Quality In Healthcare PDF 2024

Quality In Healthcare Dr /Abeer Elhawary Professor Of Chest Diseases Faculty of medicine Zagazig university 2024  Table of Contents Content...

Quality In Healthcare Dr /Abeer Elhawary Professor Of Chest Diseases Faculty of medicine Zagazig university 2024  Table of Contents Content Page Introduction to Quality 2 History of Quality 4 Basic Concepts 5 Quality in Healthcare 8 Perspectives of Quality 10 Healthcare Quality Dimensions 12 Principles for good quality management in healthcare 16 Understanding Work as Processes and Systems 17 Quality Management Process 22 Quality Planning 23 Quality Control 23 Healthcare Quality Measurement 24 Quality improvement 26 Continuous quality improvement (CQI) 28 Quality Improvement Tools 29 Patient Safety 36 Types Patient Safety 38 International Patient Safety Goals 44 Infection Control 54 Universal precautions 55 Infection control measures 56 Accreditation 95 Benefits of Accreditation 60 How to Prepare Organization for Accreditation 61 1 Introduction In many countries patients and the general public often complain from the poor quality of care in their health facilities. We often hear on the social media and even in the community about the poor quality of care that patients have received from medical staff. Some of us experience this poor quality in some health facilities when we are sick. Poor quality health services particularly unsafe care can decrease people’s trust in the health system. Today, the provision of healthcare has a prominent place in national political systems, and oral health is increasingly accepted as an integral part of general health. Quality of care has long been synonymous with the quality of practice, but a model adopted from the industrial field has gradually developed in the health field to meet the expectations of patients and other partners involved in care. Dentists, like other health professionals, are required to put in place systems that help improve the quality and safety of their care 2  Chapter 1 Objectives: 1- Define quality 2- Explain Quality of Health Care. 3- List the characteristics and dimensions of Quality Health Care. 4- Discuss the principles of quality in healthcare. 5- Describe Continuous Quality Improvement in Health care. 3  What Is Quality? To the ordinary person, quality is how good something is. This may be a service e.g. service or a product e.g. Mobile. A person's judgment about a service or product depends on what he expects of it or from it. Some of the words used to describe quality are:  Beautiful or attractive  Durable  Meeting standards  Healthy  Value for money Although different words are used to explain quality, we would define it as the extent to which a product or service satisfies a person or a group i.e. how much satisfaction the person gets from the service. Origins and history of Quality Assurance: Quality Assurance (QA) started in the 1980s in the Japanese automobile industry using theories of Edwards Deming and Joseph Juran. It was realized that through inspection, more faulty products were detected but the quality of the products did not change. It became necessary therefore to look at the ways products were made so that any changes can be made along the line before the finished product came out. This revolutionized manufacturing, and was responsible for the success of Japanese industry and World War II. Using Deming's approach, quality is maintained and improved when leaders, managers and the workforce understand and commit to constant customer satisfaction 4 through continuous quality improvement. He encouraged cooperation, continual improvement, decision-making based on fact, and viewing organizations as a "system Deming and his colleague, Shewhart, promoted the PDCA cycle (Plan, Do, Check, and Act) which is still widely used today" Joseph Juran has been called the "father" of quality. He is recognized as the person who added the human dimension to quality. Juran's approach was based on the idea that the quality improvement program must reflect the strong inter-dependency that existed among all of the operations within an organization's production processes. The criteria for selecting quality improvement (QI) projects include: potential impact on meeting customer needs, cutting waste, and gathering the necessary resources required by the project. By mid-1990s, health care professionals from the United States began learning and using QA concepts from the manufacturers. In health care the focus is on reducing medical errors and needless and morbidity. The QA methodology has been adopted by a number of developing countries to improve on their health care in the face of severe resource constraints. Basic Concepts:  Evolutionary stages of quality The evolution of quality can be described in four stages: 1- The inspection involves only the checking of the final products. 2- Quality Control focuses on the product 3- Quality Assurance (QA) focus on the process and product 5 4- The Total Quality Management (TQM) it focuses on organization, process and product. Total quality managment Quality assurance Quality control Inspection Quality Control: verifying the quality of the output Quality control is the most basic level of quality management. It includes all activities of inspecting, testing, or checking a product to ensure it meets the requirements. It is a procedure or set of procedures aimed to ensure that a manufactured product or performed service adheres to a defined set of quality criteria or meets the requirements and expectations of the customer. It is a reactive process aims to identify and correct defects in the finished product. 6  Quality Assurance: managing and planning for quality Quality assurance takes the quality management process a step further. QA is focused on planning, documenting, and agreeing on the steps, rules, and guidelines that are necessary to ensuring quality. The main purpose of QA is to prevent defects from entering into the product in the first place (before work is complete), so it’s a proactive measure to ensure quality. Planning for quality is key to mitigating risks, but also saves you a lot of time and money. Total Quality Management: TQM is the integration of all functions and processes within an organization in order to achieve continuous improvement of the quality of goods and services. It is a broad management philosophy, espousing quality and leadership commitment, which provides the energy and the rationale for implementation of the process of continuous quality improvement Total quality management (TQM) means: Total quality management (TQM) incorporates the concepts of product quality, process control, quality assurance, and quality improvement. Consequently, it is the control of all transformation processes of an organization to better satisfy customer needs in the most economical way. 7  TQM Quality assurance Product Quality control Process Product Organization Product Process It is the comprehensive and structured Product oriented approach to organizational focus on defect Process oriented focus management that seeks to improve the on defect prevention quality of product and service identification through refinements in the response to continuous feedback What is quality? Quality has been defined as excellence in the product or service that fulfills or exceeds the expectations of the customer. Why Quality in healthcare?  