The document provides information about quality management systems at the institutional and unit levels of a hospital. It discusses how quality management systems at the unit level should be aligned with and integrated into the overarching hospital quality management system. The quality management system establishes the hospital's quality policy, objectives, and processes to achieve quality goals. These systems help ensure that all departments and units are working towards the same quality aims and standards.
This document discusses quality management and quality assurance in healthcare. It defines quality as meeting or exceeding customer expectations and being free from defects. Quality management has four main components: quality planning, quality assurance, quality control, and quality improvement. Quality assurance aims to prevent mistakes and defects by ensuring quality requirements are fulfilled. It discusses Donabedian and PDCA models of quality assurance. The document also outlines various approaches to quality assurance programs including credentialing, licensure, accreditation, and certification.
Systems of health care service delivery and methods of quality assurance vary throughout the world. Proposals for quality improvement should include accreditation, licensure, and certification to comprehensively maintain and improve quality, ensure public safety, and establish entry requirements for health care professionals and organizations. Quality in health care means doing the right thing at the right time in the right way for the right person to achieve the best possible results.
The document discusses key concepts in healthcare operations management. It defines operations management as coordinating processes to deliver quality healthcare services in a cost-effective manner. Core functions include planning, scheduling, purchasing, quality control, and inventory control. Decision areas encompass designing services, managing quality, planning processes and capacity, setting locations and layouts, managing human resources, and scheduling maintenance. Metrics measure performance from financial, customer, and operational perspectives to continuously improve the healthcare system.
The document discusses quality assurance in healthcare, including defining quality, measuring it through indicators, improving quality through approaches like total quality management and continual improvement, and ensuring quality through principles like transparency, evidence-based practice, and accountability. It also addresses important dimensions of quality like safety, effectiveness, efficiency, accessibility, and patient-centeredness.
The document discusses key principles of quality healthcare in both developed and developing countries. It addresses factors like the organization of care delivery, common errors, available resources, and the roles of nursing. It also discusses goals and definitions of quality care according to organizations like the WHO and IOM. Nursing's impact on quality is discussed both positively and negatively in the US and developing countries.
The document discusses strategic planning for medical practices. It defines strategic planning as a formal process that helps organizations maintain optimal alignment with their environment through goal setting and performance measurement. The strategic planning process involves conducting an environmental scan, developing a mission and vision, setting goals and objectives, creating action plans, and evaluating performance. It provides frameworks for conducting a SWOT analysis and developing a strategic plan with all necessary components.
The document discusses the roles and responsibilities of nursing services in a hospital. It outlines the organization of nursing which focuses on patient care and education. Nursing services are categorized into nursing care, administration, and education. The roles involve ensuring quality care, staff management, monitoring performance, and maintaining standards. Different nursing approaches and methods like functional, team, and patient care are explained.
Quality in healthcare refers to adhering to predetermined specifications and standards to meet patient needs. Over time, quality practices evolved from craftsmanship to focusing on processes through thinkers like Shewhart and Deming. Donabedian introduced structure-process-outcome measures for assessing quality. National and international organizations like JCAH, ISO, and NABH were formed to standardize healthcare quality. NABH accreditation involves an application process, onsite assessments, and meeting standards in areas like patient care, management, and information systems to certify high quality care.
This document discusses quality management and quality assurance in healthcare. It defines quality as meeting or exceeding customer expectations and being free from defects. Quality management has four main components: quality planning, quality assurance, quality control, and quality improvement. Quality assurance aims to prevent mistakes and defects by ensuring quality requirements are fulfilled. It discusses Donabedian and PDCA models of quality assurance. The document also outlines various approaches to quality assurance programs including credentialing, licensure, accreditation, and certification.
Systems of health care service delivery and methods of quality assurance vary throughout the world. Proposals for quality improvement should include accreditation, licensure, and certification to comprehensively maintain and improve quality, ensure public safety, and establish entry requirements for health care professionals and organizations. Quality in health care means doing the right thing at the right time in the right way for the right person to achieve the best possible results.
The document discusses key concepts in healthcare operations management. It defines operations management as coordinating processes to deliver quality healthcare services in a cost-effective manner. Core functions include planning, scheduling, purchasing, quality control, and inventory control. Decision areas encompass designing services, managing quality, planning processes and capacity, setting locations and layouts, managing human resources, and scheduling maintenance. Metrics measure performance from financial, customer, and operational perspectives to continuously improve the healthcare system.
The document discusses quality assurance in healthcare, including defining quality, measuring it through indicators, improving quality through approaches like total quality management and continual improvement, and ensuring quality through principles like transparency, evidence-based practice, and accountability. It also addresses important dimensions of quality like safety, effectiveness, efficiency, accessibility, and patient-centeredness.
The document discusses key principles of quality healthcare in both developed and developing countries. It addresses factors like the organization of care delivery, common errors, available resources, and the roles of nursing. It also discusses goals and definitions of quality care according to organizations like the WHO and IOM. Nursing's impact on quality is discussed both positively and negatively in the US and developing countries.
The document discusses strategic planning for medical practices. It defines strategic planning as a formal process that helps organizations maintain optimal alignment with their environment through goal setting and performance measurement. The strategic planning process involves conducting an environmental scan, developing a mission and vision, setting goals and objectives, creating action plans, and evaluating performance. It provides frameworks for conducting a SWOT analysis and developing a strategic plan with all necessary components.
The document discusses the roles and responsibilities of nursing services in a hospital. It outlines the organization of nursing which focuses on patient care and education. Nursing services are categorized into nursing care, administration, and education. The roles involve ensuring quality care, staff management, monitoring performance, and maintaining standards. Different nursing approaches and methods like functional, team, and patient care are explained.
Quality in healthcare refers to adhering to predetermined specifications and standards to meet patient needs. Over time, quality practices evolved from craftsmanship to focusing on processes through thinkers like Shewhart and Deming. Donabedian introduced structure-process-outcome measures for assessing quality. National and international organizations like JCAH, ISO, and NABH were formed to standardize healthcare quality. NABH accreditation involves an application process, onsite assessments, and meeting standards in areas like patient care, management, and information systems to certify high quality care.
This document discusses quality control in healthcare. It defines quality healthcare and how it is measured using indicators of structure, process, and outcomes. Evidence shows the need to improve quality through reducing errors and inappropriate care. Quality can be achieved by either building or inspecting it, using quality assurance or quality improvement approaches. Factors influencing quality include provider skills, system structure, resources, and education. Tools to improve quality include education, guidelines, and peer review. A comprehensive strategy is needed using incentives, data monitoring, patient empowerment, standards, and information systems to support continuous quality development.
Hospital administration role in quality patient careShaharul Sohan
Hospital administration ensures that hospitals run efficiently and provide quality patient care. Key responsibilities of hospital administrators include overseeing departments, recruiting and managing staff, ensuring compliance with policies and regulations, and coordinating efforts to achieve common goals like quality care. Effective hospital administration requires planning, organizing, staffing, directing, coordinating, reporting, budgeting, supervising, and evaluating all hospital activities and processes. The role of the administrator is crucial to the success of the hospital organization and the care provided to patients.
The document discusses key aspects of quality in healthcare. It defines quality as services that increase the probability of desired health outcomes and follow best practices. There are three aspects of quality - measurable, appreciative, and perceptive. The perception of quality is most influenced by caring staff, physical environment, and physician competence rather than new technology. Quality care positively affects patients and is defined by dimensions like safety, effectiveness, timeliness, efficiency, and equity. Quality management principles center around leadership, data-driven decisions, customer focus, and continuous improvement.
The document provides facts about patient safety. Some key points:
- 20-40% of health spending is wasted due to poor quality care.
- 98,000 Americans die each year from preventable medical errors.
- Hospital errors are the 5th-8th leading cause of death in the US.
- There is a 1 in 300 chance a patient will be harmed during healthcare.
This document provides an overview of hospital revenues. The primary source of revenue for hospitals is operating revenue, which is generated from providing patient care services. Operating revenue is categorized as either gross or net patient service revenue. Gross patient service revenue is the total amount hospitals would receive if paid in full for all services, while net patient service revenue is the actual amount collected after deducting for charity care and contractual adjustments agreed to with insurance companies. Other sources of revenue include other operating revenue from non-patient care activities and gains/losses from peripheral business activities.
Quality management in nursing professionSANJAY SIR
Quality improvement requires in any field to provide best services to the community in the health care system. it is uploaded to aware the the paramedics & nursing personnel to improve the quality care & helps educators to teach their students.
Quality assurance aims to close the gap between actual health care performance and desirable outcomes through systematic activities like setting standards, monitoring compliance, and improving quality. It benefits clients through better health outcomes and satisfaction, providers through a more satisfying work environment, and institutions through higher patient satisfaction and reputation. Ensuring quality requires perspectives from communities, providers, and managers to meet stakeholder needs.
