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Handbook of Healthcare Quality & Patient Safety
Girdhar J Gyani, Alexander Thomas
SECTION 1: INTRODUCTION TO HEALTHCARE QUALITY MANAGEMENT
CHAPTER 1:
Fundamentals of Quality
INTRODUCTION
CUSTOMER FOCUS
QUALITY: THE HISTORICAL PERSPECTIVE
Cost of Poor Quality
HISTORY OF QUALITY MOVEMENT IN INDIA
NEED FOR A QUALITY MANAGEMENT SYSTEM
EVOLUTION OF ISO 9000 SERIES OF STANDARDS
The International Organization for Standardization
Quality Standards ISO 9000:1987
Quality Standard ISO 9000:2000
Structure of ISO 9000:2000 Series of Standards
CHAPTER 2:
Evolution and Journey of Quality in Healthcare
INTRODUCTION
HISTORY OF HEALTHCARE QUALITY
Management Science and the Future
THE CONCEPT ISO 9000
ISO 9000 Principles
ISO 9000 and Healthcare
The Healthcare Process
Application of the ISO 9000 Concept to Healthcare
Benefits of Using a QMS
EVOLUTION AND PRINCIPLES OF HEALTHCARE ACCREDITATION
History of Accreditation
ACCREDITATION BODIES
Joint Commision International (JCI)
Other International Healthcare Accreditation Organizations
EVOLUTION OF NABH AND ITS PRESENT STATUS
Introduction
History
What is NABH?
NABH ASSESSMENT PROCESS IN GENERAL
Why NABH?
CHAPTER 3:
Quality-driven Strategy: Role of Leadership
CASE STUDY 1
CASE STUDY 2
THE LEARNING OBJECTIVES
INTRODUCTION
QUALITY-DRIVEN STRATEGY FOR HEALTHCARE INSTITUTIONS
LEADERSHIP DEFINED
Why Leadership in Quality-driven Strategy?
What does Literature Say?
Who are the Leaders in a Healthcare Organization?
What Leaders Do?
LEADERSHIP AND STRATEGY FORMULATION
Stakeholder Involvement
Environmental/Situational Analysis
Strategy Choice/Options for Strategy Interventions
LEADERSHIP AND STRATEGY EXECUTION/IMPLEMENTATION
LEADERSHIP AND STRATEGY MONITORING AND EVALUATION
Leadership and Team Building
Leadership and Idea Generation
Successfully Introducing Change
COMMUNICATION: THE LIFELINE OF ANY QUALITY-DRIVEN STRATEGY
THE COMMON LEADERSHIP PITFALLS
THE EVOLUTION OF NABH: A SUCCESSFUL LEADERSHIP CASE STUDY
CONCLUSION
SECTION 2: PATIENT SAFETY MANAGEMENT
CHAPTER 4:
Patient Safety Measures
INTRODUCTION TO PATIENT SAFETY
WHY IS HEALTHCARE UNSAFE?
Hospital Complexity and Systems
Human Factors
Reported Problems
Examples
Case 1
Case 2
Basics are also Challenging
Twenty-first Century Medicine
IMPACT
Levels of Harm to Patients
Outcomes
PROMOTING PATIENT SAFETY
Leadership Commitment
Patient Safety Committee
‘Systems’ Approach
Use of Checklists
Reporting of Incidents and Making Improvements
Involving Patients and their Families
Key Do's for Leadership
CONCLUSION
CHAPTER 5:
Infection Control
IMPORTANCE OF INFECTION CONTROL PROGRAMS
Hand Hygiene/Handwashing
Why Hand Hygiene Practices have not Worked?
