QUALITY ASSURANCE UNPACKING AND UNDERSTANDING NATIONAL CORE - - PowerPoint PPT Presentation

QUALITY ASSURANCE UNPACKING AND UNDERSTANDING NATIONAL CORE STANDARDS 24 MAY 2018

Priority Areas

WHAT HAS TO BE REGULATED?

• 1. Patient

Rights

• 2. Safety, Clinical Risk
• 3. Clinical Support

Services

• 4. Public Health
• 5. Leadership and Corporate Gov.
• 6. Operational Management
• 7. Facilities and Infrastructure

Domains

• 1. Values and attitudes
• 2. Waiting Times
• 6. Availability of

medicines and supplies

• 4. Patient Safety
• 5. Infection Prevention

and Control

• 3. Cleanliness

C O M P L I A N C E

Sub- Domains Standards Criteria

WHAT & HOW DO WE MEASURE?

Risk Categories

Extreme Vital Essential Developmental

Assessment Methods

• DOC
• OBS
• PI
• PRA
• SI
• STATS

Check Lists

Supporting Evidence

• M- Magement
• P- Patient care
• C- Clinical support
• S - General support services

Questionnaire

Functional Area

Dependant on Type of Facility

HOW ARE MEASUREABLES GROUPED/ORDERED? THEY ARE CONCEPTUALLY DEVELOPED

NCS & SUBDOMAINS

National Core Standards Six Priorities

• 1. Patient

rights (8 Subdomains)

• 2. Safety, clinical

Risk (6 subdomains)

• 3. Clinical support

Services (7 subdomains)

Patient Rights:

• 1. Values and

attitudes

• 2. Waiting times
• 3. Cleanliness

Patient Safety, Clinical Governance & Care:

• 4. Patient safety
• 5. Infection

prevention and control

• 4. Public health (4 subdomains)
• 5. Leadership & corporate

Governance (6 subdomains)

• 6. Operational management

(7 subdomains)

• 7. Facilities & infrastructure

(7 subdomains) Clinical Support Services:

• 6. Availability of

medicines and supplies Facilities & infrastructure:

• 3. Cleanliness

6

DOMAINS AND SUB-DOMAINS

Domain 1. Patient Rights: 1.1 Respect and dignity 1.2 Information to patients 1.3 Physical access 1.4 Continuity of care 1.5 Reducing delays in care 1.6 Emergency care 1.7 Access to package of services 1.8 Complaints management Domain 2. Patient Safety - Clinical governance & Clinical Care 2.1 Patient care 2.2 Clinical management for improved health outcomes 2.3 Clinical leadership 2.4 Clinical risk 2.5 Adverse events 2.6 Infection prevention and control Domain 3. Clinical Support Services: 3.1 Pharmaceutical services 3.2 Diagnostic services 3.3 Therapeutic and support services 3.4 Health technology services 3.5 Sterilisation services 3.6 Mortuary services 3.7 Efficiency management Domain 4. Public Health: 4.1 Population based service planning and delivery 4.2 Health promotion and disease prevention 4.3 Disaster preparedness 4.4 Environmental control Domain 5. Leadership & Corporate Governance 5.1 Oversight and accountability 5.2 Strategic management 5.3 Risk management 5.4 Quality improvement 5.5 Effective leadership 5.6 Communications and public relations Domain 6. Operational Management: 6.1 Human resource management & development 6.2 Employee wellness 6.3 Financial resource management 6.4 Supply chain management 6.5 Transport and fleet management 6.6 Information management 6.7 Medical records Domain 7. Facilities & Infrastructure 7.1 Buildings and grounds 7.2 Machinery and utilities 7.3 Safety and security 7.4 Hygiene and cleanliness 7.5 Waste management 7.6 Linen and laundry 7.7 Food services

Functional Areas (cont.)

MANAGEMENT (11) M 01 - CEO / Hospital manager M 03 - Communications M 04 - Facility infrastructure M 05 - Financial management M 06 - HR management M 07 - Infection control M 08 - Management of information M 10 - Procurement M12 - Occupational Health and Safety M 14 - Clinical management group M 16 - Case Management

PATIENT CARE (13) P 01 - A+E P 02 - Outpatients P 03 - Maternity P 04 - Medical ward P 05 - Surgical ward P 06 - Paediatric ward P 07 - Generic wards P 08 - Physio P 09 - ICU / HCU / Burns / speciality ward P 10 - Operating theatre

• incl. cath labs

P 11 - Psychiatric ward P 12 - Occupational therapy P 13 - Speech therapy CLINICAL SUPPORT (5) C 01 - Blood services C 02 - Lab services C 03 - Health technology services C 04 - Pharmacy C 05 - Radiology GENERAL SUPPORT (13) S 01 - CSSD S 02 - Cleaning services S 03 - Food services S 04 - Laundry services S 05 - Maintenance services

