4 7.5 7.6
7.1 Planning and product realization (4.2 & 4.10)
7.2 Customer related
7.2.1 Determine requirements*
7.2.2 Review requirements (4.3)
7.2.3 Customer requirements*
7.3 Design & development (4.4)
7.4 Purchasing (4.6)
7.5 Production (4.7, 4.8, 4.9. 4.12, 4.15)
7.6 Calibration (4.11)
8.2
8.3
8.4
8.5
8.1 General
8.2 Monitor & measure
8.2.1 Customer Satisfaction*
8.2.2 Internal audit (4.17)
8.2.3 Processes*
8.2.4 Product (4.10)
8.3 Nonconforming product (4.13)
8.4 Analysis of data *OUTPUT
8.5 Improvement
8.5.1 Continual*
8.5.2 Corrective (4.14)
8.5.3 Preventive (4.14)
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Process Mapping
4.2 Documentation Requirements
5.0 Management Responsibility
6.1 Provision of Resources
6.2 Human Resources
6.3 Infrastructure
6.6 Work Environment
7.4 Purchasing
8. Measurement, Analysis & Improvement
Referral
Organizational Structure
Management & Support
Resources Staff &
Equipment ( Including
Training)
Support Services
(Dietary, Housekeeping,
Buildings & Grounds)
Performance Monitoring
& Review
Pre-Admission
Review of Service
Capabilities
5.2 Customer Focus
7.2 Customer Related Processes
Admission (Assessment /
Diagnosis)
5.2 Customer Focus
5.4 Planning
7.2 Customer Related Processes
6.2 Human Resources
6.3 Infrastructure
6.4 Work Environment
5.2 Customer Focus
7.2 Customer Related Processes
7.3 Design & Development (Research Hospital)
6.3 Infrastructure
6.4 Work Environment
7.1 Planning and Service Realization
7.5 Production & Service Provision
7.6 Control of Monitoring & Measuring Devices
8.2.3 Monitoring & Measurement of Processes
8.2.4 Monitoring & Measuring of Service
Development of Care /
Treatment Plan
Delivery of Care
Service
Improvement
External Input:
DOH
CMS (COPs)
HFAP
© Det Norske Veritas AS. All rights reserved
On-going Monitoring and
Measurement
7.1 Planning & Service Realization
7.4.3 Verification of Purchased Product
7.5.1 Control of Product & Service Provision
8. Measurement, Analysis &Improvement
Change Care / Treatment
Plan as Appropriate
8.3 Control of Non-Conforming Service
8.4 Analysis of Data
8.5 Improvement
Discharge / Long Term
Care
21 July 2015
4.2.4 Control of Records
8.2.1 Customer Satisfaction
ABC Regional Hospital
Inpatient Treatment
Cross Functional Flowchart
Physician/ED
Registration
Inpatient Unit
Writers admit
orders
Process Map Example
Pt registered
Transfer to another
hospital
Assessed.
Treatment initiated
Reassesses.
Develops plan/
orders
Physician
Pharmacy
Transfer back to
Nursing Home
Medication orders
processed &dispensed
Discharged home
Physical Therapy
Provides
therapy
Respiratory Care
Laboratory
Diagnostic
testing
Radiology
Cardiology
Infection Control
Social Services
Assesses IC
needs
Assesses
discharge
needs
Environmental Service
Room cleaned
Purchasing/Distribution
Supplies restocked
Medical Records
Transcription. Chart
assembly, coding
© Det Norske Veritas AS. All rights reserved
21 July 2015
Hospital Sequence and Interaction of Processes
© Det Norske Veritas AS. All rights reserved
21 July 2015