Steps for Routine Handwash
Other Aspects Related to Hand Hygiene
Surveillance
Formula for Central Line-associated Bloodstream Infection (CLABSI)
Formula for Catheter-associated Urinary Tract Infections (CAUTI)
Formula for Ventilator-associated Pneumonia (VAP)
Formula for Surgical Site Infection (SSI) Rate
ASEPTIC TECHNIQUE
STANDARD PRECAUTIONS
ISOLATION PRECAUTIONS
DROPLET PRECAUTIONS
CONTACT PRECAUTIONS
DISINFECTION AND STERILIZATION
Surface Disinfection
Potable Water, Environment and Terminal Disinfection
Management of spills
Audits
IMPORTANCE OF FOLLOWING INFECTION CONTROL PRACTICES
SUMMARY
CHAPTER 6:
Medication Safety
INTRODUCTION
TYPES OF MEDICATION ERRORS, THEIR CAUSES AND PREVENTION
Categorization of Sources of MEs
Selection and Procurement
Study Report
Storage of Medicines
Case Study
Ordering and Transcribing
Prescription Errors
Case Study
Therapeutic Duplication
Case Study
Methods to Reduce Prescription Errors
Transcription Errors
Case Study
Indent Errors
Case Study
Documentation Errors
Case Study
Misinterpretation of Verbal Order
Case Study
Preparing and Dispensing
Case Study
Administration Errors
Case Study
Monitoring
Case Study
Reporting and Detecting Medication Errors
Use of Medication Error Data for Improving Patient Safety
Medication Error Harm Stratification by NCCMERP (National Coordinating Council for Medication Error Reporting and Prevention)
ADVERSE DRUG REACTIONS (ADRS): SOME FACTS
Severity Assessment of ADRs
Casualty Assessment of ADRs
Factors Contributing to ADRs
Case Study
PATIENT COUNSELING AND EDUCATION
STANDARD TREATMENT GUIDELINES/PROTOCOLS (STGS/STPS)
Advantages of STGs/STPs
DESIGNING AND IMPLEMENTATION OF ANTIMICROBIAL USE POLICIES
CONCLUSION
SECTION 3: QUALITY ASSURANCE IN HEALTHCARE PROCESSES
CHAPTER 7:
Quality Assurance in Patient Care Processes
INTRODUCTION
PREREQUISITES FOR QUALITY ASSURANCE IN PATIENT CARE SERVICES (REFER TO FIG. 7.1)
MEASUREMENT OF OUTCOME (IMPROVING QUALITY)
Indicators
ONGOING MONITORING VERSUS SPOT CHECKS
Step 1: Monitoring Strategies
Step 2: Establish Threshold/Standard
Surgical Site Infection Rate
Quality Assurance: Pressure Sore
Step 3: Data Collection and Trend Analyses
Structure
Step 4: Report the Data
Admission
Medication Administration
Diagnostic Procedures
Treatments and Procedures
Nursing Care
Patient and Family Education and Counseling
Infection Control
Develop Flowcharts
Develop Performance Indicators
INITIATE QUALITY IMPROVEMENT
Algorithms
Clinical Pathways
Clinical Practice Guidelines
Procedures
Protocols
Standing Orders
CHAPTER 8:
Quality Assurance in Diagnostic Centers
QUALITY ASSURANCE
Why?
Total Quality Management (TQM)
QC Planning
QC Implementation
External QC
PHASES OF LABORATORY WORK
Quality Assurance in Pre-examination Procedures
Pre-examination Aspects
Sample Collection, Transport and Accession
Grossing, Tissue Processing, Paraffin Embedding
Post-examination Aspects in a Pathology Laboratory
Quality Assurance in Examination Procedures
Internal Quality Control
Internal QC
Quality Assurance in Post-examination Procedures
SUMMARY–QUALITY CONTROL PLANNING AND QUALITY CONTROL IMPLEMENTATION
Continuous Quality Improvement
INTRODUCTION
PLAIN RADIOGRAPHY
FLUOROSCOPY
ANGIOGRAPHY
MAMMOGRAPHY
COMPUTED TOMOGRAPHY SCAN
ULTRASOUND
MAGNETIC RESONANCE IMAGING
NUCLEAR MEDICINE
CHAPTER 9:
Credentialing and Privileging in Healthcare Organizations
INTRODUCTION
BASICS OF CREDENTIALING
WHAT IS PRIVILEGING
HOW ARE CREDENTIALING AND PRIVILEGING DONE?
CREDENTIALING PRINCIPLES
CONCLUSION
Delienation of Peditric Privileges
Pediatric Privileges
Category O
Category A
Category B
Category C
Category D
Category E
Neonatal Care Privileges
Surgical Procedures
Diagnostic Procedures
Pediatric Subspecialty Procedures
Recommendations of the Head of Department, Department of Pediatrics
SECTION 4: MEASURING PROCESS OUTCOMES AND PATIENT SATISFACTION
CHAPTER 10:
Hospital Information Systems
INTRODUCTION
THE SOLUTION
THERE IS AN IMMEDIATE COMPELLING NEED FOR A ROBUST HIS
Electronic Health Records/Electronic Medical Records
The benefits of EMR
The benefits of EHR
Computerized Practitioner Order Entry (CPOE)
Clinical Decision Support System (CDSS)
Patient Monitoring Devices
Imaging Systems
ARCHITECTURE
Organizational Structure
Interoperability and Standardization
So What is Interoperability?
Why a Need for Standards?
ADVANTAGES OF PRESENT AGE HEALTH INFORMATION SYSTEMS
RISKS AND BARRIERS
APPLICATION SPECIALIST AND TRAINER
Systems Administrator/Database Administrator
Hardware and Network Engineers
Networking and Connectivity
Security of SaaS
ABBREVIATIONS AND COMMONLY USED TERMINOLOGIES
CHAPTER 11:
Monitoring Clinical and Managerial Indicators
AVEDIS DONABEDIAN'S STRUCTURE—PROCESS—OUTCOME MODEL
INDICATORS
Defining Indicators and Data Collection
Interpreting Indicators
Monitoring a Clinical Indicator (Healthcare Associated Pneumonia) Case Study
Monitoring a Managerial Indicator (Patient Discharge) Case Study
What Strikes You as Common in these Two Case Studies?