• incl. garden services

S 06 - Record archive S 07 - Waste management S 08 - Transport services S 09 - Security services S 10 - Entrance reception and help desk S 11 - Patient administration S 12 - Mortuary services

5

UNDERSTANDING THE SEQUENCE

• 1. DOMAIN

1.1. SUBDOMAIN 1.1.1. STANDARD 1.1.1.1. CRITERIA 1.1.1.1.1. MEASURE / CHECKLIST

Department

• r functional

area

Domain Criteria

Measure

Assessment type – method used to assess compliance: e.g. observation, document analysis

Denotes risk level X - EXTREME V = vital E= essential D= developmental

Score – the compliant (1) or non compliant (0) score for that

• question. If it is

checklist then fraction of 1 is the score i.e. 0.75 Notes section for comments or

• bservations

RISK RATING MEASURES

• Extreme Measures (non-negotiable and the compliance is

100%) are those measures that ensure safety of patients and staff is safe guarded from harm or endanger patient life or might cause death.

• Vital Standards (90% compliance is required) are risk measures

to ensure safety of patients and employees.

• Essential Standards (80% compliance) are risk measures that

are considered fundamental to the provision of safe, decent quality care.

• Developmental Standards (60% compliance) are elements of

quality of care to which health management should aspire to in

• rder to achieve optimal care.

WEIGHTING VALUES

Weighting Values (%)

X V E D 40 % 30 % 20 % 10 %

PERFORMANCE COLOUR CODES

DOING WELL / INSIGNIFICANT MINOR MODERATE MAJOR CATASTROPHIC

Overall Performance (Weighted) Outcome 72%

Non-Compliance Cut-Off Levels

Results Outcome Extreme Measure (X): Overall score < 100% “Non-Compliance” Vital Measures (V) Overall score <90% “Non-Compliance” Essential Measures (E) Overall score < 80% “Non- Compliance” Developmental Measures (D) Overall score < 60% “Non-Compliance”

Areas with risk rating (X, V, E, D)

• Domains
• Six Key Priorities
• Standard
• Assessment Method

– Documentation (Doc) – Observation (OBS) – Patient Interview (PI) – Patient Record Assessment (PRA) – Staff Interview (SI)

Risk by domain

Domain by Risk Score

Actual

X V E D

1 Patients Rights 164 4 20 115 25 2 Patient Safety / Clinical Governance / Clinical Care 168 48 37 75 8 3 Clinical Support Services 168 2 31 123 12 4 Public Health 37 24 13 5 Leadership and Corporate Governance 62 7 49 6 6 Operational Management 96 2 14 77 3 7 Facilities and Infrastructure 166 32 35 82 17

PRIORITY BY RISK

Priority Area by Risk Score

Actual

X V E D

Availability of medicines and supplies 57 7 8 41 1 Cleanliness 53 25 21 7 Improve patient safety and security 262 71 64 117 10 Infection prevention and control 98 8 20 68 2 Positive and caring attitudes 55 1 4 47 3 Waiting times 36 2 31 3

WEIGHTING VALUES (cont)

Count of Standards Breakdown

No of

Standards

No of Standards by Score Range

80-100 50-79 <50

1 Patients’ Rights 12 4 3 5 2 Patient Safety / Clinical Governance / Clinical Care 9 8 1 3 Clinical Support Services 11 7 3 1 4 Public Health 4 2 1 1 5 Leadership and Corporate Governance 4 1 3 6 Operational Management 8 3 1 4 7 Facilities and Infrastructure 13 7 3 3 Total 60

STANDARDS BY RISK

Standards by Risk Weighted Score Actual X V E D 1.1.1 Patient are treated in a caring and respectful manner by staff with the appropriate values and attitudes 76.17% 1 25 1.1.2 Patient opinions inform quality improvements in the health establishment 28.57% 3 1 1.1.3 Health establishment meets the patients’ expectations of cleanliness / hygiene / accommodation 40.07% 4 9 1.2.1 Patients are provided with information to enable them to make informed decisions regarding their care 84.43% 97 12 4 1.2.2 Patients have access to information on the services provided by the health establishment 98.46% 1 11 1.3.1 All patients in the designated catchment area are able to access the facility and its services 72.73% 2 6 4 1.4.1 Management of referrals preserves the quality of patient care 20.7% 1 16 2 1.5.1 Waiting times in busy areas are managed to improve patient satisfaction and care 51.06% 3 18 2 1.5.2 Waiting times for patients to access elective care are managed to improve efficiency in the delivery of healthcare 100% 11 1.6.1 The management of emergency patients arriving at or referred from the health establishment preserves the quality of patient care 38.57% 4 1 1.7.1 The package of services offered at the health establishment are in accordance with national guidelines or licensing specifications 100% 1 1.8.1 Patients complaints are managed systematically and to patients satisfaction 12.5% 8