Increasing costs of healthcare in presence of rising demands and limited resources.  Variation in quality of medical performance and outcomes in similar health organizations. 8 What is quality in healthcare? Quality in healthcare has been defined in many ways. “Quality” in healthcare is defined as everything the healthcare organization undertakes to fulfill the needs and expectations of its customer as:  Well-designed services create customers satisfaction because they provide the features that customers need.  Customers' satisfaction is a high priority for any organization. “Quality is doing the right things for the right people at the right time, and doing them right first time and every time.” To ensure:  The best possible outcome for patients  Satisfaction for all our many customers  Retentions of talented staff  Sound financial performance “Quality” is the optimal achievement of therapeutic benefit and avoidance of risk and minimization of harm. Who is Involved in healthcare Practice?  Provider: Individuals responsible for providing the healthcare service  Customer: Individuals who directly receive healthcare service  Stakeholder: Individuals that have a vested interest in addressing a given issue and are in position to influence decision-making 9  » Policymakers and institutional players » Funding agencies » Dentists and staff Customers of Healthcare Customers are all those affected by our work  External customers: They are not part of the organization; Patients, third-party payers, insurance companies, employers or government agencies  Internal Customers: They are those within the organization who are affected in some way by the work output of the others Perspectives of Quality The health staff, health manager, clients and communities are all stakeholders in service delivery. Each of these groups may expect different things from health services. One of the reasons why there is low utilization of services is because the users perceive that the service is of poor quality. Quality appreciation is fundamental to clients’ willingness to pay for or take up services.  The Patient/Client The patients/clients want services that : Are delivered on time by friendly and respectful staff. 11  Are safe, produce positive result and that they can afford Provide them with adequate information about their condition and treatment. Provide them with all the medicines they need. Give privacy and confidentiality. Are within their reach (distance) and given in a language they can understand. Are comfortable. Allow continuity of care.  The Health Care Provider The health provider can provide quality care if he/she has: Adequate knowledge and skills. Enough resources, staff, medicines, supplies, equipment, transport, etc. Safe and clean workplace. Regular training. Is well paid and rewarded for good work. Respect / recognition for good work. Encouragement from colleagues and supervisors. Access to information. Guidance from other levels.  The Health Care Manager The health care manager sees quality care as: Managing efficiently the resources of the health facility. Health staff achieving set targets. Health staff being regularly supported and supervised. Having adequate and competent staff to provide care. Staff being disciplined. 11 Dimensions of Quality:  Appropriateness: Care/intervention is relevant to the patient’s needs. (Doing the right things)  Availability –Access to service: Everyone should have access to quality health care. Access refers to the ability of the individual to obtain health services. Some of the factors that can affect access are: a) Distance: e.g. where health facility is sited far away or it is difficult to get transport to the facility access to quality health care becomes a problem. b) Financial: e.g. where people cannot pay for the services provided. c) Culture, beliefs and values: The services provided may not be in line with the culture, beliefs and values of some people.  Timeliness: Needed care is provided at the most beneficial or necessary time.  Efficacy: The power of procedure/ treatment to improve health, as already shown through scientific research findings. (Evidence based).  Effectiveness: Effectiveness is the degree to which desired results (outcomes) of care are achieved. It is the extent to which a specific intervention, procedure, regimen or service, when deployed in the field in routine circumstances, does what it is intended to do for a specified population. (Doing things right) 12  Examples of effectiveness  Giving a child with diarrhea Oral Rehydration Salt (ORS)  An.effective tuberculosis (TB) control program is where the percentage of patients diagnosed with TB who complete the full treatment course is high.  Giving suitable antibiotics to a patient with tooth abscess.  Efficiency: Efficiency refers to using the minimum amount of effort or resources needed to achieve an intended result. This involves making the best use of the resources available or producing the maximum output for a given input. Efficiency minimizes wasted time, drugs, supplies and travel. Example: We waste resources by:  prescribing unnecessary drugs  stocking more drugs than is required and making them expire  buying supplies and equipment we do not use What happens when we stock more drugs than is required?  Equity: Quality services should be provided to all people who need them, be they poor, children, adults, old people, pregnant women, disabled etc. Quality services should be available in all parts of the country, in villages, towns and cities.  Competency: Adherence to professional standards of care and practice. (Skills, capability, actual performance). Technical competence as an indicator of quality assurance implies 13  that we should have adequate knowledge and skills to carry out our functions in order to provide quality service. Example: one must go to a Dentistry faculty and pass the examinations before he can work as a Dentist. Even though we are no longer in school, we have to continue to update our knowledge by reading health books and attending in-service training workshops etc. As health professionals, we should also know our limits, that is, know what we can do and what we cannot do. With respect to what we cannot do, we are expected to refer them to other centers or personnel who are more competent to handle them. Our practice should also be guided by laid down standards and guidelines e.g. Standard Treatment Guideline.  Continuity: Coordination of needed healthcare services for patient across all involved organizations over time Continuity means that the client gets the full range of health services he/she needs, and that when the case is beyond us, we refer him/her to the right level for further care. Continuity may be achieved by the patient seeing the same primary health care worker or by keeping accurate health records so that another staff can have adequate information to follow up the patient.  Respect and Caring: Patients are involved in the decision & the provider’s reaction to the patient needs. 