PPT ON QUALITY IMPROVEMENT& PATIENT SAFETYsoumyareena
This document discusses quality improvement and patient safety. It defines quality of care and notes that the WHO defines quality as care that is safe, effective, timely, efficient, equitable and people-centered. It then discusses that quality improvement in healthcare aims to systematically improve care delivery through measuring, analyzing, improving and controlling processes. Various quality improvement tools are listed such as brainstorming, data collection tools, flow charts and control charts. An example quality improvement project aims to reduce voluntary nurse turnover rates. The steps of defining the problem, organizing a team, clarifying the current process and selecting and planning improvements are outlined. Patient safety is defined as avoiding unintended harm during care. Various aspects of patient safety related to medication, surgery, electricity
Total quality management in healthcare organisationspoonam chaudhary
This document provides an overview of total quality management (TQM) in healthcare organizations. It discusses that TQM is a customer-centered and employee-driven approach to continuous improvement of processes to ensure high quality products and services. The document traces the history and development of quality control, quality assurance, and TQM in healthcare. It describes the key principles of TQM, including getting processes right the first time, listening to customers and employees, continuous improvement, and building teamwork. The document also outlines several tools that are commonly used for quality improvement in healthcare organizations under a TQM model such as flow charts, histograms, control charts, and cause analysis diagrams.
Accreditation as a Strategy / Tool for Hospital Quality Service ImprovementReynaldo Joson
The document discusses hospital accreditation as a strategy for quality improvement, defining terms like accreditation, certification, and compliance. It examines standards for accreditation in the Philippines from organizations like PhilHealth, JCI, ISO, and more. The document recommends that hospitals seek accreditation from PhilHealth first to establish a foundation before pursuing other international standards.
An introductory overview of the basic concepts of Healthcare Quality, a starter for beginners.
Prepared in 2014 for the new staff of the Quality Management Department in King Saud University Medical City in Riyadh as a part of their capacity building plan.
Acknowledgments:
*Dr. Magdy Gamal Yousef, MBBCh, MS, CPHQ - for his contribution in the scientific content
**Ms. Maram Baksh, MS, CPHQ - for the design of the full HCQ capacity building plan in KSUMC
Hospital marketing aims to promote high quality medical care while satisfying patient needs. It informs target audiences like patients, families, and doctors about hospital services. Hospital marketing has three key functions: understanding future consumer needs to plan strategy, providing consumers with treatment information to avoid delays, and making quality services affordable for communities. Social media has become an important tool for hospital reputation management by connecting with patients, raising awareness of health issues, and understanding the customer lifecycle. Activities like video marketing, image marketing, and hosting health-related events can effectively promote hospitals on social media.
This document outlines quality assurance in nursing. It defines quality assurance and discusses its concepts and purposes. It describes various approaches to quality assurance programs, including general approaches like credentialing and licensure, and specific approaches like peer review and use of standards. Frameworks for quality assurance are presented, including those from Maxwell, Wilson and Lang. The document also examines the Joint Commission on Accreditation of Healthcare Organizations and models of quality assurance, such as the systems model and the American Nurses Association model.
Comprehensive Field Practice (CFP) : District Health Service Management Mohammad Aslam Shaiekh
The document summarizes the activities and learnings of a group of public health students during their 30-day field placement in Surkhet District, Nepal. The group conducted various assessments of the district's health management system including a secondary data review, critical analysis using SWOT, an epidemiological study on major health issues, and a mini action project on plastic waste reduction. Key findings included gaps in safe motherhood services, increasing HIV trends, and issues with logistics management and data reporting. The placement helped the students gain important academic and management skills applicable to their public health careers.
Quality assurance & monitoring in opd and outreach serviceslionsleaders
This document discusses quality assurance and monitoring of outpatient and outreach services at the Alipurduar Lions Eye Hospital. It emphasizes the importance of monitoring to evaluate performance, detect issues, and ensure quality services. Key aspects of quality that should be monitored include patient wait times, follow-up rates, comfort, and clinical outcomes. For outreach camps, planning, coordination among teams, tracking participants, and collecting data are essential for quality assurance. Tools like meetings, logs, questionnaires and checklists can be used to systematically monitor services and ensure standards are met.
The document discusses the National Accreditation Board for Hospitals and Healthcare Providers (NABH) standards for healthcare organizations in India. It defines quality from different perspectives and outlines the NABH accreditation process which focuses on patient safety, staff safety, and information/education. The accreditation involves a pre-assessment survey, onsite survey to review documents, facilities, and conduct interviews. It aims to encourage healthcare organizations to improve quality through a peer-review process administered by an independent body based on published standards. Challenges include initial preparation, sustained efforts and resources required for healthcare organizations to fully comply with quality standards.
The document discusses quality improvement approaches for healthcare management in resource-constrained settings. It introduces the '5S-CQI-TQM' model which incorporates 5S principles for organizing the workplace, continuous quality improvement (CQI) using the PDCA cycle, and total quality management (TQM). The model was piloted in hospitals in Bangladesh and found to be cost-effective for driving continuous quality improvement in challenging resource environments. Key benefits included improved processes, employee satisfaction, and patient outcomes. Ongoing challenges to implementation are also discussed.
The document discusses quality improvement in hospitals. It notes that quality improvement (QI) requires sustained leadership, extensive training, robust measurement systems, and a culture receptive to change. It outlines six dimensions of healthcare quality: safety, effectiveness, appropriateness, access, patient satisfaction, and efficiency. Efficiency in healthcare involves deriving maximum benefit from available resources through technical and allocative efficiency. Common causes of medical errors include communication problems, inadequate information flow, human factors, and organizational issues. Many methods can be used to detect adverse events, both passive and active surveillance. Improvement starts with identifying an area for improvement through asking questions. Models for quality improvement include PDCA, Lean, Six Sigma, and change management. Measurement is key to
This document discusses key concepts of quality in healthcare including definitions, dimensions, and frameworks. It defines quality as meeting expectations and conforming to standards. The dimensions of quality - effectiveness, efficiency, safety, patient-centeredness, timeliness, and more - must be achieved to provide the right care. Quality is measured using a structure-process-outcome framework where structure leads to processes which lead to outcomes. Total quality management is presented as the latest approach focusing on continuous improvement, customer satisfaction, and organizational commitment to quality.
This document provides an overview of quality culture and language in healthcare. It discusses key concepts like quality planning, control, and improvement. It defines terms like product, customer, satisfaction, and deficiency. It explains the patient's six rights which define quality service standards. Objectives of quality management are outlined, including providing error-free care and ensuring patients are discharged on schedule with the correct paperwork and instructions. Barriers to quality like lack of training and education are identified. The document also discusses quality in healthcare today in terms of elements like customer focus, costs, and patient satisfaction. It provides a case study example of a quality issue and improvement process. Finally, it discusses the concept of quality in Islamic teachings and how excellence is emphasized in
This document discusses quality control in healthcare. It defines quality healthcare and how it is measured using indicators of structure, process, and outcomes. Evidence shows the need to improve quality through reducing errors and inappropriate care. Quality can be achieved by either building or inspecting it, using quality assurance or quality improvement approaches. Factors influencing quality include provider skills, system structure, resources, and education. Tools to improve quality include education, guidelines, and peer review. A comprehensive strategy is needed using incentives, data monitoring, patient empowerment, standards, and information systems to support continuous quality development.
Hospital administration role in quality patient careShaharul Sohan
Hospital administration ensures that hospitals run efficiently and provide quality patient care. Key responsibilities of hospital administrators include overseeing departments, recruiting and managing staff, ensuring compliance with policies and regulations, and coordinating efforts to achieve common goals like quality care. Effective hospital administration requires planning, organizing, staffing, directing, coordinating, reporting, budgeting, supervising, and evaluating all hospital activities and processes. The role of the administrator is crucial to the success of the hospital organization and the care provided to patients.
The document discusses key aspects of quality in healthcare. It defines quality as services that increase the probability of desired health outcomes and follow best practices. There are three aspects of quality - measurable, appreciative, and perceptive. The perception of quality is most influenced by caring staff, physical environment, and physician competence rather than new technology. Quality care positively affects patients and is defined by dimensions like safety, effectiveness, timeliness, efficiency, and equity. Quality management principles center around leadership, data-driven decisions, customer focus, and continuous improvement.
The document provides facts about patient safety. Some key points:
- 20-40% of health spending is wasted due to poor quality care.
- 98,000 Americans die each year from preventable medical errors.
- Hospital errors are the 5th-8th leading cause of death in the US.
- There is a 1 in 300 chance a patient will be harmed during healthcare.
This document provides an overview of hospital revenues. The primary source of revenue for hospitals is operating revenue, which is generated from providing patient care services. Operating revenue is categorized as either gross or net patient service revenue. Gross patient service revenue is the total amount hospitals would receive if paid in full for all services, while net patient service revenue is the actual amount collected after deducting for charity care and contractual adjustments agreed to with insurance companies. Other sources of revenue include other operating revenue from non-patient care activities and gains/losses from peripheral business activities.
