‫اﻟﻤﺤﺘﻮى‬

‫ﻣﺆﺳﺴﺎت اﻻﻋﺘﻤﺎد‬ ‫ﻧﻤﺎذج اﻟﺘﻘﻴﻴﻢ اﻟﺨﺎرﺟﻲ‬ ‫•‬

‫ﺗﻌﺮﻳﻒ اﻻﻋﺘﻤﺎد‬ ‫•‬
‫ﺧﺼﺎﺋﺺ ﺑﺮﻧﺎﻣﺞ اﻻﻋﺘﻤﺎد‬ ‫•‬
‫ﺗﻘﻴﻴﻢ ﺑﺮﻧﺎﻣﺞ اﻻﻋﺘﻤﺎد‬ ‫•‬
‫ﻧﻮر ﺷﺎﺷﺎﺗﻲ‬
‫‪4/28/2008‬‬ ‫‪2‬‬

‫ﻧﻤﺎذج اﻟﺘﻘﻴﻴﻢ اﻟﺨﺎرﺟﻲ‬ ‫اﻻﻋﺘﻤﺎد‬

‫اﻹﺷﻬﺎد‬ ‫•‬ ‫• ”اﻋﺘﺮاف ﻋﻤﻮﻣﻲ ﺑﺘﺤﻘﻴﻖ ﻣﺆﺳﺴﺔ رﻋﺎﻳﺔ ﺻﺤﻴﺔ‬
‫ﻣﺮاﺟﻌﺔ اﻟﺰﻣﻼء‬ ‫•‬ ‫ﻟﻤﻌﺎﻳﻴﺮ اﻻﻋﺘﻤﺎد‪ ،‬ﻣﺜﺒﺖ ﻣﻦ ﺧﻼل ﻋﻤﻠﻴﺔ ﺗﻘﻴﻴﻢ‬
‫اﻻﻋﺘﻤﺎد‬ ‫•‬ ‫ﺧﺎرﺟﻲ ﻣﺴﺘﻘﻞ ﻷداء اﻟﻤﺆﺳﺴﺔ ﻳﻘﻮم ﺑﻬﺎ اﻟﺰﻣﻼء‪“.‬‬
‫اﻟﺘﺴﺠﻴﻞ واﻟﺘﺮﺧﻴﺺ‬ ‫•‬
‫‪ISQua 2004‬‬

‫‪4/28/2008‬‬ ‫‪3‬‬ ‫‪4/28/2008‬‬ ‫‪4‬‬

‫ﺧﺼﺎﺋﺺ ﺑﺮﻧﺎﻣﺞ اﻻﻋﺘﻤﺎد‬ ‫‪ .1‬اﻟﻔﻠﺴﻔﺔ‬

‫اﻟﻔﻠﺴﻔﺔ‬ ‫‪.1‬‬ ‫• اﻟﻐﺎﻳﺔ‬
‫اﻟﺒﻨﻴﺔ اﻟﺘﺤﺘﻴﺔ‬ ‫‪.2‬‬ ‫– اﻟﺘﻨﻈﻴﻢ‬
‫اﻟﻤﻌﺎﻳﻴﺮ‬ ‫‪.3‬‬ ‫– اﻟﺘﺤﺴﻴﻦ‬
‫اﻹدارة اﻟﻤﻴﺪاﻧﻴﺔ‬ ‫‪.4‬‬
‫ﻗﺮار اﻻﻋﺘﻤﺎد‬ ‫‪.5‬‬ ‫• ﺗﻮﺿﻴﺢ اﻷدوار واﻟﻤﺴﺆوﻟﻴﺎت‬
‫ﻗﺎﻋﺪة اﻟﺒﻴﺎﻧﺎت‬ ‫‪.6‬‬ ‫• اﻟﺘﻤﺎﺷﻲ ﻣﻊ اﻟﻘﺮاﺋﻦ‬
‫اﻟﺪﻳﻤﻮﻣﺔ‬ ‫‪.7‬‬ ‫• اﻋﺘﺒﺎر اﻟﺤﻮاﻓﺰ واﻟﺮوادع‬
‫‪4/28/2008‬‬ ‫‪5‬‬ ‫‪4/28/2008‬‬ ‫‪6‬‬