14  Interpersonal Relations: It refers to the relationship between us and our clients and communities, between health mangers and their staff. We should: » Show respect to our clients; » Feel for our patients; » Not be rude or shout at them; » Not disclose information we get from patients to other people. » These will bring about good relations and trust between the clients/communities and us. Clients consider good interpersonal relationship as an important component of quality of care.  Safety: Patient safety is the absence of preventable harm to a patient during the process of health care. The discipline of patient safety is the coordinated efforts to prevent harm to patients, caused by the process of health care itself. It is generally agreed upon that the meaning of patient safety is…“Please do no harm”. There are multiple examples which may put the safety of the public at risk: 1- Faulty blood transfusion services can transmit HIV, hepatitis B, syphilis and malaria. 2- Incorrect diagnosis and treatment puts the safety of patients at risk. 3- Poor infection control may allow disease spread through procedures. 4- Hospital acquired infections is the most adverse event in health care in many communities. 15 Principles for good quality management in healthcare Principle 1 Patients focus: Our healthcare organization depends on the patients and therefore should understand current and future patients’ needs, should meet patients’ requirements and strive to exceed their expectations. Principle 2 Leadership: Leaders establish unity of purpose and direction of the organization. They should create and maintain the internal environment in which people can become fully involved in achieving the organization’s objectives. Principle 3 Involvement of people (employees): People at all levels are the essence of an organization and their full involvement enables their abilities to be used for the organization’s benefit. Principle 4 Process approach: A desired result is achieved more efficiently when activities and related resources are managed as a process. Principle 5 System approach to management: Identifying, understanding, and managing interrelated processes as a system contributes to the organization’s effectiveness and efficiency in achieving its objectives. Principle 6 Continual improvement: 16 Continual improvement of the organization’s overall performance should be a permanent objective of the organization. Understanding Work as Processes and Systems: An organization's effectiveness and efficiency in achieving its quality objectives are contributed by identifying, understanding and managing all interrelated processes as a system. A process is defined as،، a sequence of steps through which inputs from suppliers are converted into outputs for customers ”.In routine healthcare delivery, many processes occur at the same time and involve many professional functions in the organization. All processes are directed at achieving one goal or output from the system. There are different types of processes in healthcare, these include:  Clinical algorithms: The processes by which clinical decisions are made  Information flow processes: The processes by which information is shared across the different persons involved in the care  Material flow processes: The processes by which materials (e.g., drugs, supplies, food) are passed through the system  Patient flow processes: The processes by which patients move through the medical facility as they seek and receive care  Multiple flow processes: Most processes are actually multiple flow processes. 17  Tools such as the flowchart help people understand the steps in a process. Through the understanding of the processes of systems of care, QI teams can identify weaknesses and change processes in ways that make them produce better results A system is defined as “the sum total of all the elements (including processes) that interact together to produce a common goal or product.” A system is also defined as an interdependent group of people, items, and processes with common purpose while a process is a set of causes and conditions that repeatedly come together in a series of steps to transfer inputs into outcomes. The World Health Organization (WHO) Health System Framework describes health systems in terms of six core building blocks: 1- finances, 2- health workforce, 3- information, 4- governance, 5-medical products and technologies, 6- service delivery. Systems thinking looks at the whole, the parts, and the connections between the parts, and studying the whole in order to understand the parts. To execute any activity it is important 18 to understand what needs to be done, the individual steps that have to be taken, and in what order. Traditional Problem Solving: When facing quality challenges, practitioners often think that the cause is obvious. The tendency is to want to jump in and make improvements, without exploring the situation. This increases the risk of a mismatch between the intervention and the true cause of the quality problem. We need to understand the problem before defining the solution!  Example of solving the wrong problem - Quality challenge- Very long wait times for HIV test results - Proposed intervention - Increase number of technicians in lab - Assumption - The problem is lab-staffing - Actual problem - Stock out of gloves in the lab. System analysis focuses on inputs, processes, outputs, outcomes and impact of health services provided. Structure Process Outcomes Donabedian model (causal relationship) 19   Structure/Inputs: Inputs (resources) - materials, money, human resources, equipment, policies and other resources that are required for an activity  For example, in the hypertension treatment system, inputs include anti-hypertensive drugs and skilled health workers. Example: 1- Staff no 2- Adequate nursing :patient ratio 3- Trained nursing staff 4- Staff qualifications 5- Resources (equipment, budget, beds…….) 6- Computer system 7- Updated treatment guidelines 8- Geographical location  Process: It is the activities and tasks that turn the inputs into products and services.  Example For hypertension treatment, this process would include the tasks of taking a history and conducting a physical examination of patients complaining of headache, making a diagnosis, providing treatment, and counseling the patient. Example 1- Services (registration, lab, pharmacy …….) 2- Clinical processes (treatment, assessment, medication...) 3- Administration and management  Output: 21  The immediate results of completion of an activity. It is a direct result of interaction between inputs and a process.  Example: The outputs of hypertension treatment system are patients receiving therapy and counseling.  Outcome: Outcomes are the end result of care and a change in the patient’s current and future health status due to antecedent health care interventions. It is the relation of the output to the objective of the activity.  Example: The outcome of the hypertension treatment is improved patients. If the treatment is proper and clients satisfied, that is a good outcome, and if it is not proper, the clients are disappointed, and the outcome is poor. Example: 1. Clinical (complication rate, mortality rate…..) 2. Functional (long term health status…). 3. Perceived (patient satisfaction, peer acceptability).  