Quality management in nursing professionSANJAY SIR
Quality improvement requires in any field to provide best services to the community in the health care system. it is uploaded to aware the the paramedics & nursing personnel to improve the quality care & helps educators to teach their students.
Quality assurance aims to close the gap between actual health care performance and desirable outcomes through systematic activities like setting standards, monitoring compliance, and improving quality. It benefits clients through better health outcomes and satisfaction, providers through a more satisfying work environment, and institutions through higher patient satisfaction and reputation. Ensuring quality requires perspectives from communities, providers, and managers to meet stakeholder needs.
PPT ON QUALITY IMPROVEMENT& PATIENT SAFETYsoumyareena
This document discusses quality improvement and patient safety. It defines quality of care and notes that the WHO defines quality as care that is safe, effective, timely, efficient, equitable and people-centered. It then discusses that quality improvement in healthcare aims to systematically improve care delivery through measuring, analyzing, improving and controlling processes. Various quality improvement tools are listed such as brainstorming, data collection tools, flow charts and control charts. An example quality improvement project aims to reduce voluntary nurse turnover rates. The steps of defining the problem, organizing a team, clarifying the current process and selecting and planning improvements are outlined. Patient safety is defined as avoiding unintended harm during care. Various aspects of patient safety related to medication, surgery, electricity
Total quality management in healthcare organisationspoonam chaudhary
This document provides an overview of total quality management (TQM) in healthcare organizations. It discusses that TQM is a customer-centered and employee-driven approach to continuous improvement of processes to ensure high quality products and services. The document traces the history and development of quality control, quality assurance, and TQM in healthcare. It describes the key principles of TQM, including getting processes right the first time, listening to customers and employees, continuous improvement, and building teamwork. The document also outlines several tools that are commonly used for quality improvement in healthcare organizations under a TQM model such as flow charts, histograms, control charts, and cause analysis diagrams.
Accreditation as a Strategy / Tool for Hospital Quality Service ImprovementReynaldo Joson
The document discusses hospital accreditation as a strategy for quality improvement, defining terms like accreditation, certification, and compliance. It examines standards for accreditation in the Philippines from organizations like PhilHealth, JCI, ISO, and more. The document recommends that hospitals seek accreditation from PhilHealth first to establish a foundation before pursuing other international standards.
An introductory overview of the basic concepts of Healthcare Quality, a starter for beginners.
Prepared in 2014 for the new staff of the Quality Management Department in King Saud University Medical City in Riyadh as a part of their capacity building plan.
Acknowledgments:
*Dr. Magdy Gamal Yousef, MBBCh, MS, CPHQ - for his contribution in the scientific content
**Ms. Maram Baksh, MS, CPHQ - for the design of the full HCQ capacity building plan in KSUMC
Hospital marketing aims to promote high quality medical care while satisfying patient needs. It informs target audiences like patients, families, and doctors about hospital services. Hospital marketing has three key functions: understanding future consumer needs to plan strategy, providing consumers with treatment information to avoid delays, and making quality services affordable for communities. Social media has become an important tool for hospital reputation management by connecting with patients, raising awareness of health issues, and understanding the customer lifecycle. Activities like video marketing, image marketing, and hosting health-related events can effectively promote hospitals on social media.
This document outlines quality assurance in nursing. It defines quality assurance and discusses its concepts and purposes. It describes various approaches to quality assurance programs, including general approaches like credentialing and licensure, and specific approaches like peer review and use of standards. Frameworks for quality assurance are presented, including those from Maxwell, Wilson and Lang. The document also examines the Joint Commission on Accreditation of Healthcare Organizations and models of quality assurance, such as the systems model and the American Nurses Association model.
Comprehensive Field Practice (CFP) : District Health Service Management Mohammad Aslam Shaiekh
The document summarizes the activities and learnings of a group of public health students during their 30-day field placement in Surkhet District, Nepal. The group conducted various assessments of the district's health management system including a secondary data review, critical analysis using SWOT, an epidemiological study on major health issues, and a mini action project on plastic waste reduction. Key findings included gaps in safe motherhood services, increasing HIV trends, and issues with logistics management and data reporting. The placement helped the students gain important academic and management skills applicable to their public health careers.
Quality assurance & monitoring in opd and outreach serviceslionsleaders
This document discusses quality assurance and monitoring of outpatient and outreach services at the Alipurduar Lions Eye Hospital. It emphasizes the importance of monitoring to evaluate performance, detect issues, and ensure quality services. Key aspects of quality that should be monitored include patient wait times, follow-up rates, comfort, and clinical outcomes. For outreach camps, planning, coordination among teams, tracking participants, and collecting data are essential for quality assurance. Tools like meetings, logs, questionnaires and checklists can be used to systematically monitor services and ensure standards are met.
The document discusses the National Accreditation Board for Hospitals and Healthcare Providers (NABH) standards for healthcare organizations in India. It defines quality from different perspectives and outlines the NABH accreditation process which focuses on patient safety, staff safety, and information/education. The accreditation involves a pre-assessment survey, onsite survey to review documents, facilities, and conduct interviews. It aims to encourage healthcare organizations to improve quality through a peer-review process administered by an independent body based on published standards. Challenges include initial preparation, sustained efforts and resources required for healthcare organizations to fully comply with quality standards.
The document discusses quality improvement approaches for healthcare management in resource-constrained settings. It introduces the '5S-CQI-TQM' model which incorporates 5S principles for organizing the workplace, continuous quality improvement (CQI) using the PDCA cycle, and total quality management (TQM). The model was piloted in hospitals in Bangladesh and found to be cost-effective for driving continuous quality improvement in challenging resource environments. Key benefits included improved processes, employee satisfaction, and patient outcomes. Ongoing challenges to implementation are also discussed.
The document discusses quality improvement in hospitals. It notes that quality improvement (QI) requires sustained leadership, extensive training, robust measurement systems, and a culture receptive to change. It outlines six dimensions of healthcare quality: safety, effectiveness, appropriateness, access, patient satisfaction, and efficiency. Efficiency in healthcare involves deriving maximum benefit from available resources through technical and allocative efficiency. Common causes of medical errors include communication problems, inadequate information flow, human factors, and organizational issues. Many methods can be used to detect adverse events, both passive and active surveillance. Improvement starts with identifying an area for improvement through asking questions. Models for quality improvement include PDCA, Lean, Six Sigma, and change management. Measurement is key to
This document discusses key concepts of quality in healthcare including definitions, dimensions, and frameworks. It defines quality as meeting expectations and conforming to standards. The dimensions of quality - effectiveness, efficiency, safety, patient-centeredness, timeliness, and more - must be achieved to provide the right care. Quality is measured using a structure-process-outcome framework where structure leads to processes which lead to outcomes. Total quality management is presented as the latest approach focusing on continuous improvement, customer satisfaction, and organizational commitment to quality.
This document provides an overview of quality culture and language in healthcare. It discusses key concepts like quality planning, control, and improvement. It defines terms like product, customer, satisfaction, and deficiency. It explains the patient's six rights which define quality service standards. Objectives of quality management are outlined, including providing error-free care and ensuring patients are discharged on schedule with the correct paperwork and instructions. Barriers to quality like lack of training and education are identified. The document also discusses quality in healthcare today in terms of elements like customer focus, costs, and patient satisfaction. It provides a case study example of a quality issue and improvement process. Finally, it discusses the concept of quality in Islamic teachings and how excellence is emphasized in
Patient’s experience, improve the quality health3zsaddique
Putting patients first requires more than world-class clinical care – it requires care that addresses every aspect of a patient’s encounter with Hospital, including the patient’s physical comfort, as well as their educational, emotional, and spiritual needs. A team of professionals should serves as an advisory resource for critical initiatives across the Hospital health system. In addition, it should provide resources and data analytics; identify, support, and publish sustainable best practices; and collaborate with a variety of departments to ensure the consistent delivery of patient-centered care.
Hospital accreditation is a voluntary process that assesses healthcare organizations against established standards to ensure quality of care and patient safety. It involves a self-assessment and external peer review of an organization's structure, functions, and performance. The document discusses the goals of accreditation which include quality assurance and continuous quality improvement. Accreditation standards focus on patient-centered care and healthcare organization management. Compliance with accreditation provides benefits such as independent verification of quality and safety for commissioners, driving better patient outcomes, and supporting organizational efficiency and productivity.
This document discusses quality assurance in healthcare. It defines quality assurance and related terms like quality control, continuous quality improvement, and total quality management. It describes the key components of quality in healthcare as safety, effectiveness, patient-centeredness, and timeliness. The purposes of quality assurance are to meet customer needs, standardize care, minimize errors, and attain excellence. Nurses play an important role in quality assurance through activities like developing quality monitoring mechanisms, contributing innovations, and participating in improvement efforts.
This document discusses fundamentals of quality in healthcare. It defines key terms like quality assurance, quality of care, and factors driving attention to quality like limited resources and patient demands. It describes Donabedian's framework for assessing quality, which looks at structure, process and outcomes. Achieving quality requires accessible, efficient and acceptable services. Ensuring quality involves continuous quality improvement approaches like plan-do-check-act cycles and evidence-based medicine. The goal is to provide high quality care through ongoing evaluation and improvement.
