Patient and Family Rights (PFR)
Hak Pasien dan Keluarga
6th Edition | Effective 1 July 2017
KFSH&RC provides the highest
level of specialized healthcare in
an integrated education and
research setting.
It is important to have a culture of :
Quality
Patient safety
Continuous Improvement
JCIA accreditation is designed to create that culture.
Objectives
Re-akreditasi JCI
JCI mempersyaratkan re akreditasi setiap 3 tahun
Setiap tahun akan ada kunjungan untuk menilai kelangsungan proses
peningkatan mutu
Setiap reakreditasi diharapkan ada peningkatan mutu yang
berkesinambungan
RS YANG SUDAH JCI HARUS:
Continous quality Improvement
Monitoring dan evaluasi terus menerus untuk menilai implementasi standar
Capacity building dan Pendidikan Kedokteran Berkesinambungan bagi staff medis
untuk
meningkatkan kemampuan seluruh staf
Hak Pasien dan Keluarga
terkait komplain, konflik, dan perbedaan pendapat
Standar GLD 6 – GLD 6.2
2008 JCIA Survey visit findings
6
2008 JCIA Survey visit findings
Documentation
H&P form (Admission Notes) use.
Procedural Sedation Assessment form
completion (Endoscopy).
Pain documentation.
D4 Chronic Patients Weekly Assessment.
2008 JCIA Survey visit findings
Documentation
Authentication of telephone orders.
PRN order for Restraint.
Inconsistency in ASA score documented for
the same patient.
Renewed orders completion (e.g. cont
fentanyl)
2008 JCIA Survey visit findings
Documentation
Consultants co-signature on Residents
entries as hospital policy states
Date documentation in the progress notes
Significant Medical Record Documentation
issues: Timeliness, Eligibility, Completeness
2008 JCIA Survey visit findings
Practice & Documentation
ASA Score of III accepted for procedural
sedation in Outpatient w/o explanation
Inconsistency in the location of documenting
site marking (tooth) in dental clinic
Patient discharged from post anesthesia unit
w/o physician order
Standards Changes
Quality Management is currently
working with concerned departments
and staff to implement the required
policies & processes for the standards
changes
At least 5 Clinical
Measures
should be chosen from
(International Library of International
Measures) Library of Measures
Heart Failure (HF)
Stroke (STK)
Children’s Asthma Care (CAC)
Hospital-Based Inpatient Psychiatric Services (HBIPS)
Perinatal Care (PC)
Pneumonia (PN)
Surgical Care Improvement Project (SCIP)
Venous Thromboembolism (VTE)
Acute Myocardial infarction (AMI)
Nursing Sensitive care (NSC)
Standards Changes
(International Patient Safety Goals (IPSG))
IPSG – stay the same but more emphasis on monitoring
1. Identify Patients Correctly
2. Improve Effective Communication
3. Improve the Safety of High-Alert Medications (IPP list)
4. Ensure Correct Site , Correct- Procedure , Correct –
Patient Surgery
5. Reduce the Risk of Health Care Associated Infections
6. Reduce the risk of patient harm resulting from falls
(High Alert Medication Policy)
(High Alert Medication Policy)
Standards Changes
Standards Changes
(Patient and Family Rights – PFR)
Patient’s right to seek a second opinion without fear
Consent is obtained in a language the patient can
understand
Process to respond to patient’s request for additional
information on the practitioner
The organization obtains informed consent from live
donors
Standards Changes
Standards Changes
(Patient and Family Rights – PFR)
Patient’s right to seek a second opinion without fear
Consent is obtained in a language the patient can
understand
Process to respond to patient’s request for
additional information on the practitioner
The organization obtains informed consent from
live donors
Standards Changes
(Access to Care and Continuity of
Care – ACC)
Patients with emergent, needs are given priority for
assessment and treatment.
The clinical records of outpatients receiving continuing
care contain a summary of all significant diagnoses,
drug allergies…etc
Follow-up process for patients who leave against
medical advice.
Planning to meet the patients’ transportation needs.
Medication reconciliation upon admission.
The planned care is documented in the record in
the form of measurable progress (goals) & updated
based on assessment
The care planned is reviewed and verified by the
responsible physician.
The post-surgical plan is documented by the
responsible surgeon or verified by the responsible
surgeon
The plans of care are documented within 24 hours
of surgery.
The anesthesiologist are identified in the patient’s
anesthesia record.
Standards Changes
(Staff Qualification and Education-SQE)
Each medical staff member provides only those
services that have been permitted by the
organization.
Have a uniform process (defined by organization
policy for ongoing professional practice evaluation &
(at least) annual review on quality & safety of
services
Standards Changes
(Staff Qualification and Education-SQE)
Uses comparative data such as benchmarking to
literature-based medicine.
Use conclusions of in-depth analysis of known
complications as applicable.
Feedback to staff.
Your role as a Quality Director
Reinforce the following to department members:
Patient Safety.
Safety reporting (SRS).
Applying Infection Control Measures.
Promote the Just culture.
Your role as a Quality Director
Documentation :
(Not documented, Not completely done !!)
Identify documentation compliance issues in your
area (i.e. insufficient computers, training..etc ) and
work with Chairman for solutions.
Review tracer reports & Quarterly documentation
reports. Discuss results with the concerned staff.
Your role as a Quality Director
Medical Staff files, Ensure that :
Staff privileges are up to date
Saudi Commission registration completed
Life Support certification is completed
Fire training completed
Reference: Joint Commission
Evaluations International Accreditation Hospital
Survey Process Guide
Page 67
Your role as a Quality Director
Departmental education on :
New JCIA standards
Hospital policies related to physicians.
Quality Management Educational Role
Help directors to provide JCIA visit update in
departments’ meetings.
Provide Educational material for directors.
Prepare Readiness Tips.
Thank You
