HAADStandards for LicensureandQuality Improvement

Dr.DavidMatear ProjectManager

Agenda
1. 2. 3. 4. 5. 6.

BackgroundtotheHAADStandardsproject HAADJCIStandards HospitalStandards Majorstandardschapters Identifiedproblems Relevantstandards

PatientSafetyandQualityImprovement(PCQ) Communication(CCC) HighRiskCareProcesses(HRC) Leadership(LDS)

7.

Summary

BackgroundtotheHAADStandards project
Facilitieslicensingstandards
Standardsdocumentation(14documents)

Inspectionprocess Internationalstandards Documentationandstandardsselectionofavarietyof standards(ISO,JCI,JCAHO,CCHSA,OSHA) Achievableintheprivatesector?

Tawam andRahba achievedJCIin23years SKMCworkingtowardsJCI(1year+)

RFP Standardsdevelopmentandinspectortraining

HAADJCIStandardsPartnership
Developedandapproved HospitalStandards AmbulatoryCareStandards ContinuumofCareStandards Future MedicalTransport Laboratories Ionizingradiation

HSRCTermsofReference
AdministrativeDecisionNo.26/2007

Administrativedecision
MembershipfromHAAD,HealthServicesCompanyand managementorganizations Goal Review,amendment,andrecommendationof standardsforlicensureandinspectionofhealthfacilitiesin theEmirateofAbuDhabi. Objectives
ReviewdraftstandardssubmittedbyJCIintheareasofHospital, AmbulatoryCare,andContinuumofCare. Considerotherdevelopingandrelatedstandards. Proposeamendmentstotheproposedstandards. Recommendtheadoptionofstandardsthatareconsistentwith internationalstandards. Developamechanismforannualstandardsreview.

MajorStandardsChapters
PatientSafetyandQuality Improvement Communication Highriskcareprocesses Leadership FacilitySafety

MandatoryStandards
Representthemostimportant Basedonlaw,regulatorypolicies SelectedcriticalMeasurableElements(MEs) orstandards MUSTbemetforlicensure

ProblemsIdentified
Patientsafety Communication Provisionofhighriskcare Referralsandtransfers Documentation Professionalqualificationsandskills

GeneralPrinciples
Ensuretheclinicalandotherprofessionalqualificationsofall staffaccordingtoHAADlicensingpolicies
Expectationsofinternationalgoodpractice Maintainsafety

Ensuretheirfacilitiesandequipmentaresufficient
deliversafe,highqualitycareinaccordancewithinternationalgood practice.

Ensuretherearerobustclinicalandmanagementprocesses forthetrackingofpatientsafetyandtheeffectivenessof treatment,includingaccurate,fitforpurposeclinicalrecords. Reportanyoccurrencethatresultsinarisktopatientsafety orcompromisesthedeliveryofhighqualitycare

PatientSafetyGoals
All6PatientSafetyGoalsareMANDATORY Relevantotherstandards PCQ.1Goal1 Identifypatientscorrectly
ME5Beforetreatmentorprocedures

PCQ.2Goal2 Improveeffective communication

MonitoringRequirements
PCQ.8 MonitoringofPatientSafetyGoals PCQ.13 Identificationofkeymeasurestomonitor
ME5 Patientassessment ME13 Availability,timeliness,content,anduseof patientrecords ME16 Reportingofactivitiesasrequiredbylawand regulation ME17 Riskmanagement ME23 Preventionandcontrolofeventsthatjeopardize thesafetyofpatients,families,andstaff

InvestigationandReportingofEvents
PCQ.17 Thehospitalusesadefinedprocess foridentifyingandmanagingsentinelevents
Definitionofeventstobeinvestigated Rootcauseanalysiswithin45days Changeprocedures

PCQ.18 Dataareanalyzedwhen undesirabletrendsandvariationare identified

Communication Admission
CCC.1 Patientsareadmittedtoreceiveinpatientcare basedontheiridentifiedhealthcareneedsandthe hospitalsmissionandresources.
ME1 Screeningisinitiatedatthepointoffirstcontactwithinor outsidethehospital.

CCC.3 Patientswithemergencyorimmediateneedsare givenpriorityforassessmentandtreatment.

ME1 Thehospitalhasestablishedcriteriatoprioritizepatients withimmediateneeds.

CCC.6 Admissionortransfertoorfromunitsproviding intensiveorspecializedservicesisdeterminedby establishedcriteria.

ME1 Thehospitalhasestablishedentryand/ortransfercriteriafor itsintensiveandspecializedservicesorunits. ME5 Patientstransferredoradmittedtointensiveandspecialized units/servicesmeetthecriteriaandthisisdocumentedinthe patientsrecord.

