kyewey Flashcards
7 quality standards by Phihealth
Patients rights and organizational ethics patient care leadership and management HR management Information Management Safe Practice and Environment Performance Improvement
Indicators
measurable variables or characteristics that can be used to determine the degree of adherence to a standard or achievement of quality goals.
standards
set maximum achievable performance expectations for activities that affect the quality of care which maximize the interface between management units
What is Standard 4.2.4
All services are provided by staff with appropriate qualifications
Standard 4.2.4 Criteria
all medical and administrative staff must have current licenses, training and experiences
Standard 4.2.4 Indicators
percentage of staff with current licences
Patient’s rights and organizational ethics goal
to improve patient outcomes by respecting patient’s rights and ethically relating with patient and other organizations
Patient’s rights and organizational ethics (6) SUBSTANDARDS
- 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
CRITERIA for Promoting Patient’s Rights
- 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
CRITERIA FOR INVOLVING FAMILY IN CARE
- 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.
CRITERIA FOR promoting confidentiality, privacy, security, counselling and communication
- 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
CRITERIA in dealing with feedback from patients
- procedures that determine level of patient satisfaction of all relevant aspects of patient care
- documentation of patient’s complaints and resolution
CRITERIA in staff follow code of ethics and other relevant professional and statutory standards
- 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
CRITERIA in resolving ethical conflict
- procedures in resolving ethical issues are monitored
Patients Care Standards GOALS
- 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
The organization informs the community of its available services and the hours of their availability CRITERIA
- 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
Physical access to the organizations and its services are facilitated and is appropriate
- 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
Patients receive prompt and timely attention by qualified professionals upon entry CRITERIA
- 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.
Ensures proper patient triaging CRITERIA
- 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.
Organization identifies all patient and creates a specific patient chart for each patient that is readily accessible to authorized personnel CRITERIA
- 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
Planning for discharge begins upon entry to the organization and ensures a coordinated approach to discharge and continuing management CRITERIA
- 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
each patients physical, psychological and social aspect is assessed CRITERIA
- history and physical assessment is performed on every patient upon admission
perform coordinated and sequenced patient assessment to reduce waste and unnecessary repetition CRITERIA
- the order of assessment is determined by the patient’s prioritized needs
- previously obtained assessment is reviewed every stage to guide future assessments
assessments are performed regularly depending on the patient’s response to care CRITERIA
- 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
leadership and management goal
- 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
management team ensures the presence of effective working _____ within the organization, within the community, and with other relevant organizations and individuals.
relationships
during meetings, _______ are recorded and approved
minutes of the meetings
the organization’s management team regularly assesses _______ and the performance of the organization
its own performance
the organizations develops in mission, vision and goals based on _______.
agreed-upon values
the organization’s by-laws and procedures are consistent with its _____, ______, _______, & _____ and ______.
goals, statutory requirements, accepted standards & community and regional responsibilities
the organization communicates its policies and procedures to _______.
all levels of the workforce
standards for external services
documented agreements and contracts stated that the quality of service provided must follow standards
human resource management goals
- the right number and mix of competent staff
- recruitment, selection, appointment and reappointment of staff comply with statutory requirements
appropriately trained, qualified, _______ and _______ staff
relevant credentialed
the organization define the _____ & _______ of its staff
qualifications and competencies
_____ & _____ are based on actual clinical needs
staff numbers and skill mix
________ participate in the recruitment, selection and appointment of new staff members
relevant staff members
staff training and development are required to meet
individual and organizational needs
organizations provides ______ to meet the educational needs of management and staff
resources
orientation of new staff are _____ & _____.
documented and monitored
the organization evaluates the _____ of training and development programs to ensure they meet ____, ______ & _____ needs.
effectiveness; organizational, community and individual needs
the organization clearly defines and ensures compliance with the lines of ________ and _______.
authority and supervision
New personnel, including _____, ______, _____, & _____ are adequately supervised by qualified staff.
trainees, volunteers, new graduates and external contractors
the staff are provided job descriptions outlining _____ & ______.
