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Hospital Accreditation - Orientation for

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Fiona Liu

on 22 October 2013

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Transcript of Hospital Accreditation - Orientation for

Hospital Accreditation OWS 2014
Orientation and Sharing for New Department Coordinators and Quality Champions

22 Oct 2013

Welcome Remarks
PY Quality Journey
EQuIP 5 – Function, Standards, Criteria
Submission for Self Assessment (Jun 2013) & updates of actions on PR recommendations
Roles of Department Coordinators (DCs) & Quality Champions (QCs)
Sharing by DC & QC
On-site survey practical tips
Useful Resources
Today’s Rundown
Dr. CN Tang, DHCE
ACHS accredited by The International Society for Quality in Health Care (ISQua) had been appointed by HA to provide consultancy service and conduct accreditation surveys
Evaluation & Quality Improvement Program (EQuIP
A framework for managing health services to ensure quality care services

The Australian Council on Healthcare Standards (ACHS)
EQuIP 5 Cycle
Phase 1
- Self Assessment
New members provide a self-assessment against all criteria
Existing members provide a self assessment of progress against the recommendations from the Periodic Review
Organizations update and submit their register of key organization risks (risk register)
Phase 2
- Organisation- Wide Survey (OWS)
Members provide a Pre-Survey Assessment against all criteria and an updated risk register approximately 6 weeks prior to the organisation-wide onsite survey
All criteria are surveyed and progress on recommendations from the PR is reviewed
Phase 3
- Self Assessment
Members provide a self-assessment of progress against the recommendation from the Organisation-Wide Survey
Organisations update and submit their register of key organisation risk (risk register)
Phase 4
- Periodic Review (PR)
Members provide a Pre-Survey Assessment Against all mandatory criteria, progress against recommendations and an updated risk register
Mandatory criteria are surveyed and progress on recommendations from the Organisation-Wide Survey is reviewed
ACHS Achievement Rating
Major Changes of EQuIP 5
Overview of ACHS Standards
15 Mandatory Criteria
1.4 Effectiveness
1.4.1 Evidence Based Care & Service Planning, Development & Delivery

1.5 Safety
1.5.1 Medication Safety
1.5.2 Infection Control
1.5.3 Pressure Ulcer & Wound management
1.5.4 Fall Management
1.5.5 Blood Management
1.5.6 Correct Patient, Correct Procedure & Correct site
1.5.7 Nutritional needs

1.6 Consumer Focus
1.6.1 Community Participation in Planning, Delivery & Evaluation of Health Service
1.6.2 Patients’ Rights and Responsibilities
1.6.3 Diverse Needs & Backgrounds of Patient & Carers

1.1 Continuity of Care
1.1.1 Patient Assessment
1.1.2 Care Planning in Collaboration with Consumer / Patient
1.1.3 Informed Consent
1.1.4 Evaluation of Clinical Care Outcomes
1.1.5 Clinical Handover, Transfer of Care & Discharge
1.1.6 Ongoing Care
1.1.7 Care of Dying & Deceased
1.1.8 Health Record

1.2 Access
1.2.1 Information to Community
1.2.2 Prioritization of Access & Admission

1.3 Appropriateness
1.3.1 Appropriate Health Care, Services & Setting

Criteria of Function 1: Clinical

2.1 Quality Improvement & Risk Management
2.1.1 Continuous Quality Improvement
2.1.2 Risk Management
2.1.3 Incident management
2.1.4 Complaint & Feedback Management

2.2 Human Resources Management
2.2.1 Workforce Planning
2.2.2 Recruitment, Selection & Appointment - Staff & Volunteers
2.2.3 Employment & Performance Development - Staff & Volunteers
2.2.4 Learning & Development - Staff & Volunteers
2.2.5 Employee Support & Workplace Relations

2.3 Information Management
2.3.1 Health Records Management
2.3.2 Corporate Records Management
2.3.3 Data & Information Management
2.3.4 Information & Communication Technology

2.4 Population Promotion
2.4.1 Promotion for Better Health and Wellbeing

2.5 Research
2.5.1 Research Governance & Programs

Criteria of Function 2: Support

3.1 Leadership & Management
3.1.1 Strategic & Operational Planning & Development
3.1.2 Governance, Structure & Delegation
3.1.3 Credentialing & Scope of Clinical Practice
3.1.4 External Service Providers Management

3.1.5 Corporate and Clinical Documents Management

3.2 Safe Practice & Environment
3.2.1 Safety Management Systems
3.2.2 Facilities, Medical Devices, Equipment & Supplies Management
3.2.3 Waste & Environmental Management