This document discusses fundamentals of quality in healthcare. It defines key terms like quality assurance, total quality management, and continuous quality improvement. It explains that quality can be assessed based on structure, process, and outcomes. Structure looks at the environment where care is provided. Process examines the care provided by practitioners. Outcomes assess the benefits achieved by patients. Achieving quality requires accessible, efficient, and acceptable services based on current knowledge. Continuous efforts are needed to monitor, assess, and improve healthcare quality.
The document discusses patient expectations of health care. It notes that understanding patient expectations is important for improving patient satisfaction and delivering patient-centered care. However, most research has focused only on expectations for specific diseases. The document aims to better understand how patients conceptualize their expectations across different clinical contexts and conditions.
Quality improvement approaches can play a role in enhancing the quality of health services provided at primary, secondary and tertiary levels. A quality improvement intervention is defined as a change process intended to increase the likelihood of optimal clinical quality and positive health outcomes. Quality improvement requires an ongoing feedback loop to identify opportunities to enhance care and outcomes for future patients.
Quality and safety, Vision 2025, Specific challenges of Nursing on quality, Quality improvement division, Fish bone technique,QI model, PDCA, Role of Nurse, Empowerment, Nursing positioning and policies,
This document discusses key concepts of quality in healthcare. It begins by providing definitions of quality from various experts and emphasizes that quality is the result of intention, effort, direction and execution. It then discusses 11 dimensions of quality care including appropriateness, availability, competency, continuity, effectiveness, efficiency, prevention, respect, safety and timeliness. The document outlines principles of quality management including a focus on processes, customer relationships, variability reduction, and employee involvement. It concludes by discussing the Joint Commission's standards for assessing an organization's commitment to quality.
&&&HEALTH CARE QUALITY MANAGEMENT FOR FAMILY PHYSICIANS.pptAhmedSamir462624
Total quality management (TQM) is a management philosophy focused on customer satisfaction and continuous improvement. It emphasizes a customer-focused culture and data-driven decision making. TQM involves planning quality goals and standards, measuring performance through quality control, and improving processes through tools and statistical analysis. Quality assurance programs evaluate care quality and institute improvements by monitoring performance against standards. The key is continuous assessment and action to maintain or enhance quality of health services.
This document provides an overview of basic concepts in healthcare quality. It defines quality as meeting standards and doing things right the first time. Healthcare organizations are described as complex adaptive systems. The dimensions of healthcare quality are discussed, including safety, effectiveness, patient-centeredness, timeliness, efficiency, equity, and more. Quality is said to have measurable, perceptive, and appreciative aspects from the perspective of providers, patients, and experts. Key resources in healthcare quality include clinical practice guidelines, quality indicators, and accrediting bodies. Careers in healthcare quality are also mentioned.
This document discusses key concepts related to quality in healthcare. It defines quality from the perspectives of healthcare providers, recipients, and administrators. It also outlines dimensions of quality including appropriateness, availability, competency, continuity, effectiveness, efficiency, safety, timeliness, and prevention/early detection. 11 dimensions of quality are described in detail which provide a framework for quality management activities. These dimensions include doing the right things, meeting standards, meeting patient needs and expectations, coordination of care, achieving desired outcomes, relationship between outcomes and resources used, respect and caring for patients, reducing risk, and providing timely care.
Patient satisfaction & quality in health care (16.3.2016) dr.nyunt nyunt waiMmedsc Hahm
This document discusses patient satisfaction and quality in healthcare. It defines patient satisfaction as how an individual regards healthcare services as useful, effective or beneficial. Patient satisfaction is important for public accountability and quality improvement at both the system and individual provider levels. The document outlines factors that influence patient satisfaction, including quality and competency of providers, effectiveness and appropriateness of care, and interpersonal relationships. It also discusses the importance of a client-centered approach that prioritizes patients' needs and rights.
Patient satisfaction & quality in health care (13.3.2017) dr.nyunt nyunt waiMmedsc Hahm
This document discusses patient satisfaction and quality in healthcare. It defines patient satisfaction as the degree to which patients regard healthcare services as useful, effective or beneficial. Patient satisfaction is important for public accountability and quality improvement at both the system and individual provider levels. The document outlines factors that influence patient satisfaction, including the quality and competency of providers, effectiveness and appropriateness of care, and interpersonal relationships. It also discusses the rights of patients and needs of providers in a client-centered healthcare model.
Patient satisfaction & quality in health care (13.3.2017) dr.nyunt nyunt waiMmedsc Hahm
This document discusses patient satisfaction and quality in healthcare. It defines patient satisfaction as the degree to which patients regard healthcare services as useful, effective or beneficial. Patient satisfaction is important for public accountability and quality improvement at both the system and individual provider levels. The document outlines factors that influence patient satisfaction, including the quality and competency of providers, effectiveness and appropriateness of care, and interpersonal relationships. It also discusses the rights of patients and needs of providers in a client-centered healthcare model.
To support your work, use scholarly sources and also use outside s.docxedwardmarivel
This document discusses regulations related to long-term care. It notes that there are many federal and state regulations imposed on long-term care facilities to ensure quality of care and protect consumers. Quality of care is measured through factors like resident outcomes, pain levels, restraint use, and functional status. The Centers for Medicare and Medicaid Services implements national standards to evaluate nursing home quality. Both public agencies and private organizations work to regulate various aspects of long-term care, including quality of services and costs.
This document provides instructions for students to submit their semester and specialization to receive fully solved assignments on the topic of Quality Management in Health Care. It includes 5 questions related to medical audits, hospital accreditation, quality assurance programs, quality components in healthcare, and developing a service strategy. Students are asked to answer any 5 questions, with each question worth 10 marks.
This document provides an overview of basic concepts in healthcare quality. It defines key terms like effectiveness, efficacy, dimensions of quality care including safety, timeliness, efficiency and more. It also discusses healthcare organizations as complex adaptive systems and the importance of standards, guidelines and other resources to improve quality. Overall it aims to introduce foundational ideas around measuring, assuring and improving the quality of healthcare delivery.
Nurses play a pivotal role in hospital quality improvement initiatives. As the staff that spends the most time at the patient bedside, nurses are well-positioned to identify issues and make improvements. However, nurses face challenges in becoming more involved due to limited resources, competing demands on their time, and the need for cultural changes. Hospitals must support nurse leadership in quality improvement through dedicated programs, accountability measures, and by valuing nurse feedback to continuously enhance care quality and safety.
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4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
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1. Quality Management System
(Institutional Level)
Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg
Lecture
Effective Nursing Service Administration Training
(Clinical Administration and Business Management Skills)
ManilaMed, May 10, 2017
2. Quality Management System
(Institutional Level)
Institutional Level – hospital or medical center wide
vs
Unit Level – department or section level
such as Medical Departments, Nursing Departments,
Allied Medical Departments, Finance Department, and
other Support Departments
4. Quality Management System
(Institutional and Unit Levels)
[ALIGNED and INTEGRATED]
Hospital QMS
Unit 1 QMSUnit 4 QMS
Unit 2 QMSUnit 3 QMS
Vision,
Mission,
Core Values
Quality
Policy
Specific Quality
Objectives
Specific Quality
Objectives
Specific Quality
Objectives
Specific Quality
Objectives
5. Quality Management System
(Institutional Level)
Outline of Talk
>Concepts, Definitions, and Meanings
• Quality / Quality and Safe Patient Care
• Quality Management System / Total Quality Management System
>Importance of QMS in a Hospital
>QMS Standards and Accreditation
• ISO 9001 / PhilHealth Benchbook / Joint Commission International
/ Accreditation Canada International / others
>QMS Principles
>Process Approach to QMS (Inputs / Throughputs / Outputs)
>ROJoson’s Personal Recommendations on QMS
>Patient Experience (Video)
6. Concepts, Definitions, and Meanings
Quality
Quality and Safe Patient Care
Quality Management System
Total Quality Management System
7. Concepts, Definitions, and Meanings
Quality
Quality – poor, good, excellent
• Medical care
• Nursing care
• Radiology services
• Housekeeping services
• Billing services
• SERVICE – any type of service in the hospital
What is quality?
9. Concepts, Definitions, and Meanings
What is quality?
A subjective term for which each person has his or her own
definition.
10. Concepts, Definitions, and Meanings
What is Quality?
• different concepts, definitions, and meanings depending on context
and perceptions
In technical usage, quality can have two meanings:
• characteristics of a product or service that bear on
its ability to satisfy stated or implied needs
• a product or service free of deficiencies
American Society for Quality (ASQ)
11. Concepts, Definitions, and Meanings
What is Quality?
• different concepts, definitions, and meanings depending on context
and perceptions
• Quality is the degree to which health services for
individuals and populations increase the likelihood of
desired health outcomes and are consistent with current
professional knowledge. (Institute of Medicine)
• Key attributes of high quality healthcare systems, as
defined by the Institute of Medicine (U.S.) include safety,
timeliness, effectiveness, efficiency, equity and patient
centeredness.
