MSQH Hospital Accreditation Standards 5 th Edition Ms

MSQH Hospital Accreditation Standards 5 th Edition Ms Rebecca John MSQH Project Manager

MALAYSIAN HOSPITAL ACCREDITATION STANDARDS Ø The MSQH Hospital Accreditation Standards provide the basis for assessment of healthcare facilities and services, and are applicable to all types of hospital both public and private, large and small, urban and rural.

MSQH Hospital Accreditation Standards No Std 4 th Edition No Std 5 th Edition Organizational wide Service Standards 1 1 Governance, Leadership and Direction 2 2 Environmental and Safety Services 3 3 Facility Management and Safety 4 4 Nursing Services 5 5 Prevention and Control of Infection 6 6 Patient and Family Rights 7 7 Health Information Management System (HIMS)

MSQH Hospital Accreditation Standards No Std 4 th Edition No Std 5 th Edition Service Standards 8 8 Emergency Services 9 9 Clinical Services (Generic) 9 9 Clinical Services – Non Specialist Facility 10 9 A Cardiology Services 10 9 A Clinical Services – Medical Related 11 9 B Oncology Services 11 9 B Clinical Services – Surgical Related 12 9 C Obstetrics & Gynaecology Services 13 9 D Paediatric Services 14 9 E Cardiology Services 15 9 F Oncology Services 16 10 Anaesthetic Services 12 10 Anaesthetic Services

MSQH Hospital Accreditation Standards No Std 4 th Edition No Std 17 11 5 th Edition Service Standards 13 11 Operating Suite Services 14 12 Ambulatory Care Service 18 12 Ambulatory Care Services 15 13 Critical Care Services (Generic) : ICU, CCU, NICU, PICU & Haemodialysis 19 13 Critical Care Services: ICU/CICU/CRW/HDU/Burns Care Unit 16 13 A Critical Care Services: Labour Delivery Services 20 13 A Critical Care Services : SCN/NICU/PHDW Operating Suite Services

MSQH Hospital Accreditation Standards No Std 4 th Edition No Std 5 th Edition 21 13 B Critical Care Services : Labour/Delivery Services 22 13 C Chronic Dialysis Treatment Service Standards 17 14 Radiology/Diagnostic Imaging Services 23 14 Radiology/Diagnostic Imaging Services 18 15 Pathology Services 24 15 Pathology Services 19 16 Blood Transfusion Services 25 16 Blood Transfusion Services

MSQH Hospital Accreditation Standards No Std 4 th Edition No Std 5 th Edition Service Standards 20 17 21 17 A 22 17 B 23 17 C 24 17 D 25 17 E Rehabilitation Medicine Services Allied Health Professional Services - Physiotherapy Services Allied Health Professional Services - Occupational Therapy Services Allied Health Professional Services - Dietetic Services Allied Health Professional Services – Speech Language Pathology Services 26 17 27 17 A Allied Health Professional Services Physiotherapy Services 28 17 B Allied Health Professional Services Occupational Therapy Services 29 17 C Allied Health Professional Services Dietetic Services 30 17 D Allied Health Professional 31 Services – Audiology Services Rehabilitation Medicine Services Allied Health Professional Services – Speech - Language Therapy Services 17 E Allied Health Professional Services – Audiology Services

MSQH Hospital Accreditation Standards No Std 5 th Edition 17 F Allied Health Professional Services – Optometry Services 17 Allied Health Professional G Services – Health Education Services 32 17 F 33 17 G Allied Health Professional Services – Optometry Services Allied Health Professional Services – Health Education Services 28 17 H Allied Health Professional Services – Medical Social Services 34 17 H Allied Health