3.2.4 Emergency & Disaster Management
3.2.5 Security Management

Criteria of Function 3: Corporate

Sharing by Quality Champion
Ms. Ida Yip, SNO(IC)
Sharing by Department Coordinator
Dr. Grace Lam, AC(ICU)
Sharing by Department Coordinator
Ms. Karen Lee, APN(DR)
Experience Sharing
Hospital Accreditation Status
OWS 2014
OWS 2014
Survey Scope
Coverage & Process
Cluster Services
- e.g. Human Resources, Finance, Procurement, Facilities Management, et.c
Hospital Services
- all clinical services, Allied Health, Nursing services including SOPD, all Administrative service departments
Cover the
entire EQuIP5 standards & 47 criteria
(15 mandatory & 32 non-mandatory)
Pre-survey document submission
(6 weeks before in advance):
governance structure & committee structure
annual plan & report
at MA level for each criterion
key & intended improvement
On-site survey:
5 days from
on Key Improvement programs,
with Quality Champions &
to all clinical and on-clinical areas,
Summation Conference
On-site Survey practical tips
Practical Tips (3)
Question & Answer time
allow surveyor to take the lead & ask questions
assign staff to response where appropriate e.g. OSH link person, Infection Control link nurse, etc.
Evidence / Documents
upon request by surveyor
don't panic if you have not got it but ...
& reply will provide later
(ASAP & must before noon on Day 5!)
Practical Tips (4)
Evidence which surveyors are interested:
Mandatory training records
for OSH, fire Safety, Infection Control, Data Privacy
Health informatics
patient records - confidentiality & satellite medical record storage
: fire inspection reports, register of chemicals, statistics on manual handling, environmental hazards
Risk Register
, incident report, patient satisfaction survey, quality plan
: policies on medication administration, esp. about multi-dose medication
Infection Control
: staff immunization register, separation of clean & dirty instruments, endoscopes tracking system
Emergency Management
: e-trolley - standardization of item storage & checking procedure
Practical Tips (5)
Evidence which surveyors are interested
Document Management
Access to the new
electronic Document Management (eDMS) SYstem
Note where to find
Hospital Policies
esp. related to mandatory criteria, e.g. OSH, Credentialing, Infection Control, etc
Fact sheet about HK system - available to Surveyors
Notes of M&M meeting
cross-hospital clinical review meetings
Clinical competency table
- annual reviewed & last in 4Q12
Training log book
Record for
verifying registration & qualification
of clinical staff
Evaluation / Review
Clinical audit / evaluations/ patient satisfaction survey
Key Performance Indicators
external inspection records e.g.
MPD, NM, Onc, Path, Adm, OSH, Environmental Management
Set the scene
neat & tidy venue
5-6 core members with name badge
leader to greet & introduce members
propose rundown for surveyor's agreement (~1/3 for discussion, 2/3 for walk around)
Practical Tips (1)
Brief about department / service (~10 min)
Hardcopy of summary (3-4 pages) highlighting:
QC: system / framework / committee structure
Dept: Organization chart, dept general information e.g. scope of service, no. of wards, beds & staff
Risk Register / Pressure area
KPI, incident, complaint, appreciation, audit
Key Improvements / Risk reduction programs
(2-3 major ones with quantitative results will be good)
Intended Improvements (e.g. new facilities, major equipment, additional beds, etc)
Practical Tips (2)
Practical Tips (6)
Wrap Up
Recap any outstanding Items or documents
Visit all wards and areas as far as possible according to timetable
Walk along & Introduce the workflow or show what have been mentioned in the discussion
Surveyor may request for re-visit to a particular area later in the week if any non-conformance is found ...
pls. rectify "problem" ASAP after 1st visit
Roles of DCs & QCs
Roles of DCs and QCs
Department Coordinators (DC)
Roles of DCs & QCs
Department Coordinators (DC)
1. Communication
2. Promulgation of CQI Culture
Roles of DCs & QCs
Department Coordinators (DC)
3. Implementation of Improvement Programs
Roles of DCs & QCs
Department Coordinators (DC)
4. Engaging Staff
Roles of DCs & QCs
Quality Champions (QC)
Key leaders coordinating all parties concerned for conducting Self-assessment & implementing

improvement programs
Dr. Loletta So
Joanne Zhao
Dr. Jonathan Chan
Dr. Marcus Wong
Submission in June 2013
#1 Hospital Profile
Update of changes over the last 2 years ( Jun 2011- May 2013)
e.g. Governance, new facilities & patient safety initiatives, etc.
Demographics: highest proportion of elderly population
Contracts / Relationships with external bodies
Diseases Related Group (DRGs) statistics
Clinical Indicators
Statistical Data e.g. IP, OP, staff
Inspection / reviews undertaken by external parties
#3 Updates on actions for PR (2013) recommendation
#2 Risk Register
DCs... pls. pay attention to your department specific risk register
Recap: 18 recommendations across 9 criteria
Actions on PR recommendations
Paediatric assessment tools kept in e-trolleys where will admit Paed patients, including A7 & respective specialty wards
Actions on PR recommendations (cont'd)
Actions on PR recommendations (cont'd)
Actions on PR recommendations (cont'd)

– 7 clinical specialties have trimmed & endorsed their list of common abbreviations or declared not to use abbreviations in consent forms while others are working on the subject
– departments have been encouraged to use pre-printed consent forms with the common procedure name printed on them or use ink chops
Feedback on a draft corporate guideline of ‘Administration of Multi-dosing Vial Medication in HA’ is being collected by HAHO. Meanwhile, staff are reminded to follow standard infection control measure when administering insulin or other drugs in multi-dose

– Consent form was reviewed & compliance audit and feedback on quality of obtaining informed consent will be conducted in 4Q2013
– Currently, there are 13 locations keeping patients’ records for continuity of care process. MRO & CISPO walk around was carried out in early Oct to ensure records are kept in accordance with the Corporate Policy on Good Practices in Medical Records Management. MRO will also discuss with departments concerned to set up designated satellite medical record storage where appropriate & necessary

– Checklist was reviewed by Medical Record QA subcommittee meeting & items including legibility of author's names/use of chops, white space between entries, use of color pen, have been added to the audit checklist. Documentation audit completed in 3Q2013.