Discharge,Referral,Followup
CCC.8 Thereisapolicyguidingtheappropriate referralordischargeofpatients
ME1 Thereisapolicyguidingtheappropriatereferral and/ordischargeofpatients ME2 Thereferraland/ordischargeisbasedonthe patientsneedsforcontinuingcare

CCC.9 Patientrecordscontainacopyofthe dischargesummary

ME4 Acopyofthedischargesummaryisprovidedto thepractitionerresponsibleforthepatientscontinuing orfollowupcare

TransferofPatients
CCC.10 Thereisapolicyguidingtheappropriatetransferof patientstoanotherhospitalororganizationtomeettheir continuingcareneeds
ME2 Theprocessaddressesthetransferofresponsibilityto anotherproviderorsetting ME5 Theprocessaddresseswhoisresponsibleduringtransfer ME7 Patientsareappropriatelytransferredtootherhospitalsor organizations

CCC.11 Thereferringhospitalorganizationdeterminesthat thereceivinghospitalcanmeetthepatientscontinuingcare needs

ME1 Thereferringhospitaldeterminesthatthereceivinghospital canmeettheneedsofthepatienttobetransferred ME2 Patientclinicalinformationoraclinicalsummaryis transferredwiththepatient

TransferofPatients
CCC.12 Duringdirecttransfer,aqualifiedstaffmember monitorsthepatientscondition
ME1 Allpatientsaremonitoredduringdirecttransfertoanother hospital

CCC.13 Thetransferprocessisdocumentedinthepatients record

ME1 Therecordsoftransferredpatientsnotethenameofthe hospitalandnameoftheindividualagreeingtoreceivethepatient ME2 Therecordsoftransferredpatientsnotethereason(s)for transfer ME3 Therecordsoftransferredpatientsnoteanyspecial conditionsrelatedtotransfer ME4 Therecordsoftransferredpatientsnoteanychangeof patientconditionorstatusduringtransfer

Transportation
CCC.14 Theprocessforreferring, transferring,ordischargingthepatient considerstransportationneeds
ME1 Theprocessforreferringpatients considerstransportationneeds ME4 Transportationisappropriatetothe patientsneeds

HighRiskCare AssessmentsandCare
HRC11 Qualifiedindividualsconductthe assessmentsandreassessments
ME2 Onlythoseindividualspermittedbylicensure, applicablelawsandregulations,orcertificationperform patientassessments ME3 Emergencyassessmentsareconductedby individualsqualifiedtodoso

HRC16 Policiesandproceduresguidethecareof highriskpatientsandtheprovisionofhighrisk services

ME1 (a)Careofemergencypatients

Leadership Ethics
LDS.3 Thehospitalestablishesaframeworkfor ethicalmanagementthatensuresthatpatientcare isprovidedwithinbusiness,financial,ethical,and legalnormsandthatprotectspatientsandtheir rights
ME4 Thehospitalprovidesclearadmission,transfer,and dischargepolicies ME6 Thehospitaldisclosesandresolvesconflictswhen financialincentivesandpaymentarrangements compromisepatientcare

DepartmentalLeadership
LDS.8 Oneormorequalifiedindividuals providedirectionforeachdepartmentor serviceinthehospital
ME1 Anindividualwithappropriatetraining,education, andexperiencedirectseachdepartmentorserviceinthe hospital

StaffEducation
LDS.17 Staffmemberswhoprovidedirectcareandservices andotherstaffidentifiedbythehospitalareannually trainedinbasicoradvancedcardiaclifesupport ME1 Staffmemberstobetrainedincardiaclifesupport areidentifiedbythedevelopmentofalist.Thelist includesatleastalldirectcaregivers ME2 Theappropriateleveloftrainingisprovided(e.g., basiclifesupport(BLS),advancedlifesupport(ALS), pediatricadvancedlifesupport(PALS)) ME3 Staffmembersareretrainedeverytwoyears ME4 Thereisevidencetoshowifastaffmemberpassed thetrainingwhichincludesbothawrittentestandreturn demonstration

MedicalStaffing
LDS.18 Thehospitalhasaneffectiveprocessforgathering, verifying,andevaluatingthecredentials(license,education, training,andexperience)ofthosemedicalstaffpermittedto providecareandservicestoindividualswithoutsupervision ME1 Thosepermittedbylawsandregulationsandby thehospitaltoprovidecareandservicestoindividuals withoutsupervisionareidentified ME2 Currentlicensure,education,training,and experiencearedocumentedfortheseprofessionals ME3 Suchinformationisverifiedfromtheoriginal source

MedicalStaffing
LDS.19 Thehospitalmaintainsforeverymedical staffmemberarecordofthecurrentprofessional license,certificate,orregistrationwhenrequiredby lawsorregulationsorbytheorganization
ME2(c) Currentlistofprivileges

LDS.20 Thecredentialsofmedicalstaffmembers arereevaluatedatleastevery3yearstodetermine theirqualificationstocontinuetoprovidecareand servicesintheorganization

ME1 Thereisaprocesstoevaluateeachmedicalstaff membereverythreeyears

MedicalStaffing
LDS.21 Thehospitalhasastandardized,objective, evidencebasedproceduretoauthorizeallmedical staffmemberstoadmitandtreatpatientsand provideotherclinicalservicesconsistentwiththeir qualifications
ME1 Thereisastandardizedproceduretogrant privilegestopractitionersoninitialappointmentandon reappointmenteverythreeyears ME5 Theaggregationoftheannualdataisusedinthe evaluationforreappointmentwhichoccurseverythree years

Summary
Approvedlicensingstandardsgovernhealthcare Mandatorystandardsmustbemet Theproblemsidentifiedarecoveredinthestandards Patientsafety Communication Provisionofhighriskcare Referralsandtransfers Documentation Professionalqualificationsandskills Relevantstandardstoidentifiedproblems PatientSafetyandQualityImprovement(PCQ) Communication(CCC) HighRiskCareProcesses(HRC) Leadership(LDS) Inspectorswillenforcethatstandardsaremet

QUESTIONS?