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Required Medical stand. CBAHI

ملتقى الجودة وسلامة المرضى
موضوع مغلق
  #1  
قديم 10-08-2012, 03:27 PM
الصورة الرمزية الكفاح
 


الكفاح will become famous soon enoughالكفاح will become famous soon enough


المعيار الأول
The Medical Director is qualified for the position by:
MS.1.1 Having the appropriate experience and education.
MS.1.2 Having basic knowledge of quality management principles

Recommendation: Medical / Personnel File / Medical Director


The Medical Director has a qualification certificate in medicine


The Medical Director has basic knowledge of quality management principles

The Medical Director has appropriate experience and education

المعيار الثاني
The Medical Director has a current (at least 3 years) written job description that clearly describes his roles and responsibilities

Recommendation
The Medical Director has a current (at least 3 years) written job description that clearly describes his roles and responsibilities

المعيار الثالث
The Medical Director is responsible and accountable to the Hospital Director for the clinical performance of the medical staff and their professional conduct
Recommendation
The medical director reports to hospital director as identified in the organizational chart

المعيار الرابع
The Medical Director appoints or recommends the appointment of department heads to the Hospital Director

Recommendation Medical / Personnel File / Head of Department

There is appointment or recommendation of department heads by the medical director

المعيار الخامس
The Medical Director holds regular formal at least (monthly) meetings with all clinical department heads to ensure that all department heads work together to coordinate the provision of care.

Recommendation
The monthly meeting minutes with all clinical department heads contain evidence of discussion of aspects of medical care and services provided to patients
.
المعيار السادس
The Medical Director reviews and approves policies and procedures written by the department heads when collaboration with other departments occurs.

Recommendation
Sample of inter-departmental (multidisciplinary) policies with Medical Director review and approval
المعيار السابع
The Medical Director co-signs all staff evaluations (appraisal forms) completed by department heads in the Medical Division.

Recommendation Medical / Personnel File / Head of Department

The medical director co-signs all medical staff evaluations (appraisal forms

المعيار الثامن
The Medical Director supports the Hospital Quality Management plan and works closely with the Quality Director/leader and Nursing Director/leader to implement the standards. Formal meetings are documented.

Recommendation
There are meetings between medical director with quality director and nursing director discussing aspects quality plan (meeting minutes

المعيار التاسع
The Medical Director works closely with the Nursing Director/leader and other department heads to develop and maintain the following policies for the care of vulnerable dependent patients (Immune-compromised, comatose, elderly and/or frail, terminally ill

· MS.9.1 Infection control guidelines.
· MS.9.2 Security and safety guidelines.
MS.9.3 Ethical guidelines.

Recommendation
There is medical director involvement in the development of infection control guidelines (policy) for the care of vulnerable dependent patients (immune-compromised, comatose, elderly and/or frail, terminally ill

There is medical director involvement in the development of security and safety guidelines (policy) for the care of vulnerable dependent patients

There is medical director involvement in the development of ethical guidelines (policy) for the care of vulnerable dependent patients.

المعيار العاشر
The Medical Director works closely with the Nursing Director/leader and the Quality Management Director/leader to implement the patient safety plan and formal meetings are documented

Recommendation
There are meetings between medical director with quality director and nursing director discussing patient safety issues (meeting minutes).


شارك
مشاركة في فيسبوك مشاركة في تويترمشاركة في قوقل بلص


من مواضيعي : الكفاح
  رقم المشاركة : [ 2 ]
قديم 10-08-2012, 04:22 PM
افتراضي رد: متطلبات معايير الخدمات الطبية

المعيار الحادي عشر
The Medical Director works closely with the Quality Management Director/leader and Risk Manager in handling all near misses and incidents and:

MS.11.1 Root cause analysis is performed when appropriate.
MS.11.2 Emphasis is placed on improving systems.
MS.11.3 The “Actions taken” are documented
Recommendation
The medical director handles all near misses and incidents (sample of incident/OVR reports).
Root cause analysis is conducted for selected incidents
The actions taken in handling near misses are documented
المعيار الثاني عشر
The Medical Director together with the department heads and Quality Director, monitors departments for the following:

MS.12.1 Patient assessments.
MS.12.2 Adverse events.
MS.12.3 Conscious sedation
MS.12.4 Quality of medical records.
MS.12.5 Medication errors.
MS.12.6 Sentinel events.
MS.12.7 High-risk services and procedures (e.g. angiogram, ERCP, etc).
Recommendation
The medical director collaborates with the department heads and quality director in monitoring and reviewing reports of patient assessments, adverse events, conscious sedation, quality of medical records, medication errors, and high risk services and procedures
المعيار الثالث عشر
The Medical Director together with the department heads and Quality Director, monitors departments for the following:
MS.13.1 Mortality and morbidity.
MS.13.2 Blood and blood product usage.
MS.13.3. Outcomes of surgeries.
MS.13.4 Any discrepancies between preoperative and postoperative diagnosis.
MS.13.5 Appropriateness of admissions from the emergency room.
MS.13.6 Appropriateness of admissions from the outpatient area.
Recommendation
The Medical Director collaborates with the department heads and quality director in monitoring and reviewing reports of mortality and morbidity, blood and blood product usage, outcomes of surgeries, preoperative and postoperative diagnosis, and appropriateness of admissions from the outpatient area
المعيار الرابع عشر
The Medical Director or the clinical department heads uses the above information, to continuously improve the system, and this includes but is not limited to:

