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Innovation in joint health command clinical governance murphy

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Innovation in joint health command clinical governance  murphy Innovation in joint health command clinical governance murphy Presentation Transcript

  • JOINT HEALTH COMMAND GAS GAS GAS LTCOL Helen Murphy SO1 Clinical Governance Directorate Defence Clinical Services Joint Health Command 30 October 2010
  • JOINT HEALTH COMMAND Outline Background Research and Design Implementation Process IIAA Validation Culture change Findings Future
  • JOINT HEALTH COMMAND Background •ISO 9001:2000 – Quality Management Systems
  • JOINT HEALTH COMMAND Research & Design •Research •Continuous improvement
  • JOINT HEALTH COMMAND Research & Design Included requirement for accreditation to: ISO ACHS AGPAL NATA 2 years of design of GAS including: policy SOP Tools Forms Risk matrix g
  • Risk Sectio SAC SAC SAC System SAC 1 n 2 3 4 1 Credentialling of Health Professionals 2 Staff Orientation 3 Clinical Practice - Physio 4 Clinical Practice - Dentistry (Reserved) 5 Radiation safety 6 Clinical Practice - Radiography (Reserved) Clinical Practice - Dental Hygienist 7 (Reserved) 8 Clinical Practice - Rehabilitation 9 Clinical Practice - Medicine 10 Clinical Handover 11 Clinical Practice - Nursing 12 Clinical Practice - Mental Health (Reserved) 13 Clinical Practice - Pharmacy 14 Medication Safety 15 Operating Theatre Practice 16 Clinical Practice - Pathology (Reserved) 17 Patient Identification 18 Sterilization 19 Infection Control 20 Mental Health Services (Reserved) 21 1800IMSICK 22 Rehabilitation Services (Reserved)
  • 22 Rehabilitation Services (Reserved) 23 Patients Rights and Responsibilities 24 Complaints Management 25 Customer Feedback Management 26 Internal Audit & Quality Improvement 27 Health Incident Management 28 Access 29 Patient Recall 30 Emergency Procedures 31 Secondary Appointments 32 Documentation 33 Medical Records Management 34 Equipment and Callibration 35 Waste Management 36 Patient Transport (Reserved) 37 Catering 38 Medical Stores Management 39 Linen 40 Cleaning 41 Building Maintenance 42 Vector Control/Pest Management 43 Financial Management (Reserved) 44 Fixed Plant 45 Contract Management (Reserved) 46 KPI IAW HD 920 47 Occupation Health (reserved)
  • JOINT HEALTH COMMAND INTERNAL & EXTERNAL VALIDATION April 2010 IIA International standards for the Professional Practice of Internal Auditing Customer satisfaction surveys
  • JOINT HEALTH COMMAND IMPLEMENTATION Commenced Mar 2010 Pilot until mid 2011 Completed 9 audits (7 health and 2 dental facilities) and 2 follow-up audits
  • JOINT HEALTH COMMAND PROCESS • Triennial audits •Ongoing internal audits
  • JOINT HEALTH COMMAND CULTURE CHANGE Allow time for change tools for ongoing internal auditing Risk Register
  • JOINT HEALTH COMMAND FINDINGS  Poor communication Medical Records Management Infection Control and Sterilization Patient Recall Processes Medication Safety Clinical Handover Credentialling
  • JOINT HEALTH COMMAND Evaluation  End of pilot stage Cost
  • JOINT HEALTH COMMAND FUTURE  Include an AHS/RHS module Include a communication module Include a HHCP module  Risk based audit schedule Use of electronic KPI data
  • JOINT HEALTH COMMAND Summary • Sub-system of CI
  • JOINT HEALTH COMMAND Thank you