The organization provides care and services that achieve effective outcomes and ensures that the correct consumer /patient receives the correct procedure

2.  Appropriate care and services are provided to consumers/patients
 The organization provides care and services that achieve effective outcomes
 The organization ensures that the correct consumer /patient receives the correct
procedure
 The organization ensures that the nutritional needs of consumers /patients are met
 The governing body is committed to consumer/patient participation

3.  Brainstorming
 ? are there any situation/instances of care given is inappropriate ?
 ? are we satisfied with care delivered ?
 ? are there any situation/instances of care given in an inappropriate setting ?
 ? are we happy with the care setup ?
 Appropriateness - doing right treatment/intervention/service in the right way
 Effectiveness - is the extent to which those treatments, interventions or services
achieve the desired outcomes. (desired outcomes to clinician and patient)

4.  Two units of blood transfused to a 17 year old girl presenting with Hb 6g/dl due to iron
deficiency !
 A patient with poorly controlled diabetes presents with UTI. Started IV antibiotics after
sending samples for all the Ix. Fever settles next day.Clinician change antibiotics to oral in
spite of mild abdominal distension, BNO and nausea. Next day C/O bilious vomiting.
Surgical referral done. Surgeon writes – no surgical causes – most likely sepsis.ABST
report receives – all antibiotics patient on are resistant. Same day patient succumb !
 Patients with PV admitted to wards for venesection
 Patients with severe neutropenia managed in the same ward setup
 Patient with trauma related disability managed in a ward and send for physiotherapy daily

5.  Use standard interventions – (proven to be effective)
 are we happy with LSCS rate private sector vs public sector ?
 are we happy with subfertility care provided in public sector ?
 All the care activities are based on the available best evidence /
 Dengue care in all the hospitals ?
 Care of haemophilia patients with bleeding ?
 Care is provided in the most effective way – how do we know whether it is the
most effective way ?

6.  Appropriate care ? Guidelines / evidence based practice/ what is the gap?
 National guidelines / institutional guidelines –
 adopt international guidelines with or without modifications
 Help of professional colleges
 Hospital operating procedures, standard operating procedures
 pain management, fall prevention, infection prevention/control,
 Appropriate setting ? –
 outpatient, inward, day centre, home based, rehabilitation centre/ unit, dengue dependency
units,
 Have we documented what is available/done ?

7.  Underuse or failure to provide a service which had a benefit that is greater than
risk
 Overuse , risks are higher than benefits
 Assessment and evaluation of appropriateness includes credentialing, scope of
clinical practice system, peer review meetings and or clinical audit reviews

10.  Clinical guidelines direct appropriate care
 Policies and procedures available to assess appropriateness of care
 Care assessment policies and procedures readily available to staff
 Processes available to minimize risks to consumers – specially outside specialty
area
 Policy and guidelines address use of restraint
 Physical restraint
 Chemical restraint
 seclusion
 “Home-ward outlier” ?

13.  Most common care processes identified
 Patient admission, pre-op evaluation, discharging, transfer of care, giving medications
in the ward, storage of drugs in the ward, sample collection for testing…………………..
 Document best way to carryout those processes
 Establish mechanism all involved in such care processes understand and carryout
the process same way as expected
 “uniformity of performance irrespective of change in personnel”

14.  How to know whether appropriate care is given?
 How to know care is given at the appropriate site ?
 Guidelines > check list > audits > customer feedback > direct observation > statistics> employee views>
 Identify reasons for “NOT” s…..whyinappropriate
 Unaware ? Difficult to follow / limitations / inadequate facilities ?
 Why care is not given at the appropriate site ? – practical problems / accessibility/ limitations of time/
limitation of facilities – equipment breakdown ?
 Defective CT scan at AmparaGH, MDS/ MPD managed at Apeksha hospital , private sector “GP” practice
 Root cause analysis – planning/decision making/ monitoring/ regulation/
surveillance

