NABH AND NURSES CONTRIBUTION TO QUALITY Mrs. Justina Nancy Mendonca Chief of Nursing Services...

NABH AND NURSES CONTRIBUTION TO QUALITY

Mrs. Justina Nancy MendoncaChief of Nursing ServicesColumbia Asia Referral HospitalBangalore

ISQUA ACCREDITATION

India has become the 12th country in the world to be accredited by the International Society for Quality in Health Care (ISQua) for four years. The accreditation follows the submission of the hospital standards set by NABH to ISQua.

STANDARDS

Access Assessment & Continuity of care

Care of Patients

Management of medication

Hospital Infection control Patient

Centered

Patients Rights and Education

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1. ACCESS, ASSESSMENT AND CONTINUITY OF CARE (AAC).

15 standards Services display Patient registration. Transfer / Referral of patients. Admission of patients – Informed Consent. and Relative education. Initial assessment / Regular reassessment. Laboratory services to patient need – safety /QI. Imaging services – safety /QI. Patient care continuous /multidisciplinary in nature Discharge process - documents and discharge

summary.

2. CARE OF PATIENTS (COP). 18 standards

Uniform care of Patients in all settings. Emergency/Ambulance services – CPR guidelines

/Blood product usage. ICU standards –Care of Vulnerable patients P&P on High risk pregnancy, Pediatrics, Anesthesia,

Surgical, Pain management, Restrains, Rehabilitation, research activities, nutritional and end of life care.

4. MANAGEMENT OF MEDICATION (MOM) . 13 standards

P&P - pharmacy services/usage of medication - hospital formulary - storage - prescription - safe dispensing - administration - patient and family educated on safe medication.

Monitoring after medication – food drug interaction - policies in narcotic drugs and psychotropic - chemotherapy - radioactive drugs - prosthesis implantation and use of medical gases.

4. PATIENT RIGHT AND EDUCATION (PRE). 5 standards

Organization protection to patient and family rights during care.

Support to patient's family for decision making process.

Documented - consent - for informed decision making.

Information on health needs to patient's family. Cost of care

5. HOSPITAL INFECTION AND CONTROL (HIC). 9 standards

Well designed comprehensive infection control programme – manual- surveillance activities.

Prevention of Hospital Associated infection (patients & employees).

Adequate resources for IC programme. Control of out break of infection. Sterilization activities - biomedical waste

management. Training of employees on IC

STANDARDS

Management Centered

Continuous Quality Improvement

Responsibility of management

Facility Management & Safety

Human resource Management

Information Management System

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6. CONTINUOUS QUALITY IMPROVEMENT (CQI).

6 standards Quality improvement programme QI indicators and Monitoring – patient care areas QI indicators and Monitoring – Management areas QI programme supported by the management. Audit of patient care services. Sentinel events analysis.

7.RESPONSIBILITIES OF MANAGEMENT (ROM).

5 standards Defined management responsibilities. Documented service provided. Leaders manage in ethical manner. Qualified/Experienced person heads the

organization. Ensures pt safety and knows the risk management

issues.

8. FACILITY MANAGEMENT AND SAFETY (FMS). 9 standards

Organization is aware of rules and regulations complies.

Safe environment for patients/families/employees. Clinical and support service equipment

management. Plan for Fire and Non fire emergencies. No smoking policy. Plan for community emergencies - Epidemics -

disasters - hazardous material management.

9.HUMAN RESOURCE MANAGEMENT (HRM).

13 standards Human resource planning documented. Orientation of newly joined. Ongoing training. Job responsibilities. Appraisal documented. Disciplinary procedure. Grievance handling. Health needs of the employees. Personal records. Medical professional - Nursing staff – credentials.

10. INFORMATION MANAGEMENT SYSTEM (IMS).

7 standards Data information to all patient care providers. Process of management of data. Medical record keeping. EMRD reflects continuity of care. Records confidentiality - integrity – security of

information. Policy and procedures for retention time of records,

data and information. Medical audits.

Nurses Contribution

•Assessment and reassessment. •Patient rights•Management of medications.•Infection control•Medical records.•Patient safety•Emergency and disaster.

•Patient care related-

•Code Blue•ICU protocols•Restraint•Vulnerable•Pain.

•All Infection Control Policies.•Adverse drug events and reactions•Adverse events.•Patient Identification•Staff Hazards.

Nurses Contribution

•Admission and discharge.•Inter and intra hospital transfers.•Assessment and reassessment•Informed consent.•Confidentiality and privacy.•Patients rights.•Complaint handling.

•Prescription standards.•Medication administrations.•Verbal orders.•High risk medication •Labeling and storage.•Narcotics.•Sound alike look alike medicines.

No Sentinel Event.

•Time out practice .•Pre op Checklist.•Identification bands.•Theater Record.•Surgical Site Marking.•Surgical safety checklist.•Allergy Bands also started.•Regular trainings.•Regular audits.

No Sentinel Event.

•Time out practice .•Pre op Checklist.•Identification bands.•Theater Record.•Surgical Site Marking.•Surgical safety checklist.•Allergy Bands also started.•Regular trainings.•Regular audits.

Sentinel Events Being

•PARA AESTHESIA FOLLOWING SPINAL ANESTHESIA.•SURGERY ON WRONG SIDE AND•WRONG PATIENT•WRONG SURGICAL PROCEDURE •ADVERSE DRUG REACTION•DEATH DURING A PLANNED SURGERY

Sentinel Events Being

•PARA AESTHESIA FOLLOWING SPINAL ANESTHESIA.•SURGERY ON WRONG SIDE AND•WRONG PATIENT•WRONG SURGICAL PROCEDURE •ADVERSE DRUG REACTION•DEATH DURING A PLANNED SURGERY

Sentinel Events

INFECTION CONTROL

Quality Indicators. Steps of Hand hygiene. BMW act and segregation of waste. Cleaning protocol. Staff vaccination. Spill kits. Isolation protocols. Needle stick injury.

NURSING QUALITY INDICATORS

Call bell response. Patient Fall. Medication error. Bedsore. Completion of crash cart checklist. Completion of nursing initial assessment.

DISASTER MANAGEMENT

Code Blue. Code yellow. Code Red. Code Pink.

HOW TO FACE AN AUDIT

Know your hospital procedure and policies. Know your infection control manual. Awareness on hospital set up and your unit

orientation. Awareness of emergency management. Departmental flow chart. Legal issues. Job description and HR policies.

THANK YOU