12. Concepts, Definitions, and Meanings
What is Quality?
• different concepts, definitions, and meanings depending on context
and perceptions
• Quality in health care is the degree to which its processes
and results meet or exceed the needs and desires of the
people it serves. (Joint Commission International)
• Quality is “the degree of excellence; the extent to which an
organization meets clients needs and exceeds their
expectations”. (Accreditation Canada International)
13. Concepts, Definitions, and Meanings
What is Quality?
• different concepts, definitions, and meanings depending on context
and perceptions
PhilHealth Benchbook
• timely, safe, patient-centered and effective (patient care)
14. Concepts, Definitions, and Meanings
What is Quality?
• different concepts, definitions, and meanings depending on
context and perceptions
• Quality means degree to which a set of inherent
characteristics of an object fulfills requirements
(ISO).
• Degree to which services fulfill the requirements of
customers.
15. Concepts, Definitions, and Meanings
What is Quality?
• different concepts, definitions, and meanings depending on context
and perceptions
General generic concepts:
• Quality means meeting the customer's requirements.
• Doing the right thing right at the right time and every time.
(Right thing = customer requirements)
16. Concepts, Definitions, and Meanings
What is Quality?
• different concepts, definitions, and meanings depending on context
and perceptions
Specific concepts in patient care setting:
• Timely, safe, patient-centered, effective, efficient (patient
care)
LEADING TO
• Patient satisfaction
• Patient experience
17. Concepts, Definitions, and Meanings
What is Quality?
• different concepts, definitions, and meanings depending on context and
perceptions
Patient Satisfaction vs Patient Experience
Patient Satisfaction:
Satisfaction is about whether a patient’s expectations about a
health encounter were met.
Patient Experience:
“The sum of all interactions, shaped by and organization's
culture, that influence patient perceptions across the
continuum of care.”
The Beryl Institute
18. Patient Experience
The patient's cumulative evaluation
of the journey they have with you,
starting when they first need you
and based on their clinical and
emotional interactions, which are
shaped.
Patient Experience Journal
19. Patient Experience
Patient experience encompasses the
range of interactions that patients have
with the health care system, including
their care from health plans, and from
doctors, nurses, and staff in hospitals,
physician practices, and other health
care facilities.
Agency for Healthcare Research and
Quality
20. Patient Experience
As an integral component of health care
quality, patient experience includes several
aspects of health care delivery that patients
value highly when they seek and receive
care, such as getting timely appointments,
easy access to information, and good
communication with health care providers.
Agency for Healthcare Research and
Quality
21. Patient Satisfaction vs Experience
Patient Experience
(More than satisfaction / delight)
Satisfaction is about whether a patient’s
expectations about a health encounter were
met.
Two people who receive the exact same care,
but who have different expectations for how
that care is supposed to be delivered, can give
different satisfaction ratings because of their
different expectations.
22. Patient Satisfaction vs Experience
Patient Experience
(More than satisfaction / delight)
To assess patient experience, one must
find out from patients whether
something that should happen in a
health care setting (such as clear
communication with a provider)
actually happened or how often it
happened.
24. Concepts, Definitions, and Meanings
Quality and Safe Patient Care
Recent Emphasis on Patient Safety
• Is there a difference between quality and safe
patient care?
• Should the quality and safety goals be independent
of each other?
25. Concepts, Definitions, and Meanings
Quality and Safe Patient Care
Recent Emphasis on Patient Safety
Quality in health care is the degree to which its processes
and results meet or exceed the needs and desires of the
people it serves.
Patient safety, as defined by the World Health Organization,
is the prevention of errors and adverse effects to patients
that are associated with health care.
26. Concepts, Definitions, and Meanings
Quality and Safe Patient Care
Recent Emphasis on Patient Safety
Quality and safety are inextricably linked.
Quality in health care is the degree to which its processes
and results meet or exceed the needs and desires of the
people it serves.
Those needs and desires include safety.
27. Concepts, Definitions, and Meanings
Quality and Safe Patient Care
Recent Emphasis on Patient Safety
Safety is within the quality dimension.
It is recommended for the safety goals to be extracted from
the quality goals for emphasis reason.
However, the ultimate goals should still be an alignment and
integration of quality and safety in patient care.
28. Concepts, Definitions, and Meanings
Quality and Safe Patient Care
Recent Emphasis on Patient Safety
Patient safety emerges as a central aim of quality.
Patient safety is often considered a component of
quality, thus, practices to improve patient safety
improve the overall quality of care.
The ultimate goals are quality of care and patient
safety.
29. Concepts, Definitions, and Meanings
Quality and Safe Patient Care
Recent Emphasis on Patient Safety
PhilHealth Benchbook
•timely, safe, patient-centered and effective
(patient care)
31. Concepts, Definitions, and Meanings
What is Quality Management System?
• Management System with regard to quality
• Financial Management System Finance
• Environment Management System Environment
32. Concepts, Definitions, and Meanings
What is management system?
• set of interrelated or interacting elements of
an organization to establish policies and objectives
and processes to achieve certain objectives.
• elements include organization’s structure, roles and
responsibilities, planning, operation, policies,
practices, rules, beliefs, objectives and processes to
achieve certain objectives.
33. Concepts, Definitions, and Meanings
What is Quality Management System?
• organizational structure, processes, procedures and
resources needed to implement, maintain and
continually improve the management of quality
(American Society for Quality)
34. Concepts, Definitions, and Meanings
What is Quality Management System? (ISO)
• management system with regard to quality
• include establishing quality policies and quality
objectives
• processes to achieve these quality objectives through
• quality planning
• quality assurance
• quality control
• quality improvement
35. Concepts, Definitions, and Meanings
Quality planning
• focused on setting quality objectives and specifying
necessary operational processes and related resources
to achieve the quality objectives
Quality assurance
• focused on providing confidence that quality
requirements will be fulfilled
Quality control
• focused on fulfilling quality requirements
Quality improvement
• focused on increasing the ability to fulfil quality
requirements
37. Concepts, Definitions, and Meanings
What is Total Quality Management System?
• organization-wide efforts to install and make
permanent a climate to continuously improve its
ability to deliver quality products and services
• all members of an organization participate in
improving processes, products, services, and the
culture in which they work
Management approach to long–term success
through customer satisfaction!
41. ISO 9001:2015 Quality Management System
Organization
and its
Context
Products and
Services
Improvement
Leadership
Support
and
Operations
Performance
Evaluation
Planning
Customer
Requirements
Customer
Satisfaction
Plan Do
Act Check
Needs and
Expectations
of Relevant
Interested
Parties
Results of
QMS
42. PhilHealth Benchbook 2nd Edition
A. PATIENT CENTERED STANDARDS
1. PATIENT RIGHTS AND ORGANIZATIONAL ETHICS
2. ACCESS TO HEALTHCARE
3. INPATIENT ADMISSION AND OUTPATIENT REGISTRATION
4. ASSESSMENT OF PATIENTS
5. CARE PLANNING CARE DELIVERY
6. MEDICATION MANAGEMENT
7. SURGICAL AND ANESTHESIA CARE
B. FACILITY FOCUSED STANDARDS
8. LEADERSHIP AND MANAGEMENT
9. HUMAN RESOURCE MANAGEMENT
10. INFORMATION MANAGEMENT
11. SAFE PRACTICE AND ENVIRONMENT
12. INFECTION CONTROL
13. IMPROVING PERFORMANCE
44. Concepts, Definitions, and Meanings
QMS = TQMS
ORGANIZATION-WIDE EFFORT
• QM Office – QM Representative / Officer (Coordinator /
Education Function)
• Not the only one responsible for the QMS / TQMS of the
hospital!
• All units must have a QMS.
• All units must have a QM Officer.
• All units’ QMS must be aligned and integrated into the hospital
QMS Framework.
• ALL UNITS MUST BE CONTRIBUTING TO THE TQMS OF THE
HOSPITAL!
45. Hospital Quality and Safety Management System
Documented Information
Organizational
Context
Performance
Excellence
Improvement
Leadership
Support
Clients
Workforce
Operations
IT
EvaluationPlanning
Client
Requirements
Organizational
Vision
Client
Engagement
Plan Do
Act Check
Legal
Requirements
46. UNIT Quality and Safety Management System
Documented Information
Organizational
Context
Performance
Excellence
Improvement
Leadership
Support
Clients
Workforce
Operations
IT
EvaluationPlanning
Client
Requirements
Organizational
Vision
Client
Engagement
Plan Do
Act Check
Legal
Requirements
48. Quality and Safety Management System
Hospital-wide Unit (ALIGNMENT AND INTEGRATION)
• Quality and Safety Management System
• Organizational Context Management System
• Organizational Vision Management System
• Legal Requirements Management System
• Client Requirements Management System
• Leadership Management System
• Planning Management System
• Support Management System
49. Quality and Safety Management System
Hospital-wide Unit
(ALIGNMENT AND INTEGRATION)
• Clients Management System
• Workforce Management System
• Operations Management System
• IT Management System
• Evaluation Management System
• Improvement Management System
• Documented Information
Management System
• Client Engagement Management
System
• Performance Excellence
Management System
50. Quality and Safety Management System
ALIGNMENT AND INTEGRATION OF ALL MANAGEMENT
SYSTEMS!