‫‪1‬‬
 ‫ اﻟﺒﻨﻴﺔ اﻟﺘﺤﺘﻴﺔ‬.2 ‫ ﻣﻌﺎﻳﻴﺮ اﻷداء‬.3
‫• اﻹدارة اﻟﻔﻌﺎﻟﺔ‬ ‫• وﺿﻊ اﻟﻤﻌﺎﻳﻴﺮ‬
‫– ﻟﺘﺤﻘﻴﻖ اﻷﻏﺮاض اﻻﺳﺘﺮاﺗﻴﺠﻴﺔ واﻟﺘﺸﻐﻴﻠﻴﺔ واﻟﻤﺎﻟﻴﺔ‬
‫– ﺗﺤﻤﻞ اﻟﻤﺴﺆوﻟﻴﺎت‬ ‫• اﻟﺘﻮﺟﻬﺎت اﻟﻤﻌﺎﺻﺮة‬
‫– إدارة اﻟﻤﺨﺎﻃﺮ وﺗﺤﺴﻴﻦ اﻷداء‬ ‫• اﻟﻌﺜﺮات اﻟﻤﺤﺘﻤﻠﺔ‬
‫• ﻣﺮﺟﻌﻴﺔ اﻟﺒﺮﻧﺎﻣﺞ‬
‫– اﻻﺳﺘﻘﻼﻟﻴﺔ‬
‫– اﻟﺼﻼﺣﻴﺔ‬

4/28/2008 7 4/28/2008 8

CAM BHC 2007 Patient Safety Goals

CBAHI Standards for Psychiatric Units

Client-Focused Standards Organization Standards

Department Head Restraint Processes
Ethics, Rights and Responsibilities Improving Organization Performance

Nurse Manager Seclusion Areas

Provision of Care, Treatment, and Services Leadership
Admission and Discharge Criteria Physical Layout
Medication Management Management of the Environment of Care
Unit Policies and Procedures Plan of Care
Surveillance, Prevention and Control of Infections Management of Human Resources
Nursing Continuing Education Crash Cart

Management of Information
Restraint Orders

4/28/2008 9 4/28/2008 10

‫ إدارة اﻟﻌﻤﻠﻴﺎت اﻟﻤﻴﺪاﻧﻴﺔ‬.4 ‫ إﻃﺎر اﺗﺨﺎذ ﻗﺮارات اﻻﻋﺘﻤﺎد‬.5

‫• إدارة اﻟﻤﻘﻴّﻤﻴﻦ‬ ‫وﺿﻊ ﻗﻮاﻋﺪ اﺗﺨﺎذ اﻟﻘﺮار‬ •
‫– اﻻﺧﺘﻴﺎر‬
‫– اﻟﺘﺪرﻳﺐ‬ ‫ﻣﺴﺘﻮﻳﺎت ﻗﺮار اﻻﻋﺘﻤﺎد‬ •
‫– اﻟﺘﻘﻴﻴﻢ‬
‫اﻹﺟﺮاءات اﻟﻤﺘﺒﻌﺔ ﻟﺘﺤﺪﻳﺪ ﻗﺮار اﻻﻋﺘﻤﺎد‬ •
‫• إدارة ﻋﻤﻠﻴﺔ اﻟﺘﻘﻴﻴﻢ‬
‫– اﻹﻋﺪاد ﻟﻠﺘﻘﻴﻴﻢ‬ ‫ﺗﺎرﻳﺦ وﻣﺪة اﻻﻋﺘﻤﺎد‬ •
‫– إﺟﺮاء اﻟﺘﻘﻴﻴﻢ‬
‫– اﻟﻤﺘﺎﺑﻌﺔ ﺑﻌﺪ اﻟﺘﻘﻴﻴﻢ‬

