accident emergency care related standards

8/2/2019 Accident Emergency Care Related Standards

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HAADStandards

forLicensureandQuality

Improvement

Dr.David

Matear

ProjectManager


2/26

Agenda

1. BackgroundtotheHAADStandardsproject

2. HAADJCIStandards

3. HospitalStandards

4. Majorstandardschapters

5. Identifiedproblems

6. Relevantstandards

PatientSafetyandQualityImprovement(PCQ)

Communication(CCC)

HighRiskCareProcesses(HRC)

Leadership(LDS)

7. Summary


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BackgroundtotheHAADStandards

project

Facilitieslicensingstandards

Standardsdocumentation

(14

documents)

Inspectionprocess

Internationalstandards

Documentationandstandardsselectionofavarietyofstandards(ISO,JCI,JCAHO,CCHSA,OSHA)

Achievable

in

the

private

sector?

Tawam andRahba achievedJCIin23years

SKMCworkingtowardsJCI(1year+)

RFP Standards

development

and

inspector

training


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HAADJCIStandardsPartnership

Developedandapproved Hospital

Standards

AmbulatoryCareStandards

Continuumof

Care

Standards

Future

MedicalTransport

Laboratories

Ionizingradiation


5/26

HSRCTermsofReferenceAdministrative

Decision

No.26/2007

Administrativedecision MembershipfromHAAD,HealthServicesCompanyand

managementorganizations

Goal Review,amendment,andrecommendationofstandardsforlicensureandinspectionofhealthfacilitiesintheEmirateofAbuDhabi.

Objectives ReviewdraftstandardssubmittedbyJCIintheareasofHospital,

AmbulatoryCare,andContinuumofCare.

Consider

other

developing

and

related

standards. Proposeamendmentstotheproposedstandards.

Recommendtheadoptionofstandardsthatareconsistentwithinternationalstandards.

Developamechanismforannualstandardsreview.


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MajorStandardsChapters

PatientSafetyandQuality

Improvement

Communication

Highrisk

care

processes

Leadership

FacilitySafety


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MandatoryStandards

Representthemostimportant

Basedon

law,

regulatory

policies

SelectedcriticalMeasurableElements(MEs)

orstandards

MUSTbemetforlicensure


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ProblemsIdentified

Patientsafety

Communication

Provisionofhighriskcare

Referralsand

transfers

Documentation

Professionalqualifications

and

skills


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GeneralPrinciples

Ensuretheclinicalandotherprofessionalqualificationsofall

staffaccordingtoHAADlicensingpolicies

Expectationsofinternationalgoodpractice

Maintainsafety

Ensuretheirfacilitiesandequipmentaresufficient

deliversafe,

high

quality

care

in

accordance

with

international

good

practice.

Ensuretherearerobustclinicalandmanagementprocesses

forthe

tracking

of

patient

safety

and

the

effectiveness

of

treatment,includingaccurate,fitforpurposeclinicalrecords.

Reportanyoccurrencethatresultsinarisktopatientsafety

orcompromises

the

delivery

of

high

quality

care


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PatientSafetyGoals

All6PatientSafetyGoalsareMANDATORY

Relevantother

standards

PCQ.1Goal1 Identifypatientscorrectly

ME5Before

treatment

or

procedures

PCQ.2Goal2 Improveeffective

communication


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MonitoringRequirements

PCQ.8 MonitoringofPatientSafetyGoals

PCQ.13 Identificationofkeymeasurestomonitor ME5 Patientassessment ME13 Availability,timeliness,content,anduseof

patientrecords

ME16

Reporting

of

activities

as

required

by

law

and

regulation

ME17 Riskmanagement

ME23 Preventionandcontrolofeventsthatjeopardizethe

safety

of

patients,

families,

and

staff


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InvestigationandReportingofEvents

PCQ.17 Thehospitalusesadefinedprocess

foridentifying

and

managing

sentinel

events

Definitionofeventstobeinvestigated

Rootcause

analysis

within

45

days

Changeprocedures

PCQ.18 Dataareanalyzedwhen

undesirabletrends

and

variation

are

identified

C i i


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Communication

Admission CCC.1 Patientsareadmittedtoreceiveinpatientcare

basedontheiridentifiedhealthcareneedsandthehospitalsmissionandresources. ME

1 Screening

is

initiated

at

the

point

of

first

contact

within

or

outsidethehospital.

CCC.3 Patientswithemergencyorimmediateneedsaregivenpriorityforassessmentandtreatment. ME

1 The

hospital

has

established

criteria

to

prioritize

patients

withimmediateneeds.

CCC.6 Admissionortransfertoorfromunitsprovidingintensiveorspecializedservicesisdeterminedby

establishedcriteria.

ME1 Thehospitalhasestablishedentryand/ortransfercriteriaforitsintensiveandspecializedservicesorunits.

ME5 Patientstransferredoradmittedtointensiveandspecialized

units/services

meet

the

criteria

and

this

is

documented

in

the

patientsrecord.