Leadership Management System
• BOD Leadership Management System
• CEO Leadership Management System
• SMT Leadership Management System
• Directors Leadership Management System
Client Engagement Management System
• Community Engagement Management System
• Patient Engagement Management System
• Physician Engagement Management System
• HMO and Company Engagement Management System
52. Importance of Quality Management System
Quality Management System
>Improve performance and increase customer
satisfaction with the hospital’s services leading
to
•quality and safe services
•financially viable and sustainable hospital
>Competitive with other hospitals
53. Importance of Quality Management System
Quality Management System
• Promote development of an effective and
efficient organization (hospital and all its units)
• Improve its overall performance
54. Importance of Quality Management System
Advantages of QMS (ISO 9001:2015):
• Ability to consistently provide services that meet
customer and applicable statutory and regulatory
requirements
• Facilitating opportunities to enhance customer
satisfaction
• Addressing risks and opportunities associated with
its context and objectives
• Ability to demonstrate conformity to specified
quality management requirements
56. Quality Management System Standards
and Accreditation
In a hospital setting in the Philippines, as
of 2017,
the following local and international
documented sets of standards should
guide all hospitals in achieving a high level
of quality and performance:
57. Quality Management System Standards
and Accreditation
•ISO 9001:2015 (Quality Management System)
•PhilHealth Benchbook
•Joint Commission International /
Accreditation Canada International / National
Accreditation Board for Hospitals and
Healthcare Providers
•Philippine Quality Award
58. Quality Management System Standards
and Accreditation
Accreditation Standards URLs
PhilHealth Benchbook https://www.philhealth.gov.ph/partners/provi
ders/benchbook
Joint Commission International (JCI)
Accreditation International (ACI)
National Accreditation Board for
Hospitals and Healthcare Providers
(NABH)
http://www.jointcommissioninternational.org
/
http://www.internationalaccreditation.ca/en/
home.aspx
http://www.nabh.co/
Philippine Quality Award http://www.pqa.org.ph
http://www.dti.gov.ph/dti/index.php?p=492
http://www.nist.gov/baldrige/publications/hc
_criteria.cfm
ISO (International Organization for
Standardization)
http://www.iso.org/iso/home.html
59. Quality Management System Standards
and Accreditation
ISO / PQA PhilHealth Benchbook / JCI /
ACI / NABH
Origin manufacturing
industry
hospital industry
Language manufacturing health care
Product and
Service
easily defined, tangible
item
(can be used by
hospitals)
clinical aspects of health care
not easily defined, not readily
tangible
60. Quality Management System Standards
and Accreditation
Accreditation Standards Advantages
Philippine Quality Award Designed to help provide organizations with an
integrated approach to organizational
performance that results in
-Delivery of ever-improving value to
customers and stakeholders, contributing
to organizational sustainability
-Improvement of overall organizational
effectiveness and capabilities
-Organizational and personal learning
ISO (International Organization for
Standardization)
ISO 9001: Quality Management
System
Designed to help organizations ensure that
they meet the needs of customers and other
stakeholders while meeting statutory and
regulatory requirements related to the product.
61. Quality Management System Standards and Accreditation
PQA Criteria for Performance
Excellence
ISO 9001:2015
1. Leadership
2. Strategic Planning
3. Customer Focus
4. Measurement, Analysis, and
Knowledge Management
5. Workforce Focus
6. Operations Focus
7. Results
4 Context of the organization
5 Leadership
6 Planning
7 Support
8 Operation
9 Performance Evaluation
10 Improvement
62. Quality Management System Standards
and Accreditation
Accreditation Standards Advantages
PhilHealth Benchbook Designed to encourage Philippine
hospitals improve on their quality
management system and to improve
quality and safe patient care
Joint Commission
International (JCI)
Accreditation International
(ACI)
National Accreditation Board
for Hospitals and Healthcare
Providers (NABH)
Designed to improve quality and safe
patient care
Designed to assess and improve
organization performance based on
internationally agreed standards and
stimulating continuous improvement to
achieve optimum outcomes on
healthcare
63. Quality Management System Standards and Accreditation
Accreditation
Canada
International
Joint Commission International National Accreditation Board
for Hospitals
Individual Client
/ Patient Care
Groups (14)
Information
Management
Human
Resources
Development
and
Management
Environmental
Management
Leadership and
Partnerships
Patient-centered Standards
•Access to Care and Continuity of Care
•Patient and Family Rights
•Assessment of Patients
•Care of Patients
•Anesthesia and Surgical Care
•Medication Management and Use
•Patient and Family Education
Health Care Organization Management
Standards
•Quality Improvement and Patient Safety
•Prevention and Control of Infections
•Governance, Leadership, and Direction
•Facility Management and Safety
•Staff Qualifications and Education
•Management of Communication and
Information
• Access and Planning of
Services
• Customer Rights and
Education
• Care of Customers
• Management of
Medication, Consumables
and Equipment (including
Instruments)
• Infection Control
• Continual Quality
Improvement
• Responsibilities of
Management
• Facility Management and
Safety
• Human Resource
Management
• Information Management
System
64. Quality Management System Standards and Accreditation
PhilHealth Benchbook Joint Commission International
PATIENT CENTERED STANDARDS
1. Patient Rights and Organizational Ethics
2. Access to Healthcare
3. Inpatient Admission and Outpatient
Registration
4. Assessment of Patients
5. Care Planning and Care Delivery
6. Medication Management
7. Surgical and Anesthesia Care
FACILITY FOCUSED STANDARDS
8. Leadership and Management
9. Human resource Management
10. Information Management
11. Safe Practice and Environment
12. Infection Control
13. Improving Performance
PATIENT-CENTERED STANDARDS
•Access to Care and Continuity of Care
•Patient and Family Rights
•Assessment of Patients
•Care of Patients
•Anesthesia and Surgical Care
•Medication Management and Use
•Patient and Family Education
HEALTH CARE ORGANIZATION MANAGEMEHT
STANDARDS
•Quality Improvement and Patient Safety
•Prevention and Control of Infections
•Governance, Leadership, and Direction
•Facility Management and Safety
•Staff Qualifications and Education
•Management of Communication and
Information
65. Quality Management System Standards and Accreditation
PhilHealth Benchbook PhilHealth Benchbook (2ND Ed)
• Patient Rights and
Organizational Ethics
• Patient Care
• Leadership and
Management
• Human Resource
Management
• Information Management
• Safe Practice and
Environment
• Performance Improvement
PATIENT CENTERED STANDARDS
1. Patient Rights and Organizational Ethics
2. Access to Healthcare
3. Inpatient Admission and Outpatient Registration
4. Assessment of Patients
5. Care Planning and Care Delivery
6. Medication Management
7. Surgical and Anesthesia Care
FACILITY FOCUSED STANDARDS
8. Leadership and Management
9. Human resource Management
10. Information Management
11. Safe Practice and Environment
12. Infection Control
13. Improving Performance
66. Accreditation as a Strategy / Tool for
Hospital Quality Service Improvement
67. Processes by which a hospital voluntarily applies for
recognition or attestation of compliance to certain set of
standards by a third-party
What is Hospital Accreditation?
Accredited / Accreditation
Certified / Certification
Awarded / Award
Compliance
Demonstration of
competency /
consistency
Products
Processes
Systems
Persons
68. Accreditation as a Strategy / Tool for Hospital Quality
Service Improvement
A hospital seeking accreditation from an accrediting body is
done on a voluntary basis.
The hospital has the freedom to choose the set of standards
it wants to be assessed or evaluated on by an accrediting
body.
It also has the liberty to choose the accrediting body to do
the assessment or evaluation.
69. Accreditation, Certification and Award
Hospital
Set
Standards
Criteria
Indicators
Satisfactory
degree of compliance /
achievement
Certification AwardAccreditation
Third-party
Assessor
/ Auditor
Philippine
Quality Award
ISO 9001
ISO 14000
PhilHealth
Benchbook
JCI
ACI
NABH
Levels
70. Accreditation as a Strategy / Tool for Hospital Quality
Service Improvement
Hospital accreditation almost always entails fees:
• fee for the survey or assessment
• fee for the certificate
How much the fees are is dependent on the accrediting
body.
71. Quality Management System Standards
and Accreditation
Accreditation Standards Accreditation Fees (Assessment
and Certification)
As of 2017 (may change anytime)
PhilHealth Benchbook PhP 10T
JCI
ACI
NABH
JCI – PhP 14 M
ACI – PhP 8 M
NABH – PhP 3 M
Philippine Quality Award PhP 30T – small organizations
PhP 50T – medium to big
organizations
ISO (International Organization for
Standardization)
PhP 300T
72. Accreditation as a Strategy / Tool for Hospital Quality
Service Improvement
There are a lot of benefits that can be derived from hospital
accreditation.