Impact : The long term effect of the outcomes on users and the community at large. These are the consequences: social, economic, environmental, etc.  Example :For hypertension treatment, the impacts would be improved health status in the community and reduced morbidity and mortality rates. 21  Quality Management Process: It is to help every person in the service to take responsibility for controlling quality and enable them to use quality methods to improve the process for delivering the service. Building a quality management program: Policies on quality, procedures, and processes are implemented simultaneously, starting at the top and moving down the organization. It typically begins with a review of standards and specific actions. This is followed by an assessment of healthcare and support services. Priority areas for quality improvement can be identified based on the results of comprehensive monitoring or systems analysis. This approach has three dimensions: Quality design, quality control, quality improvement which form the three sides of the “quality triangle” also called “Quality management Triad.  Juran Trilogy Quality Quality Improvement planning 1- Quality Planning (design) 2- Quality Control/Measurement 3- Quality Improvement Quality control The three components work together to provide QM Process that function like a loop. There is no starting point or end point, put all components work together in a continuous way. 22 1- Quality planning /design: Includes  Establish the project setting vision and objectives, allocating resources, and establishing standards and guidelines to ensure effectiveness and safety, training, team building.  Identify customers  Discover customer’s needs  Develop service features,  Develop detailed process  Designing various forms of regulation, including accreditation, licensure, or certification standards  Designing systems for quality output 2- Quality control/measurement: Quality control process helps health teams to understand and control their everyday work processes, and establish a basis for improvement of these processes. Consists of supervising and continuous monitoring activities and staff performance to assure that routine activities and responsibilities are performed correctly and consistently. It consists of the following steps: Step 1: Measure actual performance Step 2: Compare the results with established standards (quality expected) Step 3: Act on the difference Measurement is a tool usually a number or a statistic used to monitor the quality of some aspect of healthcare services. 23 Number/Statistic Measure Example Absolute number Number of patients served in the health clinic Number of patients who fall while in the hospital Number of billing errors Percentage Percentage of nursing home residents who develop an infection Percentage of newly hired staff who receive job training Percentage of prescriptions filled accurately by pharmacists Average Average patient length of stay in the hospital Average patient wait time in the emergency department Average charges for laboratory tests ratio Nurse-to-patient ratio Cost-to-charge ratio Technician-to-pharmacist ratio Healthcare Quality Measurement: It is the process where the healthcare providers/clinicians review their own performance and make adjustments, and probe for causes of deficiency to improve patient health outcomes Importance of Measurements 1. They provide an objective view of the existing level of quality and of the progress made as a result of the actions for improvement that have been conducted 2. prove that progress has indeed been made 3. They also give value to the work accomplished and confidence to the participants in their capacity to continuously improve the quality of the services they provide and their work organization 24  This is in order: » To improve the proposal for change » To further analyze problems in changing care » To alter strategies and measures for change » To alter the implementation plan. Measurement Tools.  Indicators  Surveys  Data collection Sheets  Expert Opinion (qualitative) Indicators Are reliable and valid measures used to screen/assess organizational and practitioner performance issues, but not direct measures of quality Types of Indicators  Outcome Indicator measures what happens or does not happen as the result of a process or processes;  Process Indicator measures a discrete activity that is carried out to provide care or service  Structure indicator measures the inputs to the process and resources allocated to provide care 25  3- Quality improvement: QI is the continuous, day to day process of identifying opportunities for improvement and implementing solutions to them. QI is a systems approach that applies the scientific method to the analysis of performance and systematic efforts to improve it. The QI Methodology and Steps QI methods are applied to improve the safety and quality of patient care and provide health care workers with the tools to 1- Identify the problem 2- Measure current performance 3- Perform a cause analysis 4- Develop and implement an improvement strategy 5- Measure the effect of the intervention 6- Modify, maintain, or spread the intervention Quality improvement differs from quality assurance (which is retrospective in nature) in that it attempts to use a quality assessment cycle and focuses on the organization or system of production as a whole. 26 One of the QI methods that can be used is a Plan–Do–Study– Act (PDSA) cycle. (Or Plan–Do–Check–Act (PDCA) cycle) Once we know what changes we want to make, we can test these using the PDCA cycle. “Plan-Do-Check-Act” or “PDCA Cycle”: It is a popular methodology to fix a problem or improve a process that emphasizes four phases of activity 1- In the planning phase:  Make a plan for the change (What, Who, How, When, Where)  Collect baseline data  Communicate the test of the change 2- In the doing phase:  Test the change  Document the results of the change  Continue to monitor the data 3- In the checking phase:  Verify the effects of the change  Check results for Achievement/Success, Constraints: Unforeseen problems / resistance to change  Collect data on the new process and compare to the baseline. 4- In the acting phase:  If the result is successful, standardize the changes and then work on further improvements or the next prioritized problem.  If the outcome is not yet successful, look for other ways to change the process or identify different causes for the problem. 27 Continuous quality improvement (CQI): The adjective “continuous” is used to indicate that the quality approach aims to gradually and permanently reduce dysfunctional processes, patient complaints or risk. Whereas quality assurance is intended to give confidence that it will inevitably achieve a specified level of quality, continuous quality improvement instead focuses always ahead in the direction of betterment Time Depiction of the PDCA cycle (or Deming Cycle). Continuous quality improvement is achieved by iterating through the cycle and consolidating achieved progress through standardization. 28 Three methodological principles characterize the continuous process of quality improvement:  Any activity may be described as a process. Quality improvement always results from the step-by-step improvement of processes and can be aimed for whatever the initial status.  