QUALITY IMPROVEMENT

AND
PATIENT SAFETY
WHAT IS QUALITY ?
 Appropriate application of medical
knowledge with due regard to the
balance between the hazard inherent
in every medical intervention and the
benefits expected from it

 It is, however more complex than

this.
 WHAT IS QUALITY
ASSURANCE
Quality assurance as making sure
that the services provided by
thehospital are the best possible
given existing resources and
current medical knowledge.
QUALITY FROM WHOSE
POINT OF VIEW ?
 Provider of Health care Services

 Recipient of the Health care

services

 Organizer of the Health care

services
 PROVIDERS CONCERNS
 To provide care as per established
norms
 Adequate resources
 Self satisfaction with the final
outcome
 Should contribute to enhancement of
skills, competence and add to
experience
 RECIPIENTS CONCERNS
 Accessibility
 Affordability
 Prompt attention
 Less waiting time
 Early diagnosis and cure
 Return to Productivity as early as possible
 Humane Treatment ie to be treated with
empathy , respect and concern
 ORGANISERS CONCERNS
 Responsible to the Society for the funds
spent on health care

 To ensure safety of public and prevent

inappropriate or suboptimal care

 To meet the requirements of the recipient

and provider of the health care services at
Acceptable costs
 QUALITY IMPROVEMENT
APPROACHES
 Credentialing
 Licensure
 Accreditation
 Certification
 Chart recognition
QUALITY ASSURANCE CYCLE
Reevalu Identify
ation values

Identify standards
Take action
criteria

Choose action Secure measurement

Identify Make
course of measurem
action ent
 NEW TRENDS IN QUALITY
ASSURANCE
 Quality council
 Concurrent monitoring
 High volume case assessment
 High risk assessment
 Standard of quality care
 Inter disciplinary quality assurance
 Automation of data sources
 Performance of the staff
WHAT IS ACCREDITATION
 Accreditation is an external review of
quality with four principal components:

 It is based on written and published

standards
 Reviews are conducted by professional
peers
 The accreditation process is
administered by an independent body
 The aim of accreditation is to encourage
organizational development.
 Focus of standards
 Patient Safety

 Staff and employee safety

 Environment and community safety

 Information Education and Communication

 Accreditation Process

 Applications
 Screening of the Applications
 Pre-assessment survey
 Assessment Survey
 Review of the recommendations of the
assessing body by the Accreditation
Committee
 Recommendations to the board
 Accreditation decision
 DOCUMENT REVIEW

• Quality Manual
• Various Policies and Procedures
• Minutes of Meetings of various committees
• Medical Records
• Medical / Nursing Audit
• Adverse Events
• HAI
• Action Taken Reports
• Personal Records of Staff
 OBSERVATIONS
• Facility Safety
• Level of compliance with laid down policies and
procedures
• BMW Management
• Standard Precautions
• Patient care
• Fire Safety
• Equipment Management
PROBLEMS AND CHALLENGES

 HCOs are very enthusiastic

 Ill prepared

 Initial preparation is shoddy

 Resources required initially

 Benefits have a longer gestation

period
PROBLEMS AND CHALLENGES
 Quality Consciousness at all levels
will take time
 Sustenance and consistency of
efforts will be required
 Commitment on a consistent basis
 High rates of attrition will require
repeated and continual training
 Public Sector will take a longer time
to get into the process
 Quality and consistency of assessors
and assessments
These May Look Difficult

Initially, But the First

steps are Never easy.

Also Nothing Is

Impossible

For,
Impossible

Means

I’ M Possible
Quality Norms and Accreditation??

Response of Medical Fraternity

Expected Response
 THE CURRENT STATUS OF
ACCREDITATION IN INDIA
 Initializing phase is over.

 Phase of consolidation.

 The initial steps have been difficult but

the journey has begun.

 The journey has to continue……….

 Especially since ---------------------------

ACCREDITATION IS A JOURNEY

AND

NOT A DESTINATION.
BON VOYAGE !!!!!