Some can be considered as major benefits and some, as
minor benefits.
Some can be considered as primary benefits and others, as
off-shoots of the primary, or secondary.
These benefits are translatable to goals and objectives of
having a hospital accreditation.
73. Accreditation as a Strategy / Tool for Hospital Quality
Service Improvement
The overarching major primary benefit or
goal is to
promote the business development
program of the hospital so as to make it
viable and sustainable.
74. Accreditation as a Strategy / Tool for Hospital Quality
Service Improvement
The secondary benefits or objectives can and should be
the following:
To use the accreditation project as an assessment tool
on hospital performance as well as a change
management tool.
To identify and institute areas of improvement towards
excellence with the help of the hospital accreditation project.
To educate the staff on performance excellence with the help
of the hospital accreditation project.
75. Accreditation as a Strategy / Tool for Hospital Quality
Service Improvement
The secondary benefits or objectives can and should be
the following:
To increase the hospital’s credibility and to demonstrate
its accountability to the community using an attained
hospital accreditation.
To enhance the hospital reputation so as to attract more
clients utilizing its services.
To increase its leverage with the potential partners and
collaborators in the health care industry using the attained
hospital accreditation.
76. Accreditation as a Strategy / Tool for Hospital Quality
Service Improvement
• Stimulate continuous improvement in service and
patient care processes and outcomes.
• Improve management of health care services
particularly on patient safety.
• Provide staff education on better or best practices.
77. Accreditation as a Strategy / Tool for Hospital Quality
Service Improvement
• Increase efficiency / reduce cost.
• Improve organization performance.
• Promote recognition for excellence.
• Strengthen public and community confidence.
78. Accreditation as a Strategy / Tool for Hospital Quality
Service Improvement
Use it as change agent!
• Know & fulfill requirements of quality! (with assessment –
internal and external)
• Educate staff on quality!
• Motivate staff on quality!
79. Hospital Accreditation:
Does it Matter?
It depends on your need and situation!
Need - to participate in National Health Insurance
Program and get benefits – go for PhilHealth
Accreditation!
Need - to participate in medical tourism program and
get benefits –international accreditation (JCI / ACI /
NBAH)
Need – to satisfy requirement of corporate accounts –
go for accreditation!
Need – to satisfy expectations of the community – go for
accreditation!
80. Hospital Accreditation:
Does it Matter?
It depends on your need and situation!
Situation – to be with the trend of having an international
accreditation (not to be left out – strong community
expectation) – go for accreditation!
Situation – want to fast-track improvement of quality and
safety of operations and services with accreditation – go
for accreditation (assessment, training, improvement,
evaluation)!
81. Hospital Accreditation:
Does it Matter?
It depends on your need and situation!
NO need; NO situation
Be COMPLIANT with the standards and criteria without
going for formal accreditation!
(examples: ISO, JCI/ACI/NABH, PQA)
(self-directed learning and improvement!)
82. What are the recommended processes in going for hospital
accreditation?
Starting point:
Top management decides to have a Hospital Accreditation
Project
• To promote the business development program of the
hospital so as to make it viable and sustainable.
• To use it as a change agent to fast-track quality
improvement.
83. What are the recommended processes in going for hospital
accreditation?
Top management creates a Steering Team / Committee for
Hospital Accreditation Project with clear functions and authority.
Membership of Steering Team / Committee
Senior Management Representative if not the Hospital
Director
Chair (with competency in hospital accreditation and
leadership)
Cross-sectoral or multisectoral membership with
representatives from key functional areas in the hospital,
such as the following:
(Note: the senior management team members may
constitute the Steering Team / Committee.)
84. What are the recommended processes in going for hospital
accreditation?
Cross-sectoral or multisectoral membership with representatives
from key functional areas in the hospital, such as the following:
(Note: the senior management team members may constitute the
Steering Team / Committee.)
Medical service sector
Nursing service sector
Ancillary medical service sector
Administrative or support service sector
Human resource development sector
Business development sector
Finance sector
Secretariat
85. What are the recommended processes in going for hospital
accreditation?
Steering Team formulates a master plan for Hospital
Accreditation Project.
Steering Team decides on set of standards to be assessed or
evaluated on by an accrediting body.
Steering Team seeks commitment for support and
collaboration from top, senior, middle, and lower
management on Hospital Accreditation Project.
86. What are the recommended processes in going for hospital
accreditation?
Contents of master plan for Hospital Accreditation Project
• Goals and objectives of accreditation project (include
short- and long-term goals and objectives)
• Selection, prioritization, and integration of the
accreditation standards
• Selection of the accrediting bodies
• Expected outputs (short- and long-term)
• Expected impact (short- and long-term)
• ………..
87. What are the recommended processes in going for hospital
accreditation?
Contents of master plan for Hospital Accreditation Project
• ..........
• Timelines (short- and long-term)
• Strategies and action plans to achieve expected outputs
and impacts (short- and long-term)
• Budget (short- and long-term)
• Monitoring and oversight plan
• Evaluation plan (short- and long-term)
89. “Quality management
principles” are a set of
fundamental beliefs, norms,
rules and values that are
accepted as true and can be
used as a basis for quality
management.
90. QMS Principles (ISO)
• Customer focus
• Leadership
• Engagement of people
• Process approach
• Improvement
• Evidence-based decision making
• Relationship management
91. QMS Principles
Customer Focus
Statement
• The primary focus of quality management is to meet
customer requirements and to strive to exceed customer
expectations.
Rationale
• Sustained success is achieved when an organization
attracts and retains the confidence of customers and other
interested parties. Every aspect of customer interaction
provides an opportunity to create more value for the
customer. Understanding current and future needs of
customers and other interested parties contributes to
sustained success of the organization.
92. QMS Principles
Customer Focus
Key benefits
• Increased customer value
• Increased customer satisfaction
• Improved customer loyalty
• Enhanced repeat business
• Enhanced reputation of the organization
• Expanded customer base
• Increased revenue and market share
93. QMS Principles
Leadership
Statement
• Leaders at all levels establish unity of purpose and
direction and create conditions in which people are
engaged in achieving the organization’s quality
objectives.
Rationale
• Creation of unity of purpose and direction and
engagement of people enable an organization to
align its strategies, policies, processes and
resources to achieve its objectives.
94. QMS Principles
Leadership
Key Benefits
• Increased effectiveness and efficiency in meeting
the organization’s quality objectives
• Better coordination of the organization’s processes
• Improved communication between levels and
functions of the organization
• Development and improvement of the capability of
the organization and its people to deliver desired
results
95. QMS Principles
Engagement of People
Statement
• Competent, empowered and engaged people at all
levels throughout the organization are essential to
enhance its capability to create and deliver value.
Rationale
• To manage an organization effectively and
efficiently, it is important to involve all people at all
levels and to respect them as individuals.
Recognition, empowerment and enhancement of
competence facilitate the engagement of people in
achieving the organization’s quality objectives.
96. QMS Principles
Engagement of People
Key Benefits
• Improved understanding of the organization’s quality
objectives by people in the organization and increased
motivation to achieve them
• Enhanced involvement of people in improvement activities
• Enhanced personal development, initiatives and creativity
• Enhanced people satisfaction
• Enhanced trust and collaboration throughout the
organization
• Increased attention to shared values and culture
throughout the organization
97. QMS Principles
Process Approach
Statement
• Consistent and predictable results are achieved
more effectively and efficiently when activities are
understood and managed as interrelated processes
that function as a coherent system.
Rationale
• The quality management system consists of
interrelated processes. Understanding how results
are produced by this system enables an
organization to optimize the system and its
performance.
98. QMS Principles
Process Approach
Key Benefits
• Enhanced ability to focus effort on key processes
and opportunities for improvement
• Consistent and predictable outcomes through a
system of aligned processes
• Optimized performance through effective process
management, efficient use of resources, and reduced
cross-functional barriers
• Enabling the organization to provide confidence to
interested parties as to its consistency, effectiveness
and efficiency
99. QMS Principles
Improvement
Statement
• Successful organizations have an ongoing focus on
improvement.
Rationale
• Improvement is essential for an organization to
maintain current levels of performance, to react to
changes in its internal and external conditions and
to create new opportunities.
100. QMS Principles
Improvement
Key Benefits
• Improved process performance, organizational capabilities
and customer satisfaction
• Enhanced focus on root-cause investigation and
determination, followed by prevention and corrective
actions
• Enhanced ability to anticipate and react to internal and
external risks and opportunities
• Enhanced consideration of both incremental and
breakthrough improvement
• Improved use of learning for improvement
• Enhanced drive for innovation
101. QMS Principles
Evidence-based Decision Making
Statement
• Decisions based on the analysis and evaluation of data and
information are more likely to produce desired results.