MS.14.1 Counseling of staff regarding their performance.
MS.14.2 Amending clinical privileges as necessary through Credentialing Privilege Committee CPC.
MS.14.3 Studying and correcting variances in processes within the system.
MS.14.4 Recommending any necessary equipment to the appropriate area.
MS.14.5 Recommending training and refresher courses as needed.
Recommendation
The medical director and clinical department heads use the information to continuously improve the system (counseling of staff, amending clinical privileges, studying and correcting variances, recommending any necessary equipment, and recommending training and refresher courses).
المعيار الخامس عشر
The Medical Director reviews all Hospital committee minutes within his scope and uses this information for:

  • MS.15.1 Guiding and prioritizing the services needed.
MS.15.2 Guiding the credentialing and privileging process.
Recommendation
There are meeting minutes reviewed by the medical director with actions for guiding and prioritizing the services needed.
There are meeting minutes reviewed by the medical director with actions for guiding the credentialing and privileging process
المعيار السادس عشر
Every Department has a department head who is the qualified in his field and:

MS.16.1 He has the appropriate experience and education (Saudi Board or equivalent)
MS.16.2 He has basic knowledge of quality management principles (participated or attended quality activities
).
Recommendation Medical / Personnel File / Head of Department
Qualification of medical department heads by Saudi Board or equivalent
Department heads have basic knowledge of quality management principles
المعيار السابع عشر
The department head’s managerial responsibilities include:

MS.17.1 Recommending space, equipment, and supplies for the existing unit and new programs within the hospital scope.
MS.17.2 Recommending the necessary staffing for their area.
MS.17.3 Writing internal policies and procedures ensuring that they are consistent with hospital and other department’s policies and procedures.
Recommendation
The department heads managerial responsibilities (job description) include recommending space, equipment, and supplies for the existing unit and new programs within the hospital scope, recommending the necessary staffing for their area, and writing internal policies and procedures

The department heads write internal policies and procedures ensuring that they are consistent with hospital and other departments policies and procedures.
المعيار الثامن عشر
The department head’s clinical responsibilities to evaluate the clinical standard within his/her department includes:

MS.18.1 Defining the necessary skills required of the medical staff to safely provide care to patients and recommend the training programs as needed.
MS.18.2 Ensuring that the patient admitted by physicians within his/her service is within the staff’s capabilities and the hospital’s resources to meet their needs by periodic monitoring of admissions.
Recommendation
The job description of department heads reflect that they evaluate the clinical standard within his/her department including defining the necessary skills required of the medical staff, and recommending the training programs as needed

The job description of department heads reflect that they evaluate the clinical standard within his/her department including ensuring that the patient admitted by physicians within his/her service is within staff capabilities and hospital resources to meet their needs by periodic monitoring of admissions.
المعيار التاسع عشر
All department heads ensure that the physicians working within their area limit their scope of practice to the clinical privileges assigned to them by the Credentialing & Privileging committee.

Recommendation
Medical / Personnel File / Head of department
All medical staff are working within the scope of practice according to the clinical privileges approved by Credentialing & Privileging committee (privileging application and approval).
المعيار العشرون
The department head holds regular meetings with his staff (documented minutes) to ensure that they all work together to coordinate the provision of care.

Recommendation
The departments regular meeting minutes contain evidence of coordination of medical care and services provided to patients.
المعيار الحادي والعشرون
The department head has a written scope of service for his/her area and this includes:

MS.21.1 The range of service i.e., Pediatrics, Gynecology or a general hospital.
MS.21.2 The age groups who receive care.
MS.21.3 The number of patients seen annually.
MS.21.4 The major diagnostics or therapeutic methods used.
MS.21.5 The scope of services is signed by the Medical Director, the Administrator, or both.
Recommendation
The written departmental scope of service that includes the range of service, age groups, number of patients seen annually, major diagnostics or therapeutic methods used, and is signed by the medical director, the administrator, or both.
المعيار الثاني والعشرون
The department head has a method (like a peer review committee) to:

MS.22.1 Assess the appropriateness of admissions.
MS.22.2 Assess the appropriateness of care.
MS.22.3 Assess the effectiveness of care and its outcome.
MS.22.4 Assess the efficacy of care.
MS.22.5 Assess the length of stay.
MS.22.6 Assess appropriate utilization of services.
Recommendation
The heads of departments have a method to assess quality of clinical services
المعيار الثالث والعشرون
The department head shares his/her findings with the Medical Director and works closely to improve and correct their deficiencies.

Recommendation
Communication between the head of department and medical director.
Sampling of quality improvement project in the medical departments.
The meeting minutes where the department head shares his/her findings with the medical director
المعيار الرابع والعشرون
The hospital has adequate equipment and supplies to safely provide care to patients who require Cardio Pulmonary Resuscitation (CPR) such as:

MS.24.1 Crash carts which contain emergency medications, intubation equipment and, venous access equipment, IV fluids, that are age specific (e.g. neonate, infant, child, adult).
MS.24.2 Defibrillators that are in good working order.
MS.24.3 Oxygen cylinder.
MS.24.4 Portable suction machine.
Recommendation
Crash carts contain emergency medications
Crash carts which contain intubation equipment
Crash carts contain venous access equipment.
Crash carts contain IV fluids
There is crash cart adequately equipped & available in all the critical areas , that are age specific (e.g. neonate, infant, child, adult).
Availability of defibrillators that are in good working order
Availability of oxygen cylinder in all the critical areas
Availability of portable suction machine in all the critical areas
المعيار الخامس والعشرون
Staff who are on the code team have the proper educational training and the CPR team is led by:

MS.25.1 A physician or an Anesthetist who is certified in ACLS for adult codes.
MS.25.2 A physician who is certified in PALS for pediatric codes.
MS.25.3 A physician who is certified in NRP for neonatal codes.
Recommendation
CPR/ code team schedule.