4/28/2008 11 4/28/2008 12

2
 ‫‪ .6‬ﻗﺎﻋﺪة ﺑﻴﺎﻧﺎت اﻻﻋﺘﻤﺎد‬ ‫‪ .7‬دﻳﻤﻮﻣﺔ ﺑﺮﻧﺎﻣﺞ اﻻﻋﺘﻤﺎد‬
‫• ﻣﺘﻄﻠﺒﺎت إدارة اﻟﻤﻌﻠﻮﻣﺎت‬ ‫اﻟﺘﺄﺛﻴﺮ ﻋﻠﻰ ﺟﻮدة اﻟﺨﺪﻣﺎت‬ ‫•‬
‫– اﻟﺴﺮﻳﺔ‬ ‫اﻟﻔﻌﺎﻟﻴﺔ ﻣﻘﺎﺑﻞ اﻟﺘﻜﻠﻔﺔ‬ ‫•‬
‫– اﻷﻣﻦ‬ ‫ﻓﻬﻢ اﻟﻘﺮاﺋﻦ اﻟﻤﺤﻠﻴﺔ‬ ‫•‬
‫• ﺗﻮﻓﻴﺮ اﻟﻤﻌﻠﻮﻣﺎت ﻟﻠﺰﺑﺎﺋﻦ‬ ‫اﻟﺘﻘﻴﻴﻢ اﻟﻤﺴﺘﻤﺮ ﺑﻬﺪف اﻟﺘﺤﺴﻴﻦ‬ ‫•‬

‫‪4/28/2008‬‬ ‫‪13‬‬ ‫‪4/28/2008‬‬ ‫‪14‬‬

‫أهﻢ اﻟﺘﺤﺪﻳﺎت اﻟﺘﻲ ﺗﻮاﺟﻪ ﺑﺮاﻣﺞ اﻻﻋﺘﻤﺎد‬ ‫اﻋﺘﻤﺎد ﻣﺆﺳﺴﺎت اﻻﻋﺘﻤﺎد‬

‫• اﻟﻐﺎﻳﺔ‬
‫ﻋﺪم ﺛﺒﺎت ﺳﻴﺎﺳﺔ اﻟﺪوﻟﺔ‬ ‫•‬ ‫– ﺿﻤﺎن اﻟﺜﻘﺔ ﺑﺄن اﻟﻤﺆﺳﺴﺔ اﻟﻤﺎﻧﺤﺔ ﻟﻼﻋﺘﻤﺎد ﺗﺤﻘﻖ اﻟﻤﻌﺎﻳﻴﺮ اﻟﻌﺎﻟﻤﻴﺔ‪ ،‬وﺗﺴﻌﻰ‬
‫ﻟﻠﺘﺤﺴﻴﻦ اﻟﻤﺴﺘﻤﺮ‬
‫ﻏﻴﺎب اﻟﺪﻋﻢ ﻓﻲ ﺻﻔﻮف اﻟﻤﺠﻤﻮﻋﺎت اﻟﻤﻬﻨﻴﺔ‬ ‫•‬ ‫• اﻟﻤﺤﺎور‬
‫ﻧﻘﺺ اﻟﺘﻤﻮﻳﻞ اﻟﻤﺴﺘﻤﺮ واﻟﺤﻮاﻓﺰ‬ ‫•‬ ‫– اﻟﻘﻴﺎدة‬
‫– اﻟﺨﺪﻣﺎت اﻟﺪاﻋﻤﺔ‬
‫اﻟﺘﻮﻗﻌﺎت ﻏﻴﺮ اﻟﻮاﻗﻌﻴﺔ‬ ‫•‬ ‫– ﺗﻘﺪﻳﻢ اﻟﺨﺪﻣﺎت‬
‫• ﺗﻘﻴﻴﻢ اﻟﺒﺮﻧﺎﻣﺞ‬
‫– إﺷﺮاف اﻟﻤﺠﻠﺲ اﻻﺗﺤﺎدي ﻟﻼﻋﺘﻤﺎد‬

‫‪4/28/2008‬‬ ‫‪15‬‬ ‫‪4/28/2008‬‬ ‫‪16‬‬

‫‪3‬‬