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Discharge,Referral,Followup

CCC.8 Thereisapolicyguidingtheappropriatereferralordischargeofpatients

ME1 Thereisapolicyguidingtheappropriatereferraland/ordischargeofpatients

ME2 Thereferraland/ordischargeisbasedonthe

patientsneeds

for

continuing

care

CCC.9 Patientrecordscontainacopyofthedischargesummary

ME4 A

copy

of

the

discharge

summary

is

provided

to

thepractitionerresponsibleforthepatientscontinuingorfollowupcare


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TransferofPatients

CCC.10 Thereisapolicyguidingtheappropriatetransferofpatientstoanotherhospitalororganizationtomeettheir

continuingcare

needs

ME2 Theprocessaddressesthetransferofresponsibilitytoanotherproviderorsetting

ME5 Theprocessaddresseswhoisresponsibleduringtransfer

ME

7

Patients

are

appropriately

transferred

to

other

hospitals

or

organizations

CCC.11 Thereferringhospitalorganizationdeterminesthatthereceivinghospitalcanmeetthepatientscontinuingcare

needs ME1 Thereferringhospitaldeterminesthatthereceivinghospitalcanmeettheneedsofthepatienttobetransferred

ME2 Patientclinicalinformationoraclinicalsummaryistransferredwiththepatient


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TransferofPatients

CCC.12 Duringdirecttransfer,aqualifiedstaffmembermonitorsthepatientscondition

ME1 All

patients

are

monitored

during

direct

transfer

to

another

hospital

CCC.13 Thetransferprocessisdocumentedinthepatientsrecord

ME1 The

records

of

transferred

patients

note

the

name

of

the

hospitalandnameoftheindividualagreeingtoreceivethepatient

ME2 Therecordsoftransferredpatientsnotethereason(s)fortransfer

ME3 Therecordsoftransferredpatientsnoteanyspecialconditions

related

to

transfer

ME4 Therecordsoftransferredpatientsnoteanychangeofpatientconditionorstatusduringtransfer


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Transportation

CCC.14 Theprocessforreferring,

transferring,or

discharging

the

patient

considerstransportationneeds

ME1 Theprocessforreferringpatients

considerstransportation

needs

ME4 Transportationisappropriatetothe

patientsneeds


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HighRiskCare

Assessmentsand

Care

HRC11 Qualifiedindividualsconducttheassessmentsandreassessments

ME2 Onlythoseindividualspermittedbylicensure,applicablelawsandregulations,orcertificationperformpatientassessments

ME3 Emergency

assessments

are

conducted

by

individualsqualifiedtodoso

HRC16 Policiesandproceduresguidethecareof

highrisk

patients

and

the

provision

of

high

risk

services

ME1 (a)Careofemergencypatients


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Leadership

Ethics LDS.3 Thehospitalestablishesaframeworkfor

ethical

management

that

ensures

that

patient

care

isprovidedwithinbusiness,financial,ethical,and

legalnormsandthatprotectspatientsandtheir

rights ME4 Thehospitalprovidesclearadmission,transfer,and

dischargepolicies

ME6 The

hospital

discloses

and

resolves

conflicts

when

financialincentivesandpaymentarrangements

compromisepatientcare


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DepartmentalLeadership

LDS.8 Oneormorequalifiedindividuals

providedirection

for

each

department

or

serviceinthehospital

ME1 Anindividualwithappropriatetraining,education,

andexperience

directs

each

department

or

service

in

the

hospital


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StaffEducation

LDS.17 Staffmemberswhoprovidedirectcareandservicesandotherstaffidentifiedbythehospitalareannually

trainedin

basic

or

advanced

cardiac

life

support

ME1 Staffmemberstobetrainedincardiaclifesupportareidentifiedbythedevelopmentofalist. Thelist

includes

at

least

all

direct

care

givers

ME2 Theappropriateleveloftrainingisprovided(e.g.,basiclifesupport(BLS),advancedlifesupport(ALS),pediatricadvancedlifesupport(PALS))

ME3 Staff

members

are

retrained

every

two

years

ME4 Thereisevidencetoshowifastaffmemberpassedthetrainingwhichincludesbothawrittentestandreturn

demonstration


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MedicalStaffing

LDS.18 Thehospitalhasaneffectiveprocessforgathering,verifying,andevaluatingthecredentials(license,education,

training,and

experience)

of

those

medical

staff

permitted

to

providecareandservicestoindividualswithoutsupervision

ME1 Thosepermittedbylawsandregulationsandby

the

hospital

to

provide

care

and

services

to

individuals

withoutsupervisionareidentified

ME2 Currentlicensure,education,training,andexperiencearedocumentedfortheseprofessionals

ME3 Such

information

is

verified

from

the

original

source


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MedicalStaffing

LDS.19 Thehospitalmaintainsforeverymedical

staff

member

a

record

of

the

current

professional

license,certificate,orregistrationwhenrequiredby

lawsorregulationsorbytheorganization

ME

2(c)

Current

list

of

privileges

LDS.20 Thecredentialsofmedicalstaffmembers

arereevaluatedatleastevery3yearstodetermine

theirqualifications

to

continue

to

provide

care

and

servicesintheorganization

ME1 Thereisaprocesstoevaluateeachmedicalstaff

memberevery

three

years


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MedicalStaffing

LDS.21 Thehospitalhasastandardized,objective,

evidencebasedproceduretoauthorizeallmedical

staffmemberstoadmitandtreatpatientsand

provideotherclinicalservicesconsistentwiththeir

qualifications ME1 Thereisastandardizedproceduretogrant

privilegestopractitionersoninitialappointmentandon

reappointment

every

three

years ME5 Theaggregationoftheannualdataisusedinthe

evaluationforreappointmentwhichoccurseverythree

years

S


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Summary

Approved

licensing

standards

govern

health

care

Mandatorystandardsmustbemet

Theproblemsidentifiedarecoveredinthestandards

Patientsafety

Communication

Provisionofhighriskcare

Referralsandtransfers

Documentation

Professionalqualificationsandskills

Relevantstandardstoidentifiedproblems

PatientSafety

and

Quality

Improvement

(PCQ)

Communication(CCC)

HighRiskCareProcesses(HRC)

Leadership

(LDS) Inspectorswillenforcethatstandardsaremet


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QUESTIONS?

accident emergency care related standards

Documents