The Difference between hospital and other organizations

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2. The Difference between hospital and other organizations

6. Definition : Assessment of health services according to a set of standards describing the structures and processes that contribute to desirable patient outcomes based on quality of care and patient safety

7. Benefits of Accreditation Shows commitment to quality Improves communication and collaboration within the organisation Promotes team building Increases credibility Demonstrates accountability Improves productivity Obtaining advice from surveyors (mentoring)

8. Accreditation methodology Function based (tracer methodology) Department based

9. JCAHO(U.S) 1-Patient-Focused Functions -Rights, ethics, responsibilities -Provision of care, treatment, services -Medication management -Surveillance, prevention, infection control

10. JCAHO (cont�)

11. Joint commission international (JCI)

12. A new task force in 1997 In EU, Middle east and Far east and then everywhere

13. Patient safety goals Goal 1 Identify Patients Correctly Goal 2 Improve Effective Communication Goal 3 Improve the Safety of High-Alert Medications �

14. Patient safety goals(cont�) Goal 4 Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery Goal 5 Reduce the Risk of Health Care-Associated Infections Goal 6 Reduce the Risk of Patient Harm Resulting from Falls

15. JCI (cont�) Functional Section I: Patient-Centered Standards ACC (Access to care and continuity if care) PFR (Patient and Family Rights) AOP (Assessment Of Patients) COP (Care Of Patients) ASC (Anesthesia and Surgical Care) MMU (Medication Management and Use) PFE (Patient and Family Education)

16. JCI (cont�) Functional Section II: Health Care Organization Management Standards QPS (Quality improvement and Patient Safety) PCI (Prevention and Control of Infections) GLD (Governance, Leadership and Direction)

17. JCI (cont�) FMS (Facility Management and Safety) SQE (Staff Qualifications and Education) MCI (Management of Communication and Information)

18. JCI Functions Functional Section I: Patient-Centered Standards ACC (Access to care and continuity of care) screening Admission Referral Transportation needs Discharge Continuity of care

19. JCI Functions PFR (Patient and Family Rights) Personal value and beliefs(pastoral services�) Privacy Confidentiality Security Processes for PFR

20. JCI Functions PFR (Patient and Family Rights) Pt will be told about care and complications Inform consent Research Organ donation

21. JCI Functions AOP (Assessment Of Patients) Initial assessment & needs for discharge planning Reassessment Lab Radiology

22. JCI Functions COP (Care Of Patients) Continuity of care Integrity of care Uniform care Based on assessment High risk Pt�s(Restraint Pt�s ,children ,elderly , comatose and�) Nutrition Pain management

23. JCI Functions ASC (Anesthesia and Surgical Care) Pre-anesthesia assessment Pre induction assessment During anesthesia monitoring Post anesthesia monitoring Risks ,benefits and alternatives

24. JCI Functions MMU (Medication Management and Use) Procurement Readiness of medication 24/24 Storage safety Medication recall system 6 stages of medication(prescribing,transecribing,dispensing,preparation,administration,documentation) Medication brought to hospital by Pt�s

25. JCI Functions MMU (Medication Management and Use) Medication orders review for appropriateness Medication error report

26. JCI Functions PFE (Patient and Family Education) Patient and family participation in decisions Patient and family education need assessment Education method consider patient and family values All health professionals collaborate to Pt education

27. JCI Functions Functional Section II: Health Care Organization Management Standards QPS (Quality improvement and Patient Safety) Participation of leaders in quality and patient safety program Process management(clinical and managerial) Key indicators(including data collection , aggregation and analysis ) who collect ,aggregate and analyze Sentinel events process Near miss events process Continuous quality and safety improvement and priority areas

28. JCI Functions PCI (Prevention and Control of Infections) Infection prevention and control Prevention and control of health associated infections Laundry Waste management Disposal of sharps Gloves and masks , eye protections Hand washing IC education for doctors ,nurses , Pt�s and�

29. JCI Functions GLD (Governance, Leadership and Direction) Bylaws , policies & procedures,� Senior manager Defining mission ,policies & procedures and their fulfillment Contracts for clinical or management services Department directors Ethical management

30. JCI Functions FMS (Facility Management and Safety) Facility inspection Maintenance plan Plan for inventory ,handling storage and use of hazardous materials Disaster plan Potable water and electricity 24/24

31. JCI Functions SQE (Staff Qualifications and Education) Determine qualification and skills for all staff Recruiting, evaluating and appointing staff Orientation program Education and training plan for all staff Gathering, verifying and evaluating the credentials Ongoing professional practice evaluation of medical and clinical staff

32. JCI Functions MCI (Management of Communication and Information) Communication with community about Pt care services Pt care information is communicated during and between shifts Information privacy and confidentiality Information security

33. JCI Functions MCI (continue) Standardized diagnosis codes, procedure codes, symbols, abbreviations and definitions Staff participating in selecting and using information

34. Accreditation infrastructure Process management Data collection Quality improvement planning Orientation program Documentation Competency testing Policies and procedures Internal audit

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