0
GAS GAS GAS
LTCOL Helen Murphy
SO1 Clinical Governance
Directorate Defence Clinical Services
Joint Health Command
30 Octob...
Outline
Background
Research and Design
Implementation
Process
IIAA Validation
Culture change
Findings
Future
JOINT...
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:
polic...
Risk
Sectio
n
System SAC 1
SAC
2
SAC
3
SAC
4
1 Credentialling of Health Professionals
2 Staff Orientation
3 Clinical Pract...
22 Rehabilitation Services (Reserved)
23
Patients Rights and Responsibilities
24 Complaints Management
25 Customer Feedbac...
INTERNAL & EXTERNAL
VALIDATION
April 2010
IIA International standards for
the Professional Practice of
Internal Auditing...
IMPLEMENTATION
Commenced Mar 2010
Pilot until mid 2011
Completed 9 audits (7 health
and 2 dental facilities) and 2
foll...
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
...
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...
Summary
• Sub-system of CI
JOINT HEALTH COMMAND
Thank you
JOINT HEALTH COMMAND
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Innovation in joint health command clinical governance murphy

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Transcript of "Innovation in joint health command clinical governance murphy"

  1. 1. GAS GAS GAS LTCOL Helen Murphy SO1 Clinical Governance Directorate Defence Clinical Services Joint Health Command 30 October 2010 JOINT HEALTH COMMAND
  2. 2. Outline Background Research and Design Implementation Process IIAA Validation Culture change Findings Future JOINT HEALTH COMMAND
  3. 3. Background •ISO 9001:2000 – Quality Management Systems JOINT HEALTH COMMAND
  4. 4. Research & Design •Research •Continuous improvement JOINT HEALTH COMMAND
  5. 5. 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 JOINT HEALTH COMMAND
  6. 6. Risk Sectio n System SAC 1 SAC 2 SAC 3 SAC 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) 7 Clinical Practice - Dental Hygienist (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)
  7. 7. 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)
  8. 8. INTERNAL & EXTERNAL VALIDATION April 2010 IIA International standards for the Professional Practice of Internal Auditing Customer satisfaction surveys JOINT HEALTH COMMAND
  9. 9. 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
  10. 10. PROCESS • Triennial audits •Ongoing internal audits JOINT HEALTH COMMAND
  11. 11. CULTURE CHANGE Allow time for change tools for ongoing internal auditing Risk Register JOINT HEALTH COMMAND
  12. 12. FINDINGS  Poor communication Medical Records Management Infection Control and Sterilization Patient Recall Processes Medication Safety Clinical Handover Credentialling JOINT HEALTH COMMAND
  13. 13. Evaluation  End of pilot stage Cost JOINT HEALTH COMMAND
  14. 14. 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
  15. 15. Summary • Sub-system of CI JOINT HEALTH COMMAND
  16. 16. Thank you JOINT HEALTH COMMAND
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