Recommendation Medical / Personnel File / Head of Department for Anesthesia,

Physician or an anesthetist who is certified in ACLS for adult codes.
Recommendation Medical / Personnel File / Head of Department for ICU, PICU
,
Physician who is certified in PALS for pediatric codes.

Recommendation Medical / Personnel File / Head of Department for NICU

Physician who is certified in NRP for neonatal codes
المعيار السادس والعشرون
The documentation for CPR is standardized by using a “CPR form” and includes the following:

MS.26.1 The name of the patient, time and location of the code.
MS.26.2 The names of the responders to the code.
MS.26.3 The medications used, and a record of all treatments given (electrical shocks, central lines inserted, intubation, etc the times administered).
MS.26.4 The outcome of the code
Recommendation
Documentation for CPR is standardized by using a CPR form that includes name of the patient, time and location, names of responders of the code, the medications used, and a record of all treatments given (electrical shocks, central lines inserted, intubation, the times administered) and the outcome of the code..
المعيار السابع والعشرون
All codes are discussed in the CPR committee and the summary of these discussions is sent to the Medical Director and the Quality Management Director/leader.

Recommendation
All codes are discussed in the CPR committee and minutes are forwarded to the medical director and the quality management director/leader.
المعيار الثامن والعشرون
The Medical Director works closely with the Nursing Director/leader and other department heads as needed to ensure there is an effective system to handle all cases of CPR at all times (24 hours/day) and includes:

MS.28.1 Standardization of all crash cart contents and includes medications, airway access, venous access, oxygen, and a defibrillator that is maintained and charged at all times.
MS.28.2 A process for checking the crash cart every shift by nursing or as appropriate by the pharmacy.
MS.28.3 A process for restocking the cart and/or exchanging the crash cart after use.
MS.28.4 A process to keep a defibrillator on each crash cart that is maintained and fully charged.
MS.28.5 A simple number such as 999 to call when summoning help for a code.
MS.28.6 Training for nurses on how to use the alarm system or call the code
Recommendation
There is a comprehensive CPR protocol that includes standardization of all crash cart contents and includes medications, airway access, venous access, oxygen, and a defibrillator that is maintained and charged at all times, process for checking and restocking the crash cart every shift by nursing or as appropriate by the pharmacy, process to keep a defibrillator on each crash cart that is maintained and fully charged, and simple number such as 999 to call when summoning help for a code.
There is training for nurses on how to use the alarm system or call the codes.
المعيار التاسع والعشرون
The roles and responsibilities of the following staff handling CPR are outlined in the hospital policy:

MS.29.1 The staff who first discover the code.
MS.29.2 The code team leader.
MS.29.3 The code team members.
Recommendation
Hospital CPR policy that outlines the staff roles and responsibilities of the staff during codes
المعيار الثلاثون
The Medical Director supports the Infection Control program by:

MS.30.1 Empowering the Infection Control practitioner to perform his/her role and enforcing his/her recommendations.
MS.30.2 Approving required resources.
MS.30.3 Communicating with the Ministry of Health for reportable infectious diseases.
Recommendation
The Medical Director supports the Infection Control program by empowering the Infection Control practitioner to perform his/her role and enforcing his/her recommendations, approving required resources, and communicating with the Ministry of Health for reportable infectious diseases
من مواضيع : الكفاح
الكفاح غير متواجد حالياً  
  رقم المشاركة : [ 3 ]
قديم 10-08-2012, 11:24 PM
افتراضي رد: Required Medical stand. CBAHI

المعيار الحادي والثلاثون
The hospital has a Medical Credentialing & Privileging committee chaired by the Medical Director or his designee that ensures only qualified physicians are hired


Recommendation

Medical Credentialing & Privileging committee terms of reference
.
المعيار الثاني والثلاثون
Applications for credentialing require the submission of a complete set of documents by the candidate for hire and include:
MS.32.1 The CV which contains the entire professional history of the candidate.
MS.32.2 Education, training, certificates, courses, experience credentials, and published research.
MS.32.3 A list of references and methods to contact them.
MS.32.4 A list of the privileges requested for approval and any requirements for skill upgrades.


Recommendation Medical / Personnel File / Head of Department

There are medical staff application and completion of credentialing documents
.
المعيار الثالث والثلاثون

The evaluation process for the Credentialing & Privileging committee ensures that every candidate undergoes the same standards for hire and includes the following:

MS.33.1 The physician’s past experience is evaluated to determine if he/she possesses current skills.
MS.33.2 The physician’s are registered with the Saudi Council for Health Specialists.
MS.33.3 The physician’s mental and physical capabilities are evaluated by obtaining letters of reference and making inquiries as needed.
MS.33.4 The physician’s past experience is evaluated when “new” skill upgrade by the physician is required.
MS.33.5 The physician’s continued scope of practice (privileging) is determined by his/her continued performance and outcomes of care rendered.
MS.33.6 Temporary or emergency privileges are approved by the Medical Director for up to 90 days while the physician’s papers are being processed by the Credentialing and Privileging committee and are not renewable.


Recommendation Medical / Personnel File / Head of Department

Credentialing & Privileging committee candidate evaluation process

There is medical staff candidates hiring process implementation

There are temporary or emergency privileges that are approved by the medical director for up to 90 days while the physicians papers are being processed by the Credentialing and Privileging committee and are not renewable.

