Healthcare Quality Management (MCQ11212) PDF

Importance of quality in healthcare : Proper use of limited resources and appropriate costs of services Decrease variation in medical performance and outcomes in different health organization. Encourage competition between different organization. Meeting...

Importance of quality in healthcare : Proper use of limited resources and appropriate costs of services Decrease variation in medical performance and outcomes in different health organization. Encourage competition between different organization. Meeting customer needs and expectation. Inspection Find and fixing problems in the product at the end-point. Control Quality Reactive approach that focus on detecting defects the product itself Quality Assurance Proactive approach that focus on preventing defects at the process level. Total Quality Management Continuous Quality Improvement 1 Dimensions of Quality : Appropriateness The degree to which the care/intervention is relevant to the patient’s clinical needs. ACCESS TO SERVICE It means that health care services are unrestricted COMPETENCY The degree to which practitioner adheres to professional standards of care and practice. CONTINUITY It means that the client receive the complete range of health services that he or she needs, without interruption. EFFECTIVENESS The degree to which care is provided in correct manner to achieve the desired outcome. EFFICIENCY Efficient services provide the greatest benefit within the resources availab le. EFFICACY The power of a procedure or treatment to improve health status, as already shown through scientific research (evidence based) findings. RESPECT AND CARING The degree to which patients are involved in the decision and the provider’s reaction in the meantime to the patient needs and expectations. 2  SAFETY The degree to which the organization environment is free from hazard. It is concerned with minimizing risks of adverse outcome for both patient and provider as a result of healthcare intervention. TIMELINESS The degree to which needed care and services are provided to the patient at the most beneficial or necessary time. Measuring quality of care : inputs (Structure):  People & skills (physicians(NUMBER OF DOCTOR), support staff)  Equipment & facilities  Organizational structure & mechanisms  Information systems Process:  Interpersonal interaction between patient and provider  Access to care  Appropriateness of care Outcome:  Death rate  Disease  Disability  Discomfort  Dissatisfaction rate 3  Standard: A statement of expected safety and quality. Indicators (measures): indicators are measures of progress. The seven basic quality tools: Cause-and-effect diagram (also called Ishikawa or fishbone diagrams): Identifies many possible causes for an effect or problem and sorts ideas into useful categories. Check sheet: Gather data about how often a problem occurs. Control chart: Graph used to study how a process changes over time. Histogram: A histogram is a special chart type used to display the distribution of continuous data like time, weight, size. 4  Pareto chart: Apply pareto principle that 80 % of trouble comes from 20 % of the factors. A bar graph that shows which factors are more significant. Scatter diagram: Analyzes strength & relationship between two variables Flowchart: A flowchart is a picture of the separate steps of a process in sequential order. Sentinel event: as "...an unexpected occurrence involving death or serious physical or psychological injury. A near miss: is defined as a potential medical error, which is caught prior to the administration to a patient. Using two patient identifiers (For Proper Patient Identify) Complete Verbal and telephone order The First Step is write down 9 Correct-Site, Correct-Procedure, Correct-Patient Time Out is Risk Management What can be our approaches?  Reactive approach: Risk grading matrix Root cause analysis (RCA)  Proactive approaches: Hazard prediction training (HPT) Failure mode and effect analysis (FMEA) Failure Modes And Effects Analysis (FMEA) Is a systematic, proactive method for evaluating a process to i how it might fail and to assess the relative impact of different fa to identify the process that are most in need of Accreditation Definition Usually a voluntary process (True Or False ‫ )ممكن يجي‬a government or non- government agency grants recognition to health ns which meet standards rtain 10  Hospital Provisional accreditation Requirements 1. Basic Requirements Is License 11 2. National Safety Requirements NSR.01 