CHAPTER 12:
Measuring, Monitoring and Improving Patient Satisfaction
INTRODUCTION
IMPORTANCE OF PATIENT SATISFACTION
MEASURES FOR PATIENT SATISFACTION
MONITORING OF PATIENT SATISFACTION
IMPROVING PATIENT SATISFACTION
Improving Nursing Communication
Improving Doctors' Communication
CONCLUSION
THIRD PARTY, INDEPENDENT PATIENT SATISFACTION SURVEYS
Essential Features
Methodology of a Typical Third Party Survey
Onsite Survey
Telephone Survey
Parking
Waiting Time
Pharmacy
Discharge Process
Amenities for Relatives and Attenders
Reception and Admissions Counters
Patient Meals
Rooms
These independent surveys are different from the in-house surveys in that, they are:
Some of the more specific benefits for Insurers, Employers, Corporates and the Government are shown below:
SECTION 5: MANAGERIAL ASPECTS FOR DELIVERY OF QUALITY HEALTHCARE
CHAPTER 13:
Clinical Governance
INTRODUCTION
DEFINITION
KEY FACTORS FOR SUCCESSFUL IMPLEMENTATION
Leadership Involvement
Ownership for Patient Safety and Clinical Quality by Clinical Leaders
Patient Involvement
Supportive and Blameless Culture
Training and Education
Assigning Key Performance Indicators and Ongoing Monitoring
Clinical Audits
Disseminations of Monitoring Results to the Clinical Staff
Quality Tools
PDCA Methodology for Successful Clinical Governance
Rewards and Recognitions
Some Success Stories
BENEFITS OF GOOD CLINICAL GOVERNANCE
CONCLUSION
CHAPTER 14:
Effective Communication for Quality Healthcare
EFFECTIVE COMMUNICATION FOR QUALITY HEALTHCARE: A STORY IN THREE PARTS
Part 1: The Challenge
Part 2: The “Communication” Response to Quality Healthcare
Definition of Communication
Stages of Communication Competence
First Impressions
Physician-Patient Encounter
Communication Styles
The Importance of Active Listening
Breaking Bad News
The Four Stages (Fig. 14.2)
Communication among Employees of a Healthcare Organization
Horizontal Communication Flows
Vertical Communication—Upward and Downward Flows
Diagonal Communication Flows
Barriers to Effective Communication
Part 3: Striving for Quality Care through Communication Excellence: A Case Study
CHAPTER 15:
Planning for Patient Safety
NEWS BYLINES
INTRODUCTION
PROCESSES
Starting with a Functional Program
Infection Risk Assessment and Control
Patient Movement and Transfers
DEPARTMENTS
Emergency Care
Radiology (Imaging)
Intensive Care Units
Neonatal Intensive Care Unit
Surgical Suite
Patient Room
Special Patient Care Room
BUILDING ENGINEERING SYSTEMS
Structure
Heating, Ventilation and Air Conditioning Systems (HVAC)
Plumbing
Power
Lighting
Electronic Safety
Communication
Fire Safety
Medical Gas Pipeline System
SECTION 6: IMPACT OF ACCREDITATION AND REGULATION ON QUALITY
CHAPTER 16:
Role of Regulation and Accreditation in Improving Patient Safety and Quality of Care
INTRODUCTION
CONCEPT OF QUALITY AND PATIENT SAFETY
COMPARISON OF ACCREDITATION, CERTIFICATION AND LICENSURE PROCESS
Accreditation Process: Reporting Requirement
Accreditation Process Begins by Educating Staff and Creating Awareness
Gap Analysis or Baseline assessment
Action Road Map
Mock Survey
Final Survey
Maintenance of the Accreditation
Reporting Requirement
Licensure
IMPACT OF REGULATION AND ACCREDITATION ON HOSPITAL PROCESS
Impact of Licensing and Regulatory Requirement on Hospital Process
Ensure Safety (Patient, Visitor, Staff and Environment)
Building
Healthcare Professionals
Equipment
Impact of Accreditation on Hospital Patient Safety
Establishing of a Formal Quality Management System
Setting Basic Guidelines and Creating Awareness
Standardizing the Process
Maintenance of Quality Management System
Improvement in Processes through QMS
Risk Management
Increasing the Efficiency of the Process, Reducing the Cost and Ensuring the Safety of the Process
Optimum Use of Resources
Benefits for Patients and Family
