Points Included in the Evaluation of a Quality Programme
The JCI Hospital standards manual provides vital points that must be included in the evaluation of a quality improvement program. They include the management of quality and patient safety activities, measuring selection and data collection, analysis and validation of the measurement data, and sustaining quality improvement. International patient safety entails various points such as correct patient identification, improving effective communication, ascertaining correct site, procedure, and patient surgery. Others include reducing the risk of healthcare-related infections and patient harm that results from falling (Ransom 9).
Standards for the Points Included in Evaluation of a Quality Program
Each of the aforementioned points comes with standards that are considered during the evaluation of the quality healthcare programs. This section identifies the details on the standards. Under the four points in the quality and safety improvements, there is a totality of twelve standards. The wellbeing of the patient requires the individual to possess an apt knowledge about the execution of the healthcare plan. The quality Standard QPS.1 offers support and coordinates the departmental leaders with a view of setting up the hospital priorities for improvement as well as implementing the programs for training the staff in the roles involved in quality management. Regular communication is also paramount to the success of the quality program (Avery et al. 79). The Standard QPS.2 section requires the quality program to support the selection of the measures throughout the hospital besides coordinating and integrating measurement into the systems of the facility. The quality and safety program should also integrate event-reporting systems into the safety culture to facilitate the coordination of the improvements and solutions. Lastly, the program tracks the progression of the planned collection of data regarding the hospital priorities (Ransom 12)
Standard QPS.3 requires the quality and patient safety program to use the most relevant and current scientific information to support professional care, clinical education, research, and management. Standard QPS.4 is a section of the data analysis and validation process. It includes the aggregation and examination of data with a view of supporting patient care, hospital management, and quality control using external databases. The quality Standard QPS.5 involves the data analysis process that includes the annual determination of hospital-wide priority improvements with a focus on costs and efficiency (Ransom 13). This part requires the quality and safety program staff to work together with other units including the HR, IT, and finance to decide the type of relevant data to be gathered. An analysis report is then provided for the leaders to determine the quality improvement levels attained.
The quality Standard QPS.6 involves the authentication of internal information. The program must validate the data internally before availing the results to the public. Specific conditions such as the implementation of the clinical measure, change of subject of data as intended, and improvement of data handling processes among others must be met before the authentication process. Standard QPS.7 requires the hospital to use a defined process for the identification and management of the sentinel events. This standard requires the quality and safety program to have robust processes for the identification and management of unexpected incidents such as the death of a patient and medical errors that result in fatal injuries. The hospital program should establish the cause of the sentinel incidences in a period provided by the leaders.
Standard QPS.8 entails the analysis of the unanticipated outcomes or changes with a view of establishing the best area for improvement. An intensive analysis is instigated in the event that the levels, patterns, and/or trends are perceived to affect the expected outcomes and other conventional standards. The unexpected events include transfusion reactions, adverse drug effects, and medical errors among others. The Standard QPS.9 category requires the hospital to employ defined processes in the identification and analysis of near-miss events to be reported, the process of reporting near-miss, and actions to take in case of both miss and near-miss.
The Standard QPS.10 falls under point four. It requires that quality improvement is attained and sustained. These improvements ought to be planned, tested, and implemented besides availing the data to demonstrate improvement. The hospital leadership should do the documentation of the improvements. The Standard QPS.11 section explicates that the program should have a risk management system to identify the adverse events and risks affecting the patients. The system’s roles include the identification, management, reporting, prioritization, and investigation of risks.
The international safety standards comprise numerous goals that include effective communication, accurate patient identification, improvement of the safety alert medications, ensuring correct site, appropriate procedures, accurate patient surgical operations, and reducing the risks of healthcare-related infections (Avery et al. 80). The program identifies the communication systems that are effective for the flow of information between the patients and hospital departments. High alert medications require the facility to implement strategies that guarantee safety and health promotion through proper storage, prescription, preparation, administration, and monitoring processes. The hospital provides evidence-based hygiene protocols to eliminate the risks of healthcare infections. In addition, it should identify patients with conditions associated with falls with a view of devising the appropriate assessment techniques and monitoring schedules to prevent such incidents.
Works Cited
Avery, Mark, Liz Fulop, Eugene Clark, Ron Fisher, Rodney Gapp, Gustavo Guzman, Carmel Herington, Ruth McPhail, Arthur Poropat and Nerina Vecchio. “Towards an Enhanced Framework for Improvement in Quality Healthcare: A Thematic Analysis of Outstanding Achievement Outcomes in Hospital and Health Service Accreditation.” Asia-Pacific Journal of Health Management 7.2(2012): 79-85. Print.
Ransom, Scott. The healthcare quality book: vision, strategy, and tools. Chicago: Health Administration Press, 2008. Print.