المعيار الرابع والثلاثون




Privileges for all surgical and invasive procedures are reviewed and updated every (2) years, and as needed



Recommendation

There is review and update of privileges for all surgical and invasive procedures every (2) years and as needed
.
المعيار الخامس والثلاثون


The hospital ensures that all physicians working as locums, part time, or any physicians from outside institutions go through the Credentialing & Privileging process and follow the Bylaws to practice within the hospital



Recommendation

All medical staff hired (locum, part time, physicians outside institutions) pass through the Credentialing & Privileging process

المعيار السادس والثلاثون
The hospital has a set of documents that describes how the medical staff are organized and how the medical staff carry out the required functions of their service (Bylaws or other methods) and includes:


MS.36.1 The organizational structure of the medical division, and all the related medical sub units and the reporting relationships.
MS.36.2 The qualification requirements for every type of medical staff position that is being considered for hire (credentialing).
MS.36.3 The membership categories (e.g. full time, part time, locum, etc).
MS.36.4 The roles and responsibilities of all levels of the medical staff.
MS.36.5 The admitting, referral, transfer, and discharge process.
MS.36.6 The list of medical departments and committees.
MS.36.7 The medical record documentation guidelines.
MS.36.8 The conduct of care expected for all levels of medical staff (e.g. daily rounds).
MS.36.9 The professional conduct (e.g. handling ethical issues).
MS.36.10 How the medical staff may be promoted, appointed, or reappointed.
MS.36.11 The disciplinary process for the medical staff including corrective action and appeals.
MS.36.12 How the scope of practice is determined for each medical staff position that is being considered for hire (privileging).
MS.36.13 How privileges will be maintained and updated for each physician.
MS.36.14 How temporary privileges are granted by the Credentialing & Privileging committee to the medical staff (locums and emergency situations
Recommendation

The organizational structure of the medical division, and all the related medical sub units and the reporting relationships

The qualification requirements for every type of medical staff position that is being considered for hire (credentialing

The medical staff by-laws outlines membership categories (e.g. full time, part time, locum, etc)

The medical staff by-laws outlines roles and responsibilities of all levels of the medical staff.

The medical staff by-laws outlines admitting, referral, transfer, and discharge process.

The medical staff by-laws outlines list of medical departments and committees

The medical staff by-laws outlines medical record documentation guidelines.

The medical staff by-laws outlines conduct of care expected for all levels of medical staff (e.g. daily rounds

The medical staff by-laws outlines professional conduct (e.g. handling ethical issues).

How the medical staff may be promoted, appointed, or reappointed.

The medical staff by-laws outlines disciplinary process for the medical staff including corrective action and appeals.

The medical staff by-laws outlines how the scope of practice is determined for each medical staff position that is being considered for hire (privileging).

The medical staff by-laws outlines how privileges will be maintained and updated for each physician.

Recommendation Medical / Personnel File / Locum or Part-time Physician Staff

The medical staff by-laws outlines how temporary privileges are granted by the Credentialing & Privileging committee to the medical staff (locum and emerg


المعيار السابع والثلاثون
The hospital has a Mortality/Morbidity committee that is chaired by the Medical Director or his designee.



Recommendation

The hospital has a mortality and morbidity committee that is chaired by the medical director or his designee. (Terms of reference





المعيار الثامن والثلاثون

of the committee includes the following:
MS.38.1 Referral sources for case review include the patient complaint committee, department heads (after performing departmental review) and the Medical Director.
MS.38.2 Cases are evaluated for appropriateness of care, timeliness of care, and efficacy of care.
MS.38.3 Findings are summarized and sent to the Medical Director and the Quality Management Director/leader


Recommendation

The mortality and morbidity committee meeting minutes reflect the functions per term of reference
المعيار التاسع والثلاثون



All departments have a monthly Mortality/Morbidity meeting which includes the following:
MS.39.1 The departmental Mortality/Morbidity meetings focus is educational.
MS.39.2 Attendance at the Mortality/Morbidity meetings is considered essential and documented.
MS.39.3 All cases of mortality and morbidity are reviewed and minutes are taken with corrective actions included.

MS.39.4 The discussions at these meetings are confidential and kept in a locked file



Recommendation

There are monthly departmental mortality and morbidity meeting (minutes and attendance).

All cases of mortality and morbidity are reviewed and minutes are taken with corrective actions included

The discussions at the mortality and morbidity meetings are confidential and kept in a locked file


المعيار الأربعون

The department head’s responsibilities for case findings from the Morbidity and Mortality meeting includes:
MS.40.1 Working with the Medical Director to decide which cases are referred to the Hospital Mortality/Morbidity committee.

MS.40.2 Sending a monthly summary report to the Medical Director and the Quality Management Director/leader



Recommendation

The cases selected for hospital mortality and morbidity review are in monthly summary reports


المعيار الحادي والأربعون


The hospital has a Medical Record Review committee including the following members: Medical staff, Nursing staff and others who document in the medical record


Recommendation


Medical record review committee terms of reference outlines the function and membership
المعيار الثاني والأربعون



The Medical Record Review committee monitors completeness and evaluates the quality of the medical record documentation by reviewing a 5% sample (quarterly) of discharged patients and patients who are still in the hospital for:
MS.42.1 History and physical.
MS.42.2 Admission assessments.
MS.42.3 Operative notes.
MS.42.4 Histopathology report.
MS.42.5 Lab results.
MS.42.6 Typed x-ray reports.
MS.42.7 Discharge summaries.
MS.42.8 Documentation of patient education activity.
MS.42.9 Progress notes.
MS.42.10 Plan of care.


Recommendation

Medical record review committee reviews 5% sample quarterly of discharged patients and patients who are still in the hospital

Medical record review form includes admission assessments, operative notes, histopathology report, lab results, typed x-ray reports, discharge summaries, documentation of patient education activity, progress notes, and plan of care



المعيار الثالث والأربعون

The hospital has a Pharmacy and Therapeutics committee.