Benefits for Employees
Limitations
FUTURE RECOMMENDED STRATEGIES TO IMPROVE QUALITY OF CARE AND PATIENT SAFETY THROUGH QMS
Alignment of Strategic Goals, Risk Management and Quality Management System
Making this as a Business Case
Origins
Growth
The Future
CHAPTER 17:
Complying with Legal and Statutory Requirements in Hospitals
INTRODUCTION
GUIDELINES FOR COMPLIANCE BY A HOSPITAL
Legal Identity
Land, Building Laws
Pollution Control Requirements
Pollution Control Acts of UK, USA and Other Countries
Laws on Drugs, Implants, Prosthesis Medical Gases and Blood
Laws for Human Resource
Laws in Relation to Finance
Economic Laws Applicable to Hospitals in India
Other Regulations
Laws-related to Information Technology and Other Related Laws
Laws Relating to Patient Treatment
Specific Laws Related to Specialized Equipment (Radiology) and Treatment
LAWS GOVERNING THE SAFETY OF PATIENTS, PUBLIC AND STAFF
SECTION 7: EXPANDING VISTAS IN IMPLEMENTATION OF QUALITY AND PATIENT SAFETY IN HEALTHCARE DELIVERY SYSTEMS
CHAPTER 18:
Preventive Maintenance for Hospital Facilities
HOSPITAL ENGINEERING SERVICES AND MAINTENANCE OF FACILITY
MAINTENANCE OF FACILITY
Water Management
Reverse Osmosis Plant
Sewage Treatment Plant
Drainage Cleaning
DG Sets and UPS
Maintenance of Transformer, UPS and DG System
Emergency Response in Case of Fire
Fire Alarm System
Public Address (PA) System
Automatic Fire Hydrant System
Locations where the Fire Hydrant Systems should be Installed
Manual System
Types of Fires
Types of Extinguishers
Alarm/Warning Systems
Plan of Action on Fire Prevention
Medical Gas
COMPRESSED AIR QUALITY
Suggested Guidelines for Air-conditioning of OT
Air Handling in the OT including Air Quality
General Guiding Notes
Preventive Maintenance
Following Documents Need to be Maintained
MEDICAL EQUIPMENT MANAGEMENT
TOTAL PRODUCTIVE MAINTENANCE OF HOSPITAL-BASED BIOMEDICAL EQUIPMENT FACILITY
OEE % = A × PE × Q = 65.13%
Pillar 1: 5S
Pillar 2: Autonomous Maintenance
Pillar 3: Kaizen
Pillar 4: Planned Maintenance
Pillar 5: Quality Maintenance
Pillar 6: Training
Pillar 7: Office TPM
Pillar 8: Safety, Health and Environment
CHAPTER 19:
Cost-effective Care
INTRODUCTION
HEALTHCARE TODAY
WHAT IS HAPPENING AROUND THE WORLD?
CURRENT KEY ISSUES AND CONCEPTS
Case 1
Case 2
Case 3
Case 4
Case 5
AN INDIAN PERSPECTIVE
HOW CAN WE DO IT?
HOSPITAL PLANNING – COST OF CARE
Project Cost
Planning and Design
Facility and Service Mix
Space Plan
Equipment Planning
Service Planning
Design Development
CHAPTER 20:
Quality Tools for Continuous Improvement
INTRODUCTION
LEAN HEALTHCARE
Why Lean Healthcare?
What is Healthcare?
What is Lean Healthcare?
Lean Thinking
Lean Principles
Getting Started
Lean Tools and Techniques for Continuous Quality Improvement
Application of Tools
Lean Results
VALUE STREAM MAPPING
Benefits of Value Stream Mapping
KAIZEN
Two Essential Elements of Kaizen
When does it become Kaizen?
Principles of Kaizen
Kaizen Workshops
Kaizen Event
How to Conduct a Kaizen Event?
Phase I: Preparation
Phase II: Implementation
Phase III: Presentation
SEVEN QC TOOLS
Check Sheet
Example
Histogram
Example
Pareto Chart
Example
Cause and Effect Diagram
Example
Scatter Diagram
Example
Control Chart
Example
Stratification
Example
FIVE S: WORKPLACE ORGANIZATION
VISUAL MANAGEMENT
SIX SIGMA
Define
Measure
Analyze
Improve
Control
CHAPTER 21:
Risk Management in Healthcare
INTRODUCTION
VARIOUS TYPES OF RISKS FACED BY HOSPITALS
SOME DEFINITIONS USED IN RISK MANAGEMENT
RISK MANAGEMENT PROGRAM IN A HOSPITAL7
TOOLS FOR RISK ASSESSMENT
Step 1: Define the HFMEA Topic
Step 2: Assemble the Team
Step 3: Graphically Describe the Process
Step 4: Conduct a Hazard Analysis
Step 5: Develop an Action Plan
Step 6: Follow up and Review
OTHER TOOLS OF RISK ASSESSMENT
INDEX
TOC
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