Accreditation of Your Hospital

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Accreditation of Your Hospital

  1. 1. The presentation is solely meant forAcademic purpose
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  10. 10. Regulation Vs. Accreditation Regulation is mandatory Accreditation is voluntary Accreditation is promoted by way of incentives and market forces In order to achieve best of both worlds, regulation in time to come can simply rely on accreditation
  11. 11. Standards AuditingQuality System
  12. 12. Accreditation Management LogisticsNursing / Technician Physician Patient Safety Surgeon Paramedical
  13. 13. Benefits to HCOStimulates continuous improvementEnables the HCO in demonstrating commitment to quality of care.Raises community confidence in the services provided.Provides opportunity to benchmark.International recognition of services.Better efficiency and Increase in revenueTransparency in the overall operationsProvides the framework for an integrated and focusedmanagement structure.Recognition by payers, government and vendors
  14. 14. PATIENTS / ASSOCIATESPATIENT DAY TO DAY OPD OPD DISCHARGE FEEREGISTRATIOREGISTRATION MONITORING ADMISSION CONSULTATION CERTIFICATE COLLECTIONN FRONT LINE STAFF REGISTRATION ,PARAMEDICAL, NURSES, REDSIDENT CONSULTANT / DOCTORSEMPOWERMENT CEO/HODs
  15. 15. Benefits to CliniciansAccredited hospital provides for effectivegovernance including structured supportservices needed by Clinicians.It provides for continuous learningthrough monitoring of clinical indicatorsincluding opportunity to benchmark.Improves overall professionaldevelopment and provides opportunityfor leadership role in quality
  16. 16. Percentage of medication errorsPercentage of transfusion reactionsUrinary tract infection rateRespiratory infection rateIntra-vascular device infection rateSurgical site infection rateIncidence of fallsIncidence of bed sores after admissionBed occupancy rate and average length of stayIncidence of needle stick injuries
  17. 17.  Systems are checked Actual practice is not Safety is given top priority Measure what you do
  18. 18. Temp PACU Temp PACU arrival exit All 34.5 (32.8 – 35.7 (34 – 36.8) 37.2)Patients with 34.8 (34 - 36 (35- 37.2)bear hugger 36.8)Without bear 34.4 (32.8 – 35.7(34 – 36.8) hugger 36.4) 19
  19. 19.  Cover preoperative patients Minimize heat loss before surgery Monitor temperature/s Warmer / warm fluids/ early closure/ cover plastic sheet Cover during transfer 20
  20. 20.  One of the top priority areas HAIs Hand hygiene compliance Antibiotic use Antibiogram Abuse Prophylactic antibiotic Resistance pattern
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  23. 23. 2005 20101 Anesthesia Spinal/epidur Nerve blocks al2 High risk pts No Yes3 Mobilization 24- 48 hrs 2-4 hrs4 Pain relief OK excellent5 Post op pts Slightly Alert, no vomiting drowsy5 Discharge 7 to 10 days 5 days 25
  24. 24. 2000 20101 Ventilator 24 hrs 2 to 3 hrs2 ICU stay 2- 3 days 18 hours3 Pain relief (0 to 10) 2 to 4 0 to 24 Postop status Slightly drowsy Alert awake5 Mobilization 3 days Day 06 Climbing steps 4 to 5 days 2 to 3 days7 Blood transfusion 4 to 5 units 0 to 1 unit8 Infection <5 % <1%9 Discharge from hospital 12 to 15 days 5 to 6 days10 Return to work 2 months 2 to 4 weeks 26
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