Processes are always analyzed in their initial functioning. This helps to identify real-life dysfunctions and to define actions for improvement with the persons concerned.  The effectiveness of any improvement should be measured objectively. Quality Improvement Tools Definition: Methods used by individuals, teams, organizations or health systems in TQM or continuous quality improvement to improve work progress. 29 Types of quality improvement tools: Process tools: 1. Brainstorming 2. Cause-effect / Fishbone Diagrams 3. Flowcharts Statistical tools: 1. Pareto Charts 2. Check Sheets 3. Histograms 4. Run Charts 5. Scatter diagram 1- Brainstorming : Generate a large number of ideas ,solutions ,root causes and customer satisfaction ideas in a short period of time. 2- Fish bone diagram (cause effect relationship ) It is a tool for discovering all the possible causes for a particular effect. The Fishbone diagrams allow the team to identify and graphically display all possible causes related to a process, procedure or system failure. The method for using this diagram is to put the problem to be solved at the head, then fill in the major branches. The major categories of causes are put on major branches connecting to the backbone, and various sub-causes are attached to the branches. A fishbone-like structure results, showing the many facets of the problem. 31  3- Flow charts A process map, also known as a flowchart , outlines all the different steps in a process - for example, all the steps that a clinic takes to deliver a particular kind of service. Flow charts are graphic representations of how a process works, showing the sequence of steps. Flow charts help QI teams identify problems that can be fixed. It is a fundamental tool that should be used with all QI initiatives because it gives team a clear insight into its processes. After a process has been identified for improvement and given high priority, it should be broken down into specific steps and displayed on paper in a flow chart. By writing down each step in a process currently taking place, a flow chart helps to clarify how things are currently working This tool is particularly useful in the early stages of a project to help the team understand how the process currently works.. 31  4- Pareto chart : This chart help teams focus on the small number of really important problems or their causes. It can be used to display categories of problems graphically so they can be properly prioritized. Pareto charts are useful throughout the performance improvement process - helping to identify which problems need further study, which causes to address first, and which are the “biggest problems.” A Pareto chart contains both bars and a line graph, where individual values are represented in descending order by bars, and the cumulative total is represented by the line. The height of each bar reflects the frequency of an item. It shows the proportion of the total problem that each of the smaller problems comprise. Generally, you gain more by working on the problem identified by the tallest bar than trying to deal with the smaller bars. 32 Once a major problem has been selected, it needs to be analyzed for possible causes. Cause-and-effect diagrams scatter plots and flow charts can be used in this part of the process. 5- Check Sheet (Tally Sheet): The check sheet is a simple document that is used for collecting data in real-time and at the location where the data is generated. 33 6- Histogram: Data collected on the check sheet is put on the histogram. This is a vertical bar chart which depicts the distribution of a data set at a single point in time. A histogram facilitates the display of a large set of measurements presented in a table, showing where the majority of values fall in a measurement scale and the amount of variation. 7- Runchart: It is a basic graph that displays data values in a time sequence. 34  Chapter 2 Objectives: 1- Define patient safety 2- Innumerate types of error 3- Discuss types of safety 4- Describe the international patient safety goals. 35  Patient Safety Introduction Significant numbers of patients are harmed due to their health care, either resulting in permanent injury, increased length of stay (LOS) in health-care facilities, or even death. Patient safety is a fundamental principle of quality highlighted in the global health agenda. It is an essential requirement for establishing resilient health care systems. Safety is one of the domain of quality improvement in healthcare.It should be given the highest priority, however patient safety is at risk anywhere, anytime ,in any process WHO defines patient safety as: The reduction and mitigation of unsafe act within healthcare system, as well as the use of best practices shown to lead to optimal patient outcomes (absence of preventable harm during the process of healthcare) Why safety in hospitals? 1- Hospital is a people intensive place. 2- Provide services to sick people round the clock 24 hours daily. 3- People have free access to enter any part of hospital any time for advice and treatment. 4- The atmosphere of hospitality is filled with emotions excitement life happiness death sorrow. 5- Since hospital operates under continuous strain it gives rise to irritation on confrontation conflicts and aggregation. 36 Who, what, where People: stuff, visitors and patients Property: equipment, assets and store Place: electrical, fire, mechanical and infrastructure  The discipline of patient safety is their coordinated efforts to prevent harm to patients caused by the process of health care itself. Origin of Patient the Safety Concept: Hippocratic Oath  I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone. Improving a patient safety means reducing patient harm. Hospital were funded to give care to those who need it and to keep patient safe is their moral duty. Whose error?  By patient.  By hospital stuff.  Both of them.  Physical mechanical electrical. Why errors occur? Systemic factors 1- Complexity of health care processes 2- Complexity of healthcare work environments 3- Lack of consistent administration practices 4- Deferred maintenance 5- Clumsy technology 37 Human factors 1- limited knowledge 2- poor application of knowledge 3- fatigue 4- sub optimal teamwork 5- attention distraction 6- inadequate training 7- reliance on memory 8- poor handwriting Types of error 1- Adverse health care event during clinical care and causing the physical or psychological injury to patient. 2- Error use of incorrect plant action. 3- Healthcare near miss situation in which event or neglect during a clinical care fails. 4- Adverse drug reaction prophylaxis, diagnosis, therapy 5- Sentinel errors surgery on the wrong body part, surgery on the wrong patient, patient receive the wrong medicine 6- Medication errors Type of safety  environmental safety  medical safety  surgical safety  electrical safety  laboratory safety  equipment installation safety  blood safety  sanitation infection control 38 Environment safety  There is the direct link between work environment and the patient safety. Therefore if not addressing work environment we are not addressing a patient safety.  