Rationale
• Decision making can be a complex process, and it always
involves some uncertainty. It often involves multiple types
and sources of inputs, as well as their interpretation, which
can be subjective. It is important to understand cause-and-
effect relationships and potential unintended
consequences. Facts, evidence and data analysis lead to
greater objectivity and confidence in decision making.
102. QMS Principles
Evidence-based Decision Making
Key Benefits
• Improved decision-making processes
• Improved assessment of process performance and
ability to achieve objectives
• Improved operational effectiveness and efficiency
• Increased ability to review, challenge and change
opinions and decisions
• Increased ability to demonstrate the effectiveness
of past decisions
103. QMS Principles
Relationship Management
Statement
• For sustained success, an organization manages its
relationships with interested parties, such as suppliers.
Rationale
• Interested parties influence the performance of an
organization. Sustained success is more likely to be
achieved when the organization manages relationships
with all of its interested parties to optimize their impact on
its performance. Relationship management with its
supplier and partner networks is of particular importance.
104. QMS Principles
Relationship Management
Key Benefits
• Enhanced performance of the organization and its
interested parties through responding to the opportunities
and constraints related to each interested party
• Common understanding of goals and values among
interested parties
• Increased capability to create value for interested parties
by sharing resources and competence and managing quality-
related risks
• A well-managed supply chain that provides a stable flow
of goods and services
106. QMS Principles
Process Approach
Statement
• Consistent and predictable results are achieved
more effectively and efficiently when activities are
understood and managed as interrelated processes
that function as a coherent system.
Rationale
• The quality management system consists of
interrelated processes. Understanding how results
are produced by this system enables an
organization to optimize the system and its
performance.
107. Process Approach to QMS
• All organizations normally use processes to achieve
their objectives.
• A process is a set of interrelated or interacting
activities that use inputs to deliver an intended
result, which consist of tangible inputs and outputs
e.g. materials, components or equipment or
intangible outputs e.g. data, information or
knowledge.
109. Process Approach to QMS
• Process approach involves systematic definition
and management of processes and their
interactions so as to achieve the intended results in
accordance with the quality policy and strategic
direction of the organization.
• Consistent and predictable results are achieved
more effectively and efficiently when activities are
understood and managed as interrelated processes
that function as a coherent system.
115. ISO 9001:2015 Quality Management System Process Approach
Organization
and its
Context
Products and
Services
Improvement
Leadership
Support
and
Operations
Performance
Evaluation
Planning
Customer
Requirements
Customer
Satisfaction
Plan Do
Act Check
Needs and
Expectations
of Relevant
Interested
Parties
Results of
QMS
116. PDCA
PDCA is a tool that can be used to manage processes and systems.
PDCA stands for:
• P Plan: set the objectives of the system and processes to deliver
results (“What to do” and “how to do it”)
• D Do: implement and control what was planned
• C Check: monitor and measure processes and results against
policies, objectives and requirements and report results
• A Act: take actions to improve the performance of processes
PDCA operates as a cycle of continual improvement, with risk‐based
thinking at each stage.
118. Personal Recommendations on QMS
Development
• Use ISO 9001:2015 and PhilHealth Benchbook as
guides and checklists (as a priority).
• Go for PhilHealth Benchbook accreditation.
• May go for ISO 9001:2015 certification if needed.
• Start with the ISO 9001:2015 QMS Framework.
Modify it to suit your hospital setting, e.g., to
include “safety.”
119. ISO 9001:2015 Quality Management System Framework
Organization
and its
Context
Products and
Services
Improvement
Leadership
Support
and
Operations
Performance
Evaluation
Planning
Customer
Requirements
Customer
Satisfaction
Plan Do
Act Check
Needs and
Expectations
of Relevant
Interested
Parties
Results of
QMS
120. -Quality and
Safe Health
Care Services
-Cost-efficient
/ Value-based
Services
-Maximal
Utilization of
Services
Patient
Experience
121. Personal Recommendations on QMS
Development
• Formulate and decide on the quality and safety
policy.
• Use the policy as a guide to formulate quality
objectives.
122. Quality and Safety Policy
To continuously provide quality and safe health care services,
products, facility and environment to all our stakeholders
(communities, families, patients, workforce and partners).
This policy shall be realized through:
• Understanding the expectations of our stakeholders on quality and
safe health care services, products, facility and environment;
• Complying with all statutory and regulatory requirements;
• Designing effective and efficient quality and safe management
systems
• Providing adequate resources and highly competent staff to support
the implementation of the management system;
• Regularly evaluating and reviewing the results of implementation of
the management system;
• Continually improving the management system with innovations.
123. Personal Recommendations on QMS
Development
• Your Manual of Governance and Operations should
be equivalent to the Manual on Quality and Safety
Management System. One, hospital wide and one,
specific for the unit. (NO more separate Quality
Manual vs Manual of Governance and Operations)
• The unit Manual of Governance and Operations or
Manual on Quality and Safety Management System
should be aligned and integrated into that of the
hospital.
124.
125. Personal Recommendations on QMS
Development
• Develop hospital wide management systems for
each box in the QSMS framework to serve as a
guide for the unit management systems for
alignment and integration purposes.
126. Quality and Safety Management System
Hospital-wide Unit (ALIGNMENT AND INTEGRATION)
• Quality and Safety Management System
• Organizational Context Management System
• Organizational Vision Management System
• Legal Requirements Management System
• Client Requirements Management System
• Leadership Management System
• Planning Management System
• Support Management System
127. Quality and Safety Management System
Hospital-wide Unit
(ALIGNMENT AND INTEGRATION)
• Clients Management System
• Workforce Management System
• Operations Management System
• IT Management System
• Evaluation Management System
• Improvement Management System
• Documented Information
Management System
• Client Engagement Management
System
• Performance Excellence
Management System
128.
129. Personal Recommendations on QMS
Development
• In the management systems, both hospital and unit
wide, make use of the standards of ISO and
PhilHealth as guides and comply.
130. ISO 9001:2015 Quality Management System Standards
4 Context of the organization
5 Leadership
6 Planning
7 Support
8 Operation
9 Performance Evaluation
10 Improvement
131. PhilHealth Benchbook 2nd Edition
A. PATIENT CENTERED STANDARDS
1. PATIENT RIGHTS AND ORGANIZATIONAL ETHICS
2. ACCESS TO HEALTHCARE
3. INPATIENT ADMISSION AND OUTPATIENT REGISTRATION
4. ASSESSMENT OF PATIENTS
5. CARE PLANNING CARE DELIVERY
6. MEDICATION MANAGEMENT
7. SURGICAL AND ANESTHESIA CARE
B. FACILITY FOCUSED STANDARDS
8. LEADERSHIP AND MANAGEMENT
9. HUMAN RESOURCE MANAGEMENT
10. INFORMATION MANAGEMENT
11. SAFE PRACTICE AND ENVIRONMENT
12. INFECTION CONTROL
13. IMPROVING PERFORMANCE
132.
133. Personal Recommendations on QMS
Development
• In all the departments, you can use this
Department Design and Development Framework
as a guide.
• Develop a Department Manual of Governance and
Operations or Manual of QSMS that contains all the
information and the needed processes in each of
the boxes.
134.
135.
136.
137.
138. Personal Recommendations on QMS
Development
• Make the goals as uniform as possible for all units
and aligned to hospital goals like so:
• Client engagement (patient experience)
• Performance excellence
• Quality and safe health care services
• Cost-efficient / value-based services
• Maximal utilization of services
139. Personal Recommendations on QMS
Development
• After you are done with the Manual of Governance
and Operations or Manual of QSMS (hospital-wide
and units),
•Deploy and educate staff
•Implement
•Check
•Improve
140. Personal Recommendations on QMS
Development
When you are audited, the auditors will
• Examine documents and records (make sure they
are available) – priority = Manual of Governance
and Operations or Manual of QSMS
• Interview and observe on the service processes,
whether they are being implemented properly (use
of tracer methodology)
• Look at the results of the implementation and
improvement plans
141. Tracer Methodology
Individual Patient Tracers
• An individual tracer follows the actual experience
of an individual who received care, treatment, or
services in a health care organization.
142. Tracer Methodology
Individual Patient Tracers
• Individual (patient) tracer activity usually includes
observing care, treatment, or services and associated
processes; reviewing open or closed medical records
related to the care recipient’s care, treatment, or services
and other processes, as well as examining other
documents; and interviewing staff as well as care
recipients and their families.
143. Personal Recommendations on QMS
Development
Lastly,
QMS = TQMS
Quality Management System = Quality and Safety
Management System
Manual of Governance and Operations = Manual of
Quality and Safety Management System
Aim for Patient Experience!!!
(show video)
144. Patient Relations Management
Patient Experience
Goal – Patient Engagement
Continuum of Care – from 1st second to last second of contact with patients
All staff involved – regardless of rank / department / specialty
- Courteous – respectful
- Friendly – caring – compassionately assistive – giving information; manual help;
advices
- Ensuing quality and safe care in each point of care; by self; by others