accountabilities and responsibilities
data collection and data aggregation are used for (4)
patient care, education, research and management of services
data in patient’s charts are encoded to be reported to _____________.
quality improvement facilities
clinical records storage comply with ______ & _____.
statutory requirements and codes of practice.
the organization has policies that devotes resources and infrastructure to protect records and patient charts against ____, _____, _____ & _____.
loss, destruction, tampering and unauthorized access
the organizational environment complies with ______ & ______ as prescribed by the law
structural standards and safety codes
there are management safety plans that address safety, security, ___________________, emergency and disaster preparedness, fire safety, radiation safety and utility systems.
disposal of hazardous materials and biological wastes,
effectiveness of safety procedures and devices are
routinely tested
incident reporting system
identifies potential harms, evaluates causal and contributing factors for the necessary corrective action
to ensure a clean and safe environment
emergency light, power supply, water and ventilation systems
maintenance of manufacturer’s specifications
done to ensure a clean and safe environment
the organization uses a _______ to reduce the risks of nosocomial infection and undetakes _____.
coordinated system-wide approach; case finding
infection control measures
- prevention and treatment of needlestick injurues
- safe disposal of used needles
- prevention of transmission of airborne infection
statutory requirements and code of practice for infection and control (7)
cleaning, disinfecting, drying, packaging, sterilizing of equipment and maintenance of associated environment
*reports infections to public health agencies
consideration for choosing equipments (6)
intended use cost benefits infection control safety waste creation and disposal storage
equipment intended for single use by manufacturer are not used unless statutory practice and code of practice has specific guidelines for safe reuse
=)
how to measure improving performance
the organization has a planned systematic organization wide approach to process design and performance measurement, assessment and improvement
Audit
a process used to identify oportunities for improvement
Affinity Diagram
used to generate a large number of ideas and then organize groups within them to understand the essence of a problem and its solutions
histogram
- summarize continuous data
- shows frequency of occurrence of different kinds of events
Benchmarking
measures an organization’s performance on certain processes/ procedures in comparison to identified centers of excellence in order to improve performance
Comparative Benchmarking
standards are derived from other performance rates of compliance to common performance measures
Prescriptive Benchmarking
standards are derived from medical literature and expert opinion
Brainstorming
an activity used to creatively and effectively generate a high volume of ideas on any topic by a process
Case mix
the type and number of patient groups an organization serves
case payment
payment based on condition itself, not interventions
check sheet
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 “..”
clinical pathway
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
complaint analysis
complaints from patients are analyzed to identify areas for improvement
control chart
line graph used to monitor, control and improve performance over time by studying process variations and their causes
equitable access
fair and impartial opportunity to enter a place or obtain a particular service
line graph
graph showing number of events through time
Matrix Diagram
diagram used to systematically identify, analyze and rate the presence and strength of relationships between two sets of information
meta- analysis
the statistical synthesis of results of several studies testing the same relationship into a same outcome measure, thus increasing the strength of the conclusion
National health insurance program
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
nominal group technique
team brainstorming method used to quickly come to a consensus on the relative importance of issues, problems or solutions by combining individual rankings
Paretto chart
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”
Pie chart
pictorial diagram that illustrates proportion of specific items to the entire unit
Plan- Do- Check- Cycle
a systematic method used for identifying areas of improvement, pilot testing solutions, evaluate results, and institutionalize long term solutions
Process decision program chart
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
Quality Assurance
a formal set of activities to review and ensure the quality of services provided.
quality assessment + corrective measures
quality circle
a group of 5 to 10 workers from one work area of an organization that meet to solve issues in quality
radar chart
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
scatterplot diagram
data analysis tool which shows if two sets of data/ observations are related to each other in linear fashion
sentinel event
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
swiss cheese model
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
Tree diagram
a graphic tool used to organize tasks into increasing levels of detailed action that must and could be done to achieve stated goals
utilization review
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
variance analysis
data interpretation tool used to document and identify the most common causes of deviation from routine care
warranties
the guarantee that a healthcare provider applying for accreditation agreed to abide by the provisions of National Health Insurance Law