Healthy work environments do not just happen, there for if we do not have a formal program in place addressing work environment issues little will change.  Creating healthy work environment requires changing long standing cultures and traditions, so everyone must be involved with in the creation of healthy work environment the onus is on organization department and unit leaders to ensure that it happens. Environment Safety: 1- Adequate light 2- Adequate ventilation exhaust fan 3- Stairs with hand rails 4- Windows ,door closure 5- Slip preventing floors 6- Fire extinguishers and alarms 7- Prevent noise pollution 8- Heavy and fixed beds 9- Safe wheel chairs and trolleys 10- No water logging in bathrooms 11- Call bell system for patients 12- Adequate no. of bed screens to maintain privacy for patient 39 Medical Safety incomlete patient information labeling miscommuni and packing cation of oroblem drug order medication error enviroment unavailable drug al factor information &distraction poor follow up & monitoring 1- Illegible Writing prescription by doctors. 2- Wrong medicines or wrong does or wrong patient. 3- Wrong injection, wrong does or wrong patient, wrong route of administration. 4- Drip sets, air bubbles, over hydration, drip speed. 5- Oxygen flow check empty gas cylinders. 6- Identification of each patient with similar patient names Medication Safety: 1- A medication orders should be written legally in ink and should include:  patient name  medication generic name  dosage frequency and rout of administration  signature of physician  date and hour was written 41 2- Any abbreviation used in medication older should be agreed to end jointly adapted by medical nursing pharmacy and medical records stuff of the institution. Lately, in the interest of patient safety, “Do Not Abbreviate” is the new practice nowadays. 3- Before dispensing the drug the pharmacist must receive the physician᾽ s original order or a direct copy of the order except an emergency stations This permits the pharmacist to: Resolve questions or problems with drug orders before the drug is dispensed and administered. Eliminate errors which may arise when drug orders are transcribed into another form for use by the pharmacy. 4- To check at least two patient identifiers before providing care, treatments or services. Patient name and medical record number. 5- Discourage telephonic orders don't accept verbal order. Surgical Safety: The right patient and under right side without any retained instrument is the mainstay objective of surgical safety Surgical Safety: 1- Consent of the patient /relative in writing. 2- Proper identification of patient name wrist band. 3- Proper identification Mark of parts to be operated. 4- Pre anesthetic checkup. 5- Anesthetic safety. 6- Ensure no foreign body left inside. 7- Safety measures from word, OT and coming back. 8- Prevention of surgical wound infections 9- Use of surgical safety preformat in all operation 10- Check safety code if available 41  Electrical safety 1- Safety fuses with each equipment 2- No lose wires or connections 3- Probably blocked and fix 4- It if short the circuit coal electrician 5- Electricity back up battery generator Laboratory safety 1- Avoid needle break and spilling of blood 2- Safety measures in radiology and radiotherapy 3- Safety norm guide lines for different areas of hospital 4- Regular pest control measures 5- Care and handling acids reagents inflammable substance Equipment installation safety Installation hazards 1- Regular checking of equipment 2- Proper earthling to avoid shock 3- Regular maintenance and repair 4- Training of nurses and technical stuff 5- Control hazards by :  eliminate hazards  Guard against hazard  Train to avoid hazards  Warn against hazards 42 Fire safety 1- Use fireproof material 2- Have fire exit in all buildings 3- Smoke detectors and water sprinkles on the roof of all floors 4- Fire extinguish in all areas 5- Fire hydrants in all buildings 6- Training in fires management Blood safety 1- proper grouping and cross matching 2- test of HIV and infectious hepatitis 3- control of mismatching reaction 4- standard operating procedures 5- screening against the HIV, hepatitis, malaria Sanitation infection control  proper segregation and the transportation of biochemical wastes  sanitation and hygiene of different parts of hospital to avoid infection  use of sterile procedures  safety and use of incinerator autoclave shredder needle destroyers and proper disposal of biomedical waste  formation of hospital infection control committee  investigation of all hospital infection  use of proper antibiotic in right doses in right time  reorientation of resident doctor and nurse staff 43 International Patient Safety Goals (IPSG) The IPSG helps the hospital addresses specific areas of concern in some of the most problematic areas of the patient safety.  Goal 1: Identify patient correctly.  Goal 2: Improve the effectiveness of communication among care givers.  Goal 3: Ensure correct site, correct procedure, and correct patient surgery.  Goal 4: Improves the safety of using medications.  Goal 5: Reduce the risk of healthcare associated infections.  Goal 6: Reduce the risk of patient harm resulting from falls. 44  Goal 1: Identify Patient Correctly Wrong-patient errors occur in virtually all aspects of diagnosis & treatment. So, the hospital develops and implements a process to improve accuracy of patient identification. The intent for this goal is two-fold:  First, to reliably identify the individual as the person for whom the service or treatment is intended;  Second, to match the service or treatment to that individual. 1- All patients are identified using two identifiers. 2- The identifiers should including the full name , and medical record number 3- Patients are identified :  Before administering medication  Before blood transfusion  Before blood extraction  Before any invasive procedure  Transporting the patient  Serving food or offering any documentation printing like different type of appointment  Prescriptions or reports 4- Not use these for identification Patients room numbers, locations Other option to place the ID Band (If not possible to wear it on wrist) 45  Situation Placement of the ID Multiple IV lines, Burns, Ankle Allergy, Wound or Dressing at Both Wrists In Emergency or Operative Patient's skin attaching using situation (where clothing is see-through plastic adhesive removed and wrist/ankle film cannot be used) If a limb is not available Attached to patient's clothing using strapping on an area of the body which is visible 5- In the event of patient's name not being known, then the identification band should state UNKNOWN MALE/FEMALE with the ER Number until the patient's TRUE Identity is established. 6- The ID band should be worn in the dominant hand. Whenever possible, the patient should be asked to confirm and or read the details on the ID band and cross check in the ID band for both the verbalized and documented file. 7- For unconscious and pediatric, refer to the ID band, verify the information to the family or watcher who knows the patient. 