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kyewey Flashcards

1
Q

7 quality standards by Phihealth

A 
Patients rights and organizational ethics
patient care
leadership and management
HR management
Information Management
Safe Practice and Environment
Performance Improvement
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2
Q

Indicators

A

measurable variables or characteristics that can be used to determine the degree of adherence to a standard or achievement of quality goals.

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3
Q

standards

A

set maximum achievable performance expectations for activities that affect the quality of care which maximize the interface between management units

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4
Q

What is Standard 4.2.4

A

All services are provided by staff with appropriate qualifications

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5
Q

Standard 4.2.4 Criteria

A

all medical and administrative staff must have current licenses, training and experiences

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6
Q

Standard 4.2.4 Indicators

A

percentage of staff with current licences

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7
Q

Patient’s rights and organizational ethics goal

A

to improve patient outcomes by respecting patient’s rights and ethically relating with patient and other organizations

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8
Q

Patient’s rights and organizational ethics (6) SUBSTANDARDS

A
  • policies and procedures respect patient’s right to quality care and responsibility to that care
  • organization involves family in patient care
  • document measures that promote confidentiality, privacy, security, counselling and communication
  • the institution systematically elicits, monitors and acts upon feedback from patients, their families, visitors and communities
  • staff follow code of ethics and other relevant professional and statutory standards
  • organization documents and follows procedures for resolving ethical issues as they arise from patient care
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9
Q

CRITERIA for Promoting Patient’s Rights

A
  • informed consent is obtained before initiation of care
  • documentation of procedures that promote patient’s rights
  • patients receive written statements of their rights and responsibilities
  • hospital protects patients and their rights during clinical trials
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10
Q

CRITERIA FOR INVOLVING FAMILY IN CARE

A
  • documentation of programs that educate patients and families on how to take a more proactive role in healthcare decision making
  • involving family in decision making such as withholding resuscitation, continuing life-sustaining treatment, palliative care, etc.
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11
Q

CRITERIA FOR promoting confidentiality, privacy, security, counselling and communication

A
  • hospital staff is aware of policies in addressing patient’s needs for confidentiality, privacy, security, counselling and communication is addressed
  • hospital systematically determines, monitors and improves the EXTENT to which the patient’s need for confidentiality, privacy, security, counselling and communication is addressed
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12
Q

CRITERIA in dealing with feedback from patients

A
  • procedures that determine level of patient satisfaction of all relevant aspects of patient care
  • documentation of patient’s complaints and resolution
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13
Q

CRITERIA in staff follow code of ethics and other relevant professional and statutory standards

A
  • organization educates staff relevant codes of professional conduct and other statutory standards
  • organization identifies compliance of personnel to code of ethics relevant to their disciplines
  • resolution of ethical conflicts are based on code of ethics and other professional and legal standards
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14
Q

CRITERIA in resolving ethical conflict

A
  • procedures in resolving ethical issues are monitored
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15
Q

Patients Care Standards GOALS

A
  • the organization is accessible to the community it aims to serve
  • the entry process meet patient’s needs and are supported by effective systems and suitable environment
  • comprehensive assessment of every patient
  • the healthcare team develops a coordinated plan of care with goals in partnership with the patients
  • care is delivered
  • the healthcare team systematically evaluates and improves the effectiveness and efficacy of care delivered to patients
  • care is coordinated between the organization and other healthcare providers in the community to ensure that the needs of the patient are continuously met
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16
Q

The organization informs the community of its available services and the hours of their availability CRITERIA

A
  • information detailing the clinical services offered and hours of their availability is strategically distributed and prominently posted
  • the services are consistent with the organizations capability
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17
Q

Physical access to the organizations and its services are facilitated and is appropriate

A
  • entrances and exits are clearly marked; no obstructions and easily accessible
  • alternate passageways for patients with special needs are available; free of any obstructions
  • major services have nearby waiting areas that are clean, well-lit, adequately ventilated and equipped with appropriate fixtures and furniture
  • provides resources for the safe and efficient direction of patients, their families and visitors and staff traffic.
  • everyone can move safely within the confines of the organization
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18
Q

Patients receive prompt and timely attention by qualified professionals upon entry CRITERIA

A
  • patients are seen within the planned waiting period
  • patients are informed of the cause of any delay in the delivery of services
  • patients are satisfied with the actual waiting time.
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19
Q

Ensures proper patient triaging CRITERIA

A
  • staff follows policies in admissibility of patients or the need for referral to other organizations
  • patients are correctly and efficiently assigned to the clinical services appropriate to their needs.
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20
Q

Organization identifies all patient and creates a specific patient chart for each patient that is readily accessible to authorized personnel CRITERIA

A
  • all patients are correctly identified by their patient charts
  • each chart has patient identifiers unique to each patient
  • patient charts are systematically indexed to facilitate retrieval, avoid duplication and loss
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21
Q