Recommendation

The hospital has a Pharmacy and Therapeutics committee (terms of reference).


المعيار الرابع والأربعون



The committees’ responsibilities include, but are not limited to:
MS.44.1 Approving the hospital formulary.
MS.44.2 Approving any new additions or deletions from the formulary.
MS.44.3 Approving the policy for the use of antibiotics in the hospital.


Recommendation

The terms of reference for Pharmacy & Therapeutics committee outlines the function by approving the hospital formulary, the additions or deletions from the formulary and the policy for the use of antibiotics

Functions of the Pharmacy and Therapeutics committee are clearly understood by the committee members


المعيار الخامس والأربعون







The hospital has a Utilization Review committee that is chaired by the Medical Director or his designee, and has representation from medical, nursing and the paramedical division to ensure optimum use of resources. The monitoring includes and is not limit
MS.45.1 Length of stay for selected types of patients and services.

MS.45.2 Appropriateness of admissions.

Recommendation

Utilization Review committee terms of reference outlines the function and membership

There is monitoring length of stay and appropriateness of admission


المعيار السادس والأربعون




The Utilization Review committee studies all aspects of patient care, including drug usage and observes for:

MS.46.1 Over utilization of resources.
MS.46.2 Under utilization of resources.
MS.46.3 Inefficient utilization of resources.

MS.46.4 Inefficient allocation of resources

Recommendation


The Utilization Review committee meeting minutes reflects the discussion of all aspects of patient care, including drug usage and observes for over utilization, under utilization and inefficient utilization or allocation of resources
.

المعيار السابع والأربعون




The hospital has a Blood Utilization committee that has representation from medical, nursing, and laboratory departments and is chaired by the Medical Director or designee.



Recommendation

The hospital has a Blood Utilization committee that has representation from medical, nursing, and laboratory departments and is chaired by the medical director or designee (formation order and meeting minutes


المعيار الثامن والأربعون

The Blood Utilization committee approves and monitors all policies and procedures that involve the administration of blood in the institution that includes but is not limited to:
MS.48.1 Taking blood samples from patients for type and cross matching; handling, storing and administration of blood products.

MS.48.2 Taking blood from the donors and processing it.




Recommendation
The Blood Utilization committee approves and monitors all policies that includes taking blood samples from patients for type and cross matching; handling, storing and administration of blood products
.
The Blood Utilization committee approves and monitors all policies that includes taking blood from the donors and processing it

المعيار التاسع والأربعون
he committee monitors the Blood Bank’s performance and reviews all the procedures used for collecting, testing, and storing blood and blood products.

Recommendation
The Blood Utilization Review committee monitors and reviews the blood bank performance (meeting minutes).
المعيار الخمسون

The hospital has a Tissue Review committee or ensures that the functions of the Tissue committee are handled by the Chief Pathologist or his designee.

Recommendation
The hospital has a Tissue Review committee or ensures that the functions of the Tissue Review committee are handled by the Chief Pathologist or his designee (formation order and meeting minutes
من مواضيع : الكفاح
الكفاح غير متواجد حالياً  
  رقم المشاركة : [ 4 ]
قديم 10-09-2012, 11:42 AM
افتراضي رد: Required Medical stand. CBAHI

المعيار الحادي والخمسون
The Tissue Review committee or its equivalent ensures that specimens and/or tissues are obtained and handled according to policy and this includes monitoring of:
MS.51.1 The accuracy of the fine needle aspirations.
MS.51.2 Obtaining specimens and transporting them to the laboratory.
MS.51.3 The accuracy and completeness for Histopathology forms: site of biopsy, number of pieces taken, clinical history, previous biopsies etc.
MS.51.4 Any variation between the preoperative, the postoperative and/or the pathological diagnosis.
MS.51.5 Any specimens or tissue removed during surgery are sent to the laboratory for Histopathological examination (e.g. hernia sac or any lump).
MS.51.6 Any “frozen section” specimens obtained from surgery
Recommendation
Written policy on obtaining and handling specimens and /or tissues

Tissue Review committee monitors accuracy of FNA, obtaining and handling specimens, accuracy and completion of histopathology forms, variation between pathological and pre-operating and post-operative diagnosis, any specimen or tissue removed during surgery is sent for histopath examination, and any frozen section specimen obtained
المعيار الثاني والخمسون
The hospital has an Operating Room committee that include the following members: medical staff, nursing staff , OR technician, infection control, and safety personnel
Recommendation
The hospital has an Operating Room committee that include the following members: medical staff, nursing staff, OR technician, infection control, and safety personnel (formation order and meeting minutes
المعيار الثالث والخمسون
The Operating Room committee approves all of the policies for conducting the work in the operating room, to include, but not limited to:
MS.53.1 Infection control measures.
MS.53.2 Supply of equipments and disposables.
MS.53.3 Proper identification of patients, and site of surgery.
MS.53.4 Code of ethical conduct in the operating room to protect patient privacy, and dignity.
MS.53.5 Cancellation rate and designs process to reduce it
Recommendation
Approved Operating Room policies by OR committee that includes infection control measures, supplies, patient identification code of conduct and cancellation
المعيار الرابع والخمسون
There is a hospital policy and process for admitting patients to the organization for the following types of admissions process:
MS.54.1 Routine admissions.
MS.54.2 Urgent and emergency admissions.
MS.54.3 How to handle patients when beds are not available
Recommendation
There are hospital policy and procedures dealing with patient admission (routine, urgent and emergent admission, when no bed is available
المعيار الخامس والخمسون
All patients are admitted under a Consultant’s name, referred to as, “The Most Responsible Physician”(MRP) or the Attending Physician
Recommendation
All medical records review that patients are admitted under a consultants name, as most responsible physician or attending physician