8- Identification in outpatient department , the appointment slip will serve as an ID for the patient until he leaves the OPD (it must contain 3 full name and MRN) 9- The patients ID band must be applied on admission to hospital, once the patient enters a department for treatment like in the minor OR. 10- Specimen container should NOT be labeled in advance of receiving the specimen. Patents ID must be checked before completing the details on the container. Samples to be label before leaving the patient’s bedsid 46  Goal 2: Improve Effective Communication Standards Ineffective communication is the most frequent cited category of root causes of sentinel events. Effective communication, which is timely, accurate, complete, unambiguous, and understood by the recipient, reduces error and results in improved patient/client/resident safety. So, the hospital develops and implements a process to improve the effectiveness of verbal and telephone communication among caregivers.  Ineffective Communication EXAMPLE: Reporting critical test results, Potassium result was reported by lab to nurse –Nurse hears result as a very low value of 2.7. –After the patient's laboratory results are entered on the screen, it was seen as 8.7. IMPROVE EFFECTIVE COMMUNICATION: 1- Effective communication, which is timely, accurate, complete, unambiguous, and understood by the recipient, reduces errors, and results in improved patient safety. 2- Reporting the critical test results, 3- Verbal and telephone orders that includes: writing down & reading back Verbal Order: - Order given in an emergency situation. - When spoken and when transcribed, will use only approved abbreviations. 47  - Must be signed by the physician immediately after emergency is over or before the physician leaves the unit. Telephone Order: - When the patient's condition does not require the physician's presence in making a medical assessment. - The authorized physician identifies himself, specifies patient's name and communicates the order. - Authorized physician must countersign the order as soon as within 24 hours 4- A standard communication method including asking and answering questions during hand-offs Improve Effective Communication Handovers of Patient Care within a Hospital Occur  between health care providers, such as between physicians and other physicians or health care providers, or from one provider to another provider during shift changes;  between different levels of care in the same hospital such as when the patient is moved from an intensive care unit to a medical unit or from an emergency department to the operating theatre; and  From inpatient units to diagnostic or other treatment departments, such as radiology or physical therapy. SBAR a structured communication technique designed to convey a great deal of information in an organized & brief manner. This is important as we all have different styles of communicating, varying by profession, culture, and gender. 48   SBAR Situation, Background, Assessment, and Recommendation Identity of patient Name/Age/MRN/Ward/Team Situation Symptom/problem Patient stability/concern Background History of presentation Date of Admission and diagnosis Relevant past medical history Assessment and Action List of changes condition Diagnosis/impression of Situation  Example: SBAR briefing 55 YO Man with HTN, admitted for GI Bleed – received 2 units, last hematocrit 31 VS: BP 90/50, Pulse 120 Looking pale, sweaty Feels confused and weak, some problem with heavy chest  Example SBAR briefing Situation: Dr. Jones, I have a 55 Y/O Man who looks pale, sweaty and is complaining of chest pressure. Background: He has a history of HTN, admitted for GI Bleed received 2 units, last critical two hours ago was 31 vital signs are: BP 90/50, Pulse 120 Assessment: I think he’s got an active bleed and we can’t rule out an MI but we don’t have a troponin or a recent H&H. Recommendation: I’d like to get an EKG and labs and I need for you to evaluate him in right away 49 Goal 3: Improve the Safety of High-alert Medications The hospital develops and implements a process to improve the safety of high-alert medications. High alert medications are drugs that bear heightened risk of causing significant patient harm when used in error. Contributing factors to medication confusions:  Incomplete knowledge of the drug name;  Newly available products;  Similar packaging or labelling;  Similar clinical use; and  Illegible prescription or misunderstanding during issuing of verbal orders. Improve the Safety of High-alert Medications:  When medications are part of the patient treatment plan, appropriate management is critical to ensuring patient safety.  Inadequate orientation of staff members.  Remove the concentrated electrolytes from the patient care unit to the pharmacy.  Areas where concentrated electrolytes are clinically necessary, Emergency Department Operating Theatre, Critical care Area  How they are clearly labeled and how they are stored 51  Goal 4: Ensure Safe Surgery - The hospital develops and implements a process for the perioperative verification and surgical/invasive procedure site marking. - The hospital develops and implements a process of timeout that is performed immediately prior to the start of the invasive/surgical procedure and the sign out that is conducted after the surgery. The essential processes found in the Universal Protocol are  Marking the surgical site;  A preoperative verification process; and  A time-out that is held immediately before the start of a procedure. Goal 5: Reduce risk of health care associated infection The hospital adopts and implements evidence based strategies to 1- Reduce the Risk of Health Care–Associated Infections 2- Infection prevention and control. 3- Reduce Catheter-associated urinary tract infections, blood stream infections and pneumonia (often associated with mechanical ventilation). 4- Hand hygiene guidelines are adapted and implemented throughout the hospital in order to prevent healthcare associated infections Hand hygiene is the cornerstone of reducing infection transmission in all healthcare settings It is considered the most 51 effective and efficient strategy for infection prevention and control Goal 6: Reduce the Risk of Patient Harm Resulting from fall The hospital develops and implements a process to reduce risk of patients harm resulting from falls for the inpatient population and out patient population Falls account for a significant portion of injuries in hospitalized patients. So,  Evaluate patients’ risk for falls  Take action to reduce the risk of falling and to reduce the risk of injury should a fall occur.  The evaluation could include fall history, medications and alcohol consumption review, gait and balance screening, and walking aids used by the patient.  A fall-risk reduction program Preventing Patient Falls 1- Trainings to patients and patient families 2- Not leaving bed without any help 3- Nurse call and frequently used objects are placed near to the patient 4- Bed height is fixed at the lowest level 5- All side rails in the up position 6- Instruct the patient to wear non-skid footwear 7- Unused equipment is removed from the room 8- Proper lighting 52  Chapter 3 Objectives: 1- Define infection control 2- Illustrate the chain of infection. 