Planning for discharge begins upon entry to the organization and ensures a coordinated approach to discharge and continuing management CRITERIA

A
  • Patients are informed of the expected duration of treatment, the extent and frequency of reassessment, the likely outcomes, and their need for follow up care for discharge
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22
Q

each patients physical, psychological and social aspect is assessed CRITERIA

A
  • history and physical assessment is performed on every patient upon admission
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23
Q

perform coordinated and sequenced patient assessment to reduce waste and unnecessary repetition CRITERIA

A
  • the order of assessment is determined by the patient’s prioritized needs
  • previously obtained assessment is reviewed every stage to guide future assessments
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24
Q

assessments are performed regularly depending on the patient’s response to care CRITERIA

A
  • reassessment is done whenever the patient’s condition take an unexpected turn
  • qualified personnel reassess the patients
  • reassess after reviewing patients condition
  • assess before surgery/ before administration of anesthetic
  • status of post-op patient is assessed upon admission into, during confinement, and upon discharge from the recovery area
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25
Q

leadership and management goal

A
  • organization is effectively and efficiently gathered according to its values and goals to ensure that care produces desired health outcomes, and is responsive to patient’s and community needs
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26
Q

management team ensures the presence of effective working _____ within the organization, within the community, and with other relevant organizations and individuals.

A

relationships

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27
Q

during meetings, _______ are recorded and approved

A

minutes of the meetings

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28
Q

the organization’s management team regularly assesses _______ and the performance of the organization

A

its own performance

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29
Q

the organizations develops in mission, vision and goals based on _______.

A

agreed-upon values

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30
Q

the organization’s by-laws and procedures are consistent with its _____, ______, _______, & _____ and ______.

A

goals, statutory requirements, accepted standards & community and regional responsibilities

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31
Q

the organization communicates its policies and procedures to _______.

A

all levels of the workforce

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32
Q

standards for external services

A

documented agreements and contracts stated that the quality of service provided must follow standards

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33
Q

human resource management goals

A
  • the right number and mix of competent staff

- recruitment, selection, appointment and reappointment of staff comply with statutory requirements

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34
Q

appropriately trained, qualified, _______ and _______ staff

A

relevant credentialed

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35
Q

the organization define the _____ & _______ of its staff

A

qualifications and competencies

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36
Q

_____ & _____ are based on actual clinical needs

A

staff numbers and skill mix

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37
Q

________ participate in the recruitment, selection and appointment of new staff members

A

relevant staff members

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38
Q

staff training and development are required to meet

A

individual and organizational needs

39
Q

organizations provides ______ to meet the educational needs of management and staff

A

resources

40
Q

orientation of new staff are _____ & _____.

A

documented and monitored

41
Q

the organization evaluates the _____ of training and development programs to ensure they meet ____, ______ & _____ needs.

A

effectiveness; organizational, community and individual needs

42
Q

the organization clearly defines and ensures compliance with the lines of ________ and _______.

A

authority and supervision

43
Q

New personnel, including _____, ______, _____, & _____ are adequately supervised by qualified staff.

A

trainees, volunteers, new graduates and external contractors

44
Q

the staff are provided job descriptions outlining _____ & ______.

A

accountabilities and responsibilities

45
Q

data collection and data aggregation are used for (4)

A

patient care, education, research and management of services

46
Q

data in patient’s charts are encoded to be reported to _____________.

A

quality improvement facilities

47
Q

clinical records storage comply with ______ & _____.

A

statutory requirements and codes of practice.

48
Q

the organization has policies that devotes resources and infrastructure to protect records and patient charts against ____, _____, _____ & _____.

A

loss, destruction, tampering and unauthorized access

49
Q

the organizational environment complies with ______ & ______ as prescribed by the law

A

structural standards and safety codes

50
Q

there are management safety plans that address safety, security, ___________________, emergency and disaster preparedness, fire safety, radiation safety and utility systems.

A

disposal of hazardous materials and biological wastes,

51
Q

effectiveness of safety procedures and devices are

A

routinely tested

52
Q

incident reporting system

A

identifies potential harms, evaluates causal and contributing factors for the necessary corrective action

53
Q

to ensure a clean and safe environment

A

emergency light, power supply, water and ventilation systems

54
Q

maintenance of manufacturer’s specifications

A

done to ensure a clean and safe environment

55
Q

the organization uses a _______ to reduce the risks of nosocomial infection and undetakes _____.