المعيار السادس والخمسون
Physicians receive timely lab results that assist with the decision making for admissions and:
MS.56.1 The laboratory has established turn around times for lab results.
MS.56.2 The laboratory communicates the turn around times to all medical staff.
MS.56.3 The laboratory monitors the turn around times
Recommendation
The laboratory has established Turn Around Time (TAT) that is communicated to all medical staff

The laboratory monitors the Turn Around Time (TAT)
المعيار السابع والخمسون
Clinical practice guidelines are used to guide the clinical care of the patient as appropriate.
Recommendation
Availability of Clinical Practice Guidelines

The medical staff follows the Clinical Practice Guidelines
المعيار الثامن والخمسون
Every physician is assigned a hospital code number and preferably a stamp that is used to identify him/her for medication prescriptions and in all entries in the patient file.
Recommendation
The physicians use the assigned hospital code number and preferably a stamp that is used to identify him/her for medication prescriptions and in all entries in
المعيار التاسع والخمسون
There is at least (1) qualified physician available at all times for each specialty according to the hospital’s scope of service
Recommendation
Availability of on call duty rota
المعيار الستون
Physicians who are “on call” have to be physically available in the hospital within 30 minutes when called.
Recommendation
The physicians are physically available in the hospital within 30 minutes from the call
المعيار الحادي والستون
There is a physician order sheet and only physicians write orders on it.
Recommendation
There is physician order sheet and only physicians write orders on it.
المعيار الثاني والستون
There is sufficient medical staff at all times to meet patient needs and with no significant variation for holidays or weekends coverage.
Recommendation
Staffing plan guidelines/schedule in medical departments that covers weekends and holidays
المعيار الثالث والستون
Medical assessments are complete and accomplished according to the following guidelines:
MS. 63.1 The assessment is done at the time of admission.
MS. 63.2 The attending physician sees patients admitted within 24 hours for routine admissions, within 4 hours for urgent cases, and within 30 minutes for emergencies.
MS. 63.3 The assessment includes the patient’s social and psychological needs.
MS. 63.4 The contents of the history and physical examination are determined by the department heads
Recommendation
Written and updated policy and procedures on medical assessments
There is a complete medical assessment for patients according to their severity index (assessment on admission, attending physician sees patients within 24 hours for routine and 4 hours for urgent cases including social and psychological needs
المعيار الرابع والستون
Patients are screened for nutritional status and nutritional risk on admission (The nutritional screening is documented
Recommendation
There is a documented complete nutritional screening for patients
المعيار الخامس والستون
Patients are screened for pain (acute/chronic) on admission which includes:
MS. 65.1 An assessment appropriate to the patient’s condition.
MS. 65.2 The pain intensity, frequency, location, and the type of pain experienced by the patient (e.g. sharp/dull.)
MS. 65.3 Documentation of the pain assessment in the clinical record.
Recommendation
The pain intensity, frequency, location, and the type of pain experienced by the patient (e.g. sharp/dull) is assessed, managed and documented in the medical record
المعيار السادس والستون
Consultants see their patients in a timely manner and this includes the following:
MS. 66.1 Consultants see their patients at least daily for routine patient needs.
MS. 66.2 Consultants see their patients anytime there is a significant change (deterioration) in the patient’s conditi
Recommendation
The patients are seen by their consultant at least daily for routine and any time while significant change or deterioration happen.
المعيار السابع والستون
The Medical Director ensures that physicians receive current, accurate, and timely communication when test results warrant immediate attention and this includes the following policies:
MS. 67.1 Timely notification to the attending physician regarding histopathology reports.
MS. 67.2 Notification to the physician regarding PANIC laboratory values within one hour and immediately for life threatening results.
MS. 67.3 Notification to the physician regarding PANIC findings of X-ray films within one hour and immediately for life threatening results.
Recommendation
There is a policy for timely notification of lab panic value within one hour and immediately for life threatening results

There is a policy for timely notification of X-ray panic finding within one hour and immediately for life threatening results.


Histopathology test results that require special attention are communicated in accurate and timely manner Logbook/sheet

There are reporting laboratory values on time (laboratory values logbook

There are reporting X-ray results on time (X-ray logbook

المعيار الثامن و الستون
There is a comprehensive plan of care documented in the record for every patient admitted that includes but is not limited to:
MS. 68.1 Information on any surgical procedure required.
MS. 68.2 Any postoperative care needed including required follow up and referrals.
MS. 68.3 All patient education provided to the patient on his/her plan of care and the anticipated outcomes, including the benefits and associated risks (e.g. for proposed surgery, procedures, treatment, etc
Recommendation
Comprehensive plan of care is documented in the patient record
Documented plan of care includes all patient education provided to the patient on his/her plan of care and the anticipated outcomes, including the benefits and associated risks (e.g. for proposed surgery, procedures, treatment, etc
المعيار التاسع والستون
The plan of care is revised and adjusted appropriately according to any change in the patient’s condition and this is documented in the patient record.
Recommendation
The plan of care is revised and adjusted appropriately according to any change in the patient condition and this is documented in the patient medical record
المعيار السبعون
Progress notes are written at least daily and for any change or deterioration in the patient’s medical condition.
Recommendation
Progress notes are written at least daily and for any change or deterioration in the patient's medical condition
المعيار الحادي السبعون
Detailed progress notes are written that include the provisional diagnosis, treatment, and the plan of care.
Recommendation
Files reviewed are documented; daily complete progress notes that include the provisional diagnosis, treatment, and plan of care
.
المعيار الثاني و السبعون
The consultation requests clearly state the question of the consultation or define the services requested, from the consultant, and are handled in a timely and appropriate manner
Recommendation