Accurate patient identification through at least two identifiers to identify the patient and other elements associated with his/her plan of care. NSR.02 Verbal or telephone orders are communicated safely and effectively. NSR.03 Hand hygiene NSR.04 prevention of catheter and tubing misconnections. NSR.05 Patient’s risk of falling is screened, assessed, periodically reassessed, and managed safely and effectively. NSR.06 Patient’s risk of developing pressure ulcers is screened, assessed, periodically reassessed, and managed safely and effectively. NSR.07 Handover communication NSR.08 Critical alarms NSR.09 Recognition of and response to clinical deterioration NSR.10 Patient’s risk of developing venous thromboembolism (deep venous thrombosis and pulmonary embolism) NSR.11 Critical results are communicated timely, accurately and safely. NSR.12 The hospital defines standardized diagnosis codes, procedure codes, definitions, symbols, and abbreviations. NSR.13 Medications are reconciled across all interfaces of care in the hospital. NSR.14 Medications are safely and securely stored in stores, pharmacies, and patient care areas according to laws and regulations. NSR.15 High-Alert medications and concentrated electrolytes are identified, stored, and dispensed in a way that assures that risk is minimized. NSR.16 Look-alike and sound-alike medications are identified and stored in a manner to minimize the risk of medication dispensing and administration errors. NSR.17 Precise site where a surgery or invasive procedure shall be performed is clearly marked by the physician with patient’s involvement. NSR.18 Documents and equipment needed for procedures and anesthesia or sedation are verified to be on hand, correct, and properly functioning before calling for the patient. NSR.19 Correct patient, procedure, and body part is confirmed preoperatively and just before starting a surgical or invasive procedure (time out). NSR.20 Accurate counting of sponges, needles, and instruments pre and postprocedure is verified. NSR.21 Fire and smoke safety plan addresses prevention, early detection, response, and safe evacuation in case of fire and/or other internal emergencies. NSR.22 Fire drills are performed in different clinical and non- clinical areas, including at least one unannounced drill annually. NSR.23 The hospital plans safe handling, storage, usage and transportation of hazardous materials and waste disposal. NSR.24 safe work environment plan addresses high-risk areas, procedures, risk mitigation requirements, tools, and responsibilities.  NSR.25 Radiation safety program NSR.26 Laboratory safety program NSR.28 Medical equipment plan ensures safe selection, inspection, testing, maintenance, and safe use of medical equipment. 3. Essential Quality Requirements 1. PCC.04 Patient and family rights 2. PCC.15 Waiting spaces 3. PCC.21 Complaints and suggestions 4. 01.ACT Granting access 5. ACT.14 Special care units’ access 6. ICD.14 Plan of care 7. ICD.38 Cardiopulmonary resuscitation and medical emergencies 8. DAS.05 Medical imaging quality assurance and control 9. DAS.19 Laboratory internal quality assessment 10. DAS.28 Blood procurement 11. SAS.08 Operative report 12. SAS.18 Physiological assessment by anesthesia 13. MMS.03 Medication procurement, formulary 14. MMS.05 Emergency medications 15. IPC.12 Isolation precautions 16. IPC.14 Disinfection, sterilization 17. IPC.21 Food services 18. OGM.01 Governing body structure 19. OGM.02 Mission statement 20. OGM.06 Committee structure 21. OGM.14 Billing system  22. OGM.20 Staff health 23. WFM.02 Staffing plan 24. WFM.06 Staff files 25. WFM.07 Orientation program 26. WFM.09 Staff performance evaluation 27. IMT.06 Integrity of data and information 28. IMT.08 Patient’s medical record management 29. IMT.11 Downtime of data systems 30. QPI.11 Incident reporting system 31. QPI.12 Significant events 32. QPI.13 Sentinel events 33. ADD.07 Research patient rights 4.Operating Manual The operating manual outlines all the documents required in GAHAR Handbook of Hospital accreditation Standards (policies, procedures, plans, programs, lists, etc.). Provisional accreditation decision Rules  1st Decision: Status of registration for one year  2nd Decision: Status of registration that requires passing the 2nd survey visit within 6 months (conditioned registration)  3rd Decision: Status of registration that requires passing the 2nd survey visit within 4 months (conditioned registration). 4th Decision: Denial of registration (absense of any of the requard licenses)