17.  Training and education support – what training is offered to
employees/ to whom /on what
 Attitudes towards EBP and research – institutional culture on
practice standard
 Consumer demand for evidence –based care – how when what &
from whom consumer
 demands considered
 Logistical and organizational considerations – allocation and
availability of resources, how organizational structure ensure
appropriate practice – eg: authorization procedures
 Institutional and leadership support – directives from
 Eg: oral care of an intubated pt has no major clinical implications!
use of H2O2 in wound cleaning, use of tourniquet for blood collection,
how many hours of fasting is needed for FBS & for Lipid profile

20.  Do we have tools to assess effectiveness of care ?
 Do we have policies, processes, procedures or guidelines on assessing overall
effectiveness of care ?
 Do we have policies, processes, procedures or guidelines to have make consumers
aware on feedback and on how to receive feedback ?

21.  Patient is “taken in” toAE unit
 Clerked
 No bed is given
 Just sleeping helpless on a bare trolley
 No pillow
 No sheet
 Carerer waiting in a corner helpless

22.  Organization supports implementation of evidence-based care
 Care process mapping is documented (multidisciplinary input when necessary)
 Organization collects “key indicators” related to effectiveness of care and interventions
 Individual patient outcomes are assessed against agreed care plan/ evidence based guidelines
 Outcomes of care is discussed with patient/caregiver and documented
 Feedback obtained from patient/ care giver

23.  Organization-wide clinical audits are performed and evaluated
 Key indicators evaluated
 Medication errors
 Patient fall
 Patient identification errors
 Incidence of pressure sores
 Patient waiting time
 TATtestreports
 Peripheral line extravasations
 Surgical site infections
 Improvements are made as per feedback/ evaluations.Customer care department ?

24.  Assessment of effectiveness of care and interventions
 Assessment of effectiveness of individual care episodes

25.  Includes all operative and invasive procedures
 “potential exposure to harm”
 Not only surgeries !
 Administration of medications – issue of drugs from indoor pharmacy/ in the
ward/ blister packs vs loose tablets/ blister packs cut in to singles !!
 Transfusions
 Diagnostic testing
 Retrieval of past data and providing such information for further care ?

26.  Other than surgical procedures where else we use check lists ?
 How does the organization ensure consistency of action and staff compliance?
 How does the organization responds to any identified instance of “non- compliance”?
 Who is responsible for investigating incidents related to wrong patient/ wrong care or
intervention ?
 How does the organization use such investigation findings for further improvement ? ( eg:
serum potassium )

27.  Accountable items management – in OT andoutside.
 Labelling of biopsies and samples ? (Brain biopsy / guided FNAC)
 Standardized documentation of test results
 Incident and risk management system
 Staff education program – non compliance and harm
 Processes for accountable items verification
 Monitoring and auditing for compliance

29. NHSL, teaching hospital, PGH, DGH, GH, BH, DH
DH vs PGH/TH
 Hospital level –
 Surgery unit -
 Paediatrics unit-
 General medicine-
 OPD-
 Emergency care-
 Obs &Gynae-

30. 1. Care based on established and accepted standards , evidence based guidelines,
or treatment protocols
2. Only vary according to consumer/patient needs
3. Not be unnecessary or inappropriate simply because the patient/ consumer
requested it
4. Be needed and provide benefit to the patient/ consumer
5. Take in to account any research /quality improvement work undertaken

31.  Have a nutrition management strategy
 Provide nutritional care as a part of overall care plan
 Identify at-risk consumers
 Information and education to staff and patients

33.  Identify main consumer groups
 Identify diverse needs
 Identify assistance needed
and extent

34.  Encourage consumer/patient participation in planning ofservices
 Eg: palliative care
 Encourage and provide opportunities for consumer/ patient / community participation in
planning
 Eg: toilet design
 How many committees ?What is advisory ?What is decision making ? How community/
patient/ consumer participate in these ? How they are selected ?
 Inclusion of consumer participation programs
 Policies governing consumer participation
 Evidence of consumer participation
 Education

35.  Are patients educated on rights and responsibilities ?
 Documented patients rights and responsibilities – in all languages
 Evidence on dissemination of information to consumers
 Improvements made as per changes/ requirements