The consultation requests clearly state the question of the consultation or define the services requested, from the consultant, and are handled in a timely and appropriate manner
المعيار الثالث والسبعون
Consultation requests provide appropriate answers to the issues raised by the Attending physician regarding the plan of care for the patient. Consultants respond within 24 hours for routine cases and 30 minutes for emergency cases after receiving proper
Recommendation
The consultants respond within 24 hours for routine cases and 30 minutes for emergency cases after receiving proper
المعيار الرابع والسبعون
All procedures performed on patients (whether the procedure is done on the ward, in the X-ray department, or in the operating room) have a complete description entered in the medical record and includes the patient’s outcome.
Recommendation
All procedures performed on patients (on the ward, in the X-ray department, or in the operating room) have a complete description entered in the medical record and includes the patient outcome

المعيار الخامس والسبعون
The Medical Director, the Nursing Director/leader, and the department heads work together to ensure that each patient receives the same standard of care when moved from one service to another during the course of treatment and this includes the following
MS. 75.1 Admission and discharge criteria for intensive care.
MS. 75.2 Transfer of patients within the hospital.
MS. 75.3 Admission of patients from the emergency room to the various services within the hospital.
Recommendation
There are policies and forms for (Admission and discharge criteria for intensive care

There are policies and forms for (Transfer of patients within the hospital).
There are policies and forms for (Admission of patients from the emergency room to the various services within the hospital).
المعيار السادس والسبعون
The medical record contains the following information for patients transferred from one service to another:
MS. 76.1 Reason for the patient’s admission.
MS. 76.2 Patient diagnosis.
MS. 76.3 Brief summary of hospitalization (therapies, consultations, non-invasive procedures to date).
MS. 76.4 Medication list.
MS. 76.5 Condition at the time of transfer.
MS. 76.6 Reason for transfer
Recommendation
Medical record documentation of patient transfer information from one service to another (includes: reason for admission, diagnosis, hospitalization summary, medication list, transfer condition, transfer reason
المعيار السابع والسبعون
The Medical Director works with the Nursing Director/leader and appropriate department heads to implement the following policies for Day Surgery:
MS. 77.1 The types of surgical procedures that are performed as Day Surgery.
MS. 77.2 The kinds of patients who are NOT candidates for Day Surgery such as Sickle cell patients and patients who require greater than (2) hours of anesthesia.
MS. 77.3 The assessments required prior to Day Surgery are followed.
MS. 77.4 The process for patients who have to be admitted to the hospital from Day surgery
Recommendation
Implementation of Day Surgery policies
Day surgery policies include the types of surgical procedures that are performed as Day Surgery,the kinds of patients who are NOT candidates for Day Surgery such as Sickle cell patients and patients who require greater than (2) hours of anesthesia, the assessments required prior to Day Surgery are followed, the process for patients who have to be admitted to the hospital from Day surgery
المعيار الثامن والسبعون

Patients who are admitted for surgery have a medical assessment that includes a history and physical examination prior to surgery.
Recommendation
There are medical assessments for patients who are admitted for surgery
المعيار التاسع والسبعون
Patients who are admitted for surgery have appropriate diagnostic tests performed and the results documented in the medical record prior to surgery
Recommendation
There is pre operative investigation and results documented for patients who are admitted for surgery

المعيار الثمانون
Patients who are admitted for surgery have an anesthesia assessment prior to surgery and includes:
MS. 80.1 Notifying the anesthesia staff in a timely manner that allows a complete anesthesia assessment to be completed (unless there is an extreme emergency).
MS. 80.2 Determining if patient is a good candidate for surgery based on findings.
MS. 80.3 Recording the anesthesia assessment in the medical record.

Recommendation
There is medical record documentation of complete and timely preoperative anesthesia assessment (except during extreme emergencies) to determine good candidates for surgery


المعيار الحادي والثمانون
No patient has surgery (except extreme emergencies) without the following documents in the chart:
MS. 81.1 History and physical examination.
MS. 81.2 The preoperative diagnosis.
MS. 81.3 Laboratory and X-ray results if applicable.
MS. 81.4 Signed consent.
Recommendation
All patients undergoing surgery (except extreme during emergencies) have a preoperative assessment which include; History and physical examination, the preoperative diagnosis, Laboratory and X-ray results if applicable, signed consent
المعيار الثاني والثمانون
Physicians ensure that the following process is implemented for patients who will receive blood and/or blood products and:
MS. 82.1 Provides information and education to the patient about the need for blood, and the benefits and the associated risks involved in receiving blood.
MS. 82.2 Obtains consent from the patient and documenting this in the patient’s medical record.
MS. 82.3 Administration of blood strictly according to hospital policy as outlined by the Blood Utilization Review committee.
MS. 82.4 Monitors for any side effects or disease transmitted resulting from blood administration
Recommendation
There is Patient education regarding benefits and risk of transfusion

There is a signed consent from the patient

The administration of blood is in line with the policy approved by the Blood Utilization Review committee.