3- Discuss Infection control measures 53 Infection control Microorganisms can spread from one person to another via direct contact, indirect contact, droplet infection and airborne infection. During patient treatment, the equipment and treatment room surfaces are likely to become contaminated with saliva or by aerosol containing blood and/or saliva. Laboratory studies have determined that microorganisms may survive on environmental surfaces for different periods of time. Assume that if the surface has had contact with saliva, blood, or other potentially infectious materials, it contains live microorganisms. Infection control in dentistry Mood of Spread of infection  Direct contact occurs by touching soft tissues or teeth of patients. It causes immediate spread of infection by the source.  Indirect contact results from injuries with contaminated sharp instruments, needle stick injuries or contact with contaminated equipment and surfaces.  Droplet infection occurs by large particle droplets spatter which is transmitted by close contact. Spatter generated during dental procedures may deliver microorganisms to the dentist.  Cross-infection is transmission of infectious agents among patients and staff within a clinical environment. Different Routes of Spread of Infection - Patient to dental healthcare provider - dental healthcare provider to patient - patient to patient 54 What is the chain of infection?  The main objective of infection control is elimination or reduction in spread of infection from all types of microorganisms.  Basically two factors are important in infection control: 1- Prevention of spread of microorganisms from their hosts. 2- Killing or removal of microorganisms from objects and surfaces. Universal precautions Definition: - Universal precautions are control guidelines designed to protect workers from exposure to diseases spread by blood and other body fluids - Observing universal precautions means you consider all human blood and certain human fluids infectious for all blood borne pathogens 55  Universal precautions include:  Immunization  Detailed medical history  Consider every patient a potentially infected patient  Maintaining hand hygiene Hand washing instructions at least 30-40 seconds, rubbing all surfaces of hand  Use of personal protective barrier techniques Infection control measures 1- Immunization: All members of the dental team (who are exposed to blood or blood contaminated articles) should be vaccinated against hepatitis B. 2- Personal protective equipment - Definition Specialized clothing or equipment worn by an employee for protection against infectious materials Personal Protection Equipment: Barrier Technique The use of barrier technique is very important, which includes gown, face mask, protective eyewear and gloves Types of PPE used in Dental healthcare settings 1- Gloves (Protect hands) 2- Masks (Protect mouth/nose) 3- Eye wear ( Protect eyes( 4- Face shields: (Protect face, mouth, nose and eyes) 56  5- Gowns/aprons: (Protect skin and clothing)  Gloves Do not wash gloves before use or for reuse Remove gloves that are cut, torn, or punctured PPE for Hepatitis patients: Double mask Double gloves Eye wear 3- Hand Hygiene: - For most routine dental procedures washing hands with plain, non-antimicrobial soap is sufficient. - For more invasive procedures, such as cutting of gum or tissue, hand antisepsis with either an antiseptic solution or alcohol-based hand rub is recommended. 57  Chapter 4 Objectives: 1- define accreditation 2- know the Benefits of accreditation 3- How to prepare your organization for accreditation 58  Accreditation Definition “A self-assessment and external peer assessment process used by health care organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve” Accreditation is typically voluntary, but it can be required by some regulatory bodies. Standard: A standard is a statement of expectation that defines the structures and processes that must be substantially in place in an organization to enhance the quality of care. Standard should be :  Address a recognized need  Evidence based (as far as practicable  ) Developed through a transparent and consultative process  Outcome focused  Achievable  Measurable ACCREDITATION LICENSURE Based on optimum standards, Based on minimum standards, professional accountability and investigation, enforcement cooperative relationships and public accountability Improved performance and General review of internal systems reducing risk In-depth probe of conditions and activities Focus on education, self- Compliance checking as a direct development response to complaints and adverse events 59 WHAT ARE THE BENEFITS OF ACCREDITATION? Benefits of accreditation for hospital 4- It Improves delivery of medical care and enhances the image of the hospital. Thus, for private healthcare organizations it also results in more business. 5- It stimulates a process of continuous improvement in delivery of medical care 6- Demonstrates commitment to quality care 7- Raises community confidence. 8- Comparison with self and other similar organizations Benefits of accreditation for staff. 1- Improves professional staff development 2- Provides education on consensus standards 3- Provides leadership for quality improvement within medicine and nursing 4- Increases satisfaction with working conditions, leadership and accountability Benefits of accreditation for employee 1- Values employee opinions 2- Measures employee satisfaction 3- Involvement in quality activities 4- Improved employee safety and security 5- Clearer lines of authority and accountability 6- Promotes teamwork 61 Benefits of accreditation for patients 1- Access to a quality focused organization 2- Rights are respected and protected 3- Understandable education and communication 4- Satisfaction is evaluated 5- Involvement in care decisions and care process 6- Focus on patient safety Accreditation system worldwide: International healthcare accreditation organizations : 1. Joint Commission International (JCI). 2. The International Society for Quality in Health Care (ISQua). National accreditation bodies: 1. GAHAR in Egypt. 2. CBAHI How to prepare your organization for Accreditation Leadership commitment  Resources allocation.  Encourage Safety culture.  Commitment to laws and regulations  Participate in activities like safety tours and committees  Feedback to reports 61  Orientation  Organization wide For all levels of administration  Use all available communication channels like posters, meetings, videos and on job training Accreditation team  A team consist of a leader for each chapter  Search for quality champions who have good influence on staff and embrace the quality concepts  Choose team members according their skills, knowledge and authority. Gap analysis  Use checklists and SAT of GAHAR  Assess the performance , the knowledge and the medical record  Assess all your policies and procedures  Assess your compliance to laws &regulations  Make a list of all required KPI  Action plan 62 Build the system  Implement the action plan  Development of P&P and related documents.  Training programs and documents.  Monitoring frequency.  Evaluation frequency. Mock survey  Train a multidisciplinary team  Or use external consultant  Use Gahar Self-Assessment Tool (Sat). Action plan  Start after the mock survey till the GAHAR accreditation visit. Accreditation  The actual visit  The accreditation decision  Celebrate with your hospital the registration or the accreditation. 63