Currently, bottling of 50% alcohol is carried out in well ventilated fume cupboard & Pharmacy will further explore with Chief Pharmacist Office to invite potential vendors for supply of commercially available 50% alcohol.
Actions on PR recommendations (cont'd)
Actions on PR recommendations (cont'd)
Actions on PR recommendations (cont'd)
Actions on PR recommendations (cont'd)
Progress – Endo carry on device for keeping dirty endoscopes during transportation
Progress - renovation work done for Oncology & C5 CEU
Progress e.g. tracking system in ENT SOPD
Labels on each scope
CMS entry + Record Book
#1 – wet tissue is used for general cleaning purpose

#2 – Staff Forum on Cold Chain Management (24 Oct)

Actions on PR recommendations (cont'd)
Fire safety audit checklist was revised & included check points on fire safety training, staff knowledge, locations of fire fighting equipment & environmental factors
Fire safety risk assessment was reviewed & revised: 18-month cycle with priority of assessment carried out according to the risk level. The round was started in Jan 2013 & will end in Jun 2014

Actions on PR recommendations (cont'd)
Index and key word search of document titles were added to the electronic Hospital Manual to facilitate searching
The new HKEC
with enhanced searching engine is on trial run by Departments of Clinical Oncology, Psychiatry, Q&S Office & Supporting Services in Oct 2013.
Tentative to roll out eDMS in Jan 2014
Staff feedback will be collected in 1Q2014

Actions on PR recommendations (cont'd)

HKEC Working Group on Near-Miss Reporting was set up in Feb 2013
A Near-Miss reporting forum was held in Mar 2013 with over 350 clinical staff attended. Evaluation showed >98% agreed it has enhanced their alertness
A new cluster-wide reporting form was designed to facilitate near-miss reporting & analysis. Review was carried out in Aug 2013
AIRS 3 with enhanced features for near-miss reporting has been rolled out wef Jul 2013

Actions on PR recommendations (cont'd)

HA Working Group of Specialty Advisory Group of Operating Theatre developed & endorsed a generic count sheet
Operating Theatre customized the corporate count sheet in 2Q2013 & implemented in 3Q2013. Evaluation will be conducted in 1Q2014
ALL in PYNEH accreditation website!
Useful Resource
Thank You
For enquiry
Dr. CN TANG, DHCE/COS(Surg) E6417
Lawrence POON, SNO(HA&OSH) E6368 / 64600556
Mabel CHAN, SHA(HA&TC) E5580 / 64600687
Janet LO, HA(HA) E6372 / 64600717
Kathy WU, HA(HA) E5566 / 64600720
Irene CHAN, EA(HA) E5563
Fiona LIU, EA(HA) E6275

Result of OWS 2010
Extensive Achievements (EA)
: 5 criteria
Criterion 1.1.7 – Care of Dying
Criterion 1.5.3 – Pressure Ulcer Management
Criterion 1.5.5 – Blood Management
Criterion 1.5.6 – Patient Identification
Criterion 3.2.3 – Waste & Environmental Management

Marked Achievement (MA) : 40 criteria

Results of Periodic Review 2012
Extensive Achievements (EA)
: 4 criteria
Criterion 1.1.4 -- Care Evaluation
Criterion 1.1.5 -- Discharge & Handover
Criterion 2.1.1 -- Continuous Quality Improvement
Criterion 3.2.1 -- Occupational Safety

Marked Achievement (MA) : 11 criteria

19 recommendations from Organization Wide Survey
in 2010 were
in view of satisfactory completion or good progress of actions

Hospital Accreditation Status
Hospital was very
well prepared
systematic focus on quality & safety
for clinical & support services
Committed to providing
high quality
health care in a
safe environment
whilst exhibiting
efficiency in service provision
to identify & address issues with very

Surveyor Teams’ overall comment

What's next?
New leaders
New Quality Champions
New Department Coordinators
New Generation
New Criteria
New structure
Wrap up ~ Sharing
Welcome Remark -
CH Sun
Mei Yi
PYNEH Quality Journey
Sept 2010
Feb 2011
June 2014
June 2011
April 2009
Awarded 4 years full accreditation by ACHS
Implementation of Continuous Quality Improvement (CQI)
Self- Assessment (Phase 3) Submission
Organization-Wide Survey
9-13 June
Quality Management System ISO 9000
ACHS Pilot Scheme by HAHO
June 2013
Self- Assessment (Phase 1) Submission
June 2012
Periodic Review
Wendy Lo
Rachel To
Joyce Yau
Kitty Ching
Full transcript