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
services
of the Health care
PROVIDERS CONCERNS

To provide care as per established
norms

Adequate resources

Self
satisfaction
with
the
final
outcome

Should contribute to enhancement of
skills,
competence
experience
and
add
to
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
ation
Identify
values
Take action
Identify standards
criteria
Choose action
Secure measurement
Identify
course of
action
Make
measurem
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
administered by an independent body
 The
is
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 !!!!!