There are monitors for any side effects or disease transmitted resulting from blood administration.
المعيار الثالث والثمانون
The Attending physician or his designee provides adequate pain relief for patients following surgery and this includes:
MS. 83.1 A pain assessment by the attending physician or his/her designee after the patient’s surgery.
MS. 83.2 Adjustments to pain medications according to the patients’ response by the attending or his designee
Recommendation
There is adequate pain relief after surgery through pain assessment and adjusting pain medications according to patient response
المعيار الرابع والثمانون
The hospital has informal or formal arrangements with other institutions to accept patients for transfer when the care required is beyond the scope of service provided by the hospital and includes communication of arrangements for care with other institutions to the concerned department heads.
Recommendation
Written policy and procedures on patient transfer to other hospitals when the required care is beyond the scope of service provided

There is transfer communication between the transfer and receiving hospital
.
المعيار الخامس والثمانون
Arrangements for patient transport include an estimation of the length of time required for transport, and an assessment of patient needs during transfer and includes:
MS. 85.1 An assessment of the patient’s needs for Medivac-transfer.
MS. 85.2 Communication of the patient’s needs during transfer to appropriate staff.
MS. 85.3 An attending physician determining the patient’s need for transfer to another institution, the most suitable time for transfer, and if the receiving institution is able to meet the patient’s needs.
MS. 85.4 Staff accompany patient are chosen according to patient condition
Recommendation
There is a comprehensive assessment of patient needs during transfer..
المعيار السادس والثمانون
Receiving institutions receive the necessary information to provide care to the patient and this includes the following:
MS. 86.1 Reason for the patient’s admission.
MS. 86.2 Patient diagnosis.
MS. 86.3 Brief summary of hospitalization (therapies, consultations, non-invasive procedures to date).
MS. 86.4 Medication list and time of last dose given.
MS. 86.5 Condition at the time of transfer.
MS. 86.6 Reason for transfer.
MS. 86.7 Copy of the patient’s Laboratory investigation and X‑rays are sent with the patient to avoid further delay in treatment
Recommendation
There is a completed hospital transfer form documenting the following; reason for the patients admission, diagnosis, summary of hospitalization, medication list, condition at the time of transfer, reason for transfer, and copy of the patients Laboratory investigation and X-rays are sent with the patient to avoid further delay in treatment
المعيار السابع والثمانون
Transfers are done quickly and safely especially in emergency cases (e.g. trauma, or cardiac emergency) and the medical staff ensure that the patient’s needs are met by:
MS. 87.1 Assigning a qualified physician or paramedic (as appropriate) to accompany the patient and handle any emergency that might happen during transfer.
MS. 87.2 Assigning a physician certified in BCLS (preferably ACLS) to accompany all critically ill patients or intubated patients.
MS. 87.3 Having adequate equipment and supplies on the ambulance
Recommendation
Availability of Physician certified in BCLS (preferably ACLS) for emergency transfer

Availability of fully equipped Ambulance
Availability of a qualified physician or paramedic for emergency transfer
المعيار الثامن والثمانون
The patient is continuously monitored by qualified physician during the transfer
Recommendation
There is continuous monitoring of patient during transfer by a qualified physician
من مواضيع : الكفاح
الكفاح غير متواجد حالياً  
  رقم المشاركة : [ 5 ]
قديم 10-09-2012, 12:28 PM
افتراضي رد: Required Medical stand. CBAHI

المعيار التاسع والثمانون
The hospital has a written policy and procedure regarding the acceptance of patients from other hospitals and the transfer of inpatients to other hospitals.
Recommendation
There is a written policy and procedure for transfer patients to other hospitals.
المعيار التسعون
The Attending physician ensures that patient’s discharge needs are met and communicates the patient’s readiness for discharge home to appropriate hospital staff.

Recommendation
There is communication between hospital staff and the attending physician for proper patients discharge process
المعيار الحادي و التسعون
The Attending physician educates his / her patient on the following issues prior to discharge:

MS. 91.1 The patient’s illness and how to provide self-care.
MS. 91.2 Times to take the medication and any special instructions.
MS. 91.3 Any equipment that the patient will use at home.
MS. 91.4 When to call the physician and how to obtain “urgent” care.
MS. 91.5 Why the patient needs to see any sub specialist. (If applicable).
MS. 91.6 The reason the patient needs to be transferred to another institution (if applicable).
MS. 91.7 Involving the family members whenever patients cannot fully understand the information provided to them (if applicable).
MS. 91.8 Documenting all education and information provided to the patient and/or family in the medical record
Recommendation
There is patient and family education prior to discharge.(patient illness, self care and support, medication use, equipment, emergency all, referral, transfer
المعيار الثاني والتسعون
The Attending physician ensures that continuity of care occurs after discharge or referral by:
MS. 92.1 Assigning the follow up appointment for the patient.
MS. 92.2 Arranging any referral services for the patient.
MS. 92.3 Communicating with other receiving physicians in case of transfer


Recommendation
There is continuity of care after discharge

المعيار الثالث والتسعون
After the patient is discharged, a discharge summary is written in the medical record by the Attending physician and includes:
· MS. 93.1 The reason for the patient’s admission.
· MS. 93.2 The patient’s diagnosis.
· MS. 93.3 A brief summary of hospitalization (therapies, consultations, non-invasive interventions and results of any important diagnostic testing).
· MS. 93.4 A list of medications used.
· MS. 93.5 Any surgery or procedures performed.
· MS. 93.6 The outcome of surgery and treatment.
· MS. 93.7 The patient’s condition at discharge.
· MS. 93.8 All the medications to be taken by the patient after discharge.
· MS. 93.9 Any special care the patient requires after discharge.
MS. 93.10 A copy of the discharge summary kept by the medical record department
Recommendation
There is a comprehensive discharge summary report provided to the patient (reason for admission, diagnosis, hospitalization summary, medication list, outcome of surgeries, discharge condition, discharge medications, special care, copy of discharge summary
من مواضيع : الكفاح
الكفاح غير متواجد حالياً  
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