PATIENT SAFETY STANDARDS SCORE X V E D 2.1.1 The basic care and treatment of patients contributes to positive health outcomes 92.06% 5 1 2.2.1 The establishment provides clinical care so as to ensure positive outcomes in identified priority initiatives including meeting the Millennium Development Goals 82.4% 2 2 2.3.1 Health professionals in the establishment champion improvements in patient centred / quality care 87.5% 4 5 2 2.4.1 There is a structured approach to the management of clinical risk in the establishment 85.56% 1 3 2.4.2 The care rendered to patients with special needs contributes to their recovery and well-being 87.82% 3 8 2 2.4.3 Specific safety protocols are in place for patients undergoing high risk procedures 86.31% 46 10 7 1 2.5.1 Adverse events are identified and promptly responded to reducing patient harm and suffering 86.52% 1 10 2.5.2 Adverse events are analysed and managed in order to prevent recurrence and reduce patient harm 40% 1 3 1 2.6.1 An Infection Prevention and Control Programme to reduce healthcare associated infections is implemented 82.35% 3 12 1

Functional Area by Risk Score

Actual

X V E D

M01P CEO or Hospital Manager Priority 60 4 43 13 M03P Communications/PRO Priority 13 2 7 4 M04P Facility Infrastructure Priority 15 1 3 9 2 M05P Financial Management Priority 15 4 11 M06P HR Management Priority 46 2 6 35 3 M07P Infection Control Priority 18 4 3 10 1 M08P Management information system Priority 6 5 1 M10P Procurement Priority 15 1 13 1 M12P Occupational health and safety Priority 9 4 5 M14P Clinical Management Group Priority 74 1 19 49 5 M16P Case Management Priority 15 8 7

Score X V E D C01P Blood services Priority 2 1 1 C02P Laboratory Priority 6 1 2 3 C03P Health technology Services Priority 3 3 C04P Pharmacy Priority 42 1 5 36 C05P Radiology Priority 17 16 1

Patient care functional area by risk

Functional Area Score

X V E D

P01P Accident and Emergency Unit Priority 45 8 7 29 1 P02P Outpatient department Priority 33 4 4 23 2 P03P Maternity Ward incl maternity theatres Priority 28 8 5 14 1 P04_1P Medical ward Priority 19 6 3 10 P05_1P Surgical ward Priority 14 8 2 4 P06P Paediatric ward Priority 27 5 6 15 1 P07_2P Generic wards / Measure is generic to any ward or day ward Priority 42 6 9 22 5 P08P Therapeutic support services - Physio Priority 36 4 5 23 4 P09P Speciality wards and services/ICU/HCU/Burn units/Oncology/Dialysis Units Priority 32 8 4 18 2 P10_1P Operating theatre incl cath labs Priority 15 8 4 3 P11P Psychiatric ward Priority 11 4 5 2

MEASURES BY RISKS

Measure Type by Risk

Weighted

Score

Actual

X V E D

Documentation (Doc) 57.8% 10 68 285 40 Observation (OBS) 83.87% 83 55 148 31 Patient Interview (PI) 73.32% 4 11 Patient Record Assessment (PRA) 81.42% 15 12 32 Staff Interview (SI) 81.55% 10 41 1

QUALITY IMPROVEMENT PLAN

Problem Item Activity By Whom Name) By When (Date) Status / Result

Area: M01 CEO or Hospital Manager Risk Rating: E Standard: 1.1.2 Patient opinions inform quality improvements in the health establishment Measure: 1.1.2.2.2 The patient satisfaction survey results show that there has been improvement over time in the results Notes: (1) No evidence List all activities to be undertaken if more than one Attach a name next to each activity Attach date Do not leave empty space, avoid on going Area: M01 CEO or Hospital Manager Risk Rating: E Standard: 1.1.3 Health establishment meets the patients’ expectations of cleanliness / hygiene / accommodation Measure: 1.1.3.1.1 Patient satisfaction survey results show that patients are satisfied with cleanliness of health establishment Notes: (1) No evidence

NCS REGULATIONS (R67 of 2 February 2018)

What has been regulated Domain1: Patient / User Rights 1.2 Information to patients 1.3 Physical access Domain 2:Patient Safety - Clinical governance & Clinical Care 2.2Clinical management for improved health outcomes 2.6 Infection prevention and control 7.5 Waste management 6.7. User Health Records & Management Domain 3. Clinical Support Services 3.1 Pharmaceutical services 3.2 Diagnostic services 3.3 Therapeutic and support services 3.4 Health technology services

Domain 6. Operational Management: 6.1 Human Resource management & development 6.5 Transport and fleet management 6.7 Medical records Domain 7. Facilities & Infrastructure 7.1 Buildings and grounds 7.2 Machinery and utilities (Engineering Services) 7.3 Safety and security General Provision Adverse Events (National Guidelines for PSI Learning & Reporting in SA) Waiting Times (One of the six key priorities)

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