A

coordinated system-wide approach; case finding

56
Q

infection control measures

A
  • prevention and treatment of needlestick injurues
  • safe disposal of used needles
  • prevention of transmission of airborne infection
57
Q

statutory requirements and code of practice for infection and control (7)

A

cleaning, disinfecting, drying, packaging, sterilizing of equipment and maintenance of associated environment

*reports infections to public health agencies

58
Q

consideration for choosing equipments (6)

A 
intended use
cost benefits
infection control
safety
waste creation and disposal
storage
59
Q

equipment intended for single use by manufacturer are not used unless statutory practice and code of practice has specific guidelines for safe reuse

A

=)

60
Q

how to measure improving performance

A

the organization has a planned systematic organization wide approach to process design and performance measurement, assessment and improvement

61
Q

Audit

A

a process used to identify oportunities for improvement

62
Q

Affinity Diagram

A

used to generate a large number of ideas and then organize groups within them to understand the essence of a problem and its solutions

63
Q

histogram

A
  • summarize continuous data

- shows frequency of occurrence of different kinds of events

64
Q

Benchmarking

A

measures an organization’s performance on certain processes/ procedures in comparison to identified centers of excellence in order to improve performance

65
Q

Comparative Benchmarking

A

standards are derived from other performance rates of compliance to common performance measures

66
Q

Prescriptive Benchmarking

A

standards are derived from medical literature and expert opinion

67
Q

Brainstorming

A

an activity used to creatively and effectively generate a high volume of ideas on any topic by a process

68
Q

Case mix

A

the type and number of patient groups an organization serves

69
Q

case payment

A

payment based on condition itself, not interventions

70
Q

check sheet

A

used to systematically record and compile observations as they happen so that pattern and trends can be detected. can also be used to systematically record and compile data from historical sources so that “..”

71
Q

clinical pathway

A

interdisciplinary plan of care that outlines the optimal sequencing and timing of interventions and expected outcomes for patients with a particular diagnosis, procedure and symptom

72
Q

complaint analysis

A

complaints from patients are analyzed to identify areas for improvement

73
Q

control chart

A

line graph used to monitor, control and improve performance over time by studying process variations and their causes

74
Q

equitable access

A

fair and impartial opportunity to enter a place or obtain a particular service

75
Q

line graph

A

graph showing number of events through time

76
Q

Matrix Diagram

A

diagram used to systematically identify, analyze and rate the presence and strength of relationships between two sets of information

77
Q

meta- analysis

A

the statistical synthesis of results of several studies testing the same relationship into a same outcome measure, thus increasing the strength of the conclusion

78
Q

National health insurance program

A

compulsory health insurance program from the government (National health insurance act of 1995 or RA 7875) which provides universal health insurance coverage and ensure affordable, acceptable, available, and accessible healthcare services for all filipino citizens

79
Q

nominal group technique

A

team brainstorming method used to quickly come to a consensus on the relative importance of issues, problems or solutions by combining individual rankings

80
Q

Paretto chart

A

data analysis tool that combines analysis of the frequency of a specific problem and analysis of its causes, also called the “vital few” thereby separating them from the “trivial many”

81
Q

Pie chart

A

pictorial diagram that illustrates proportion of specific items to the entire unit

82
Q

Plan- Do- Check- Cycle

A

a systematic method used for identifying areas of improvement, pilot testing solutions, evaluate results, and institutionalize long term solutions

83
Q

Process decision program chart

A

used for contingency planning after the identification of a possible solution to a certain problem, wherein possible problems are identified for each step of the proposed solution and reasonable steps are listed for countermeasures

84
Q

Quality Assurance

A

a formal set of activities to review and ensure the quality of services provided.

quality assessment + corrective measures

85
Q

quality circle

A

a group of 5 to 10 workers from one work area of an organization that meet to solve issues in quality

86
Q

radar chart

A

data analysis tool which illustrates in one graph the size of the gaps between a number of current organizational performance levels and ideal performance levels

87
Q

scatterplot diagram

A

data analysis tool which shows if two sets of data/ observations are related to each other in linear fashion

88
Q

sentinel event

A

an unexpected occurrence involving death or serious physical or psychological injury and includes any process variation for which the recurrence would carry a significant chance of a serious adverse outcome

89
Q

swiss cheese model

A

a theory by James Reason which states that errors happen in any organization because there are “holes” in the system and where they “align” happening at a certain sequence or combination. They form a trajectory which opens up opportunities for errors to happen

90
Q

Tree diagram

A

a graphic tool used to organize tasks into increasing levels of detailed action that must and could be done to achieve stated goals

91
Q

utilization review

A

a formal evaluation of the necessity, appropriateness and efficiency of the use of medical services, procedures and/or facilities on a prospective, concurrent or retrospective basis including but not limited to examination of the clinical application of medical knowledge as revealed by medical records

92
Q

variance analysis

A

data interpretation tool used to document and identify the most common causes of deviation from routine care

93
Q

warranties

A

the guarantee that a healthcare provider applying for accreditation agreed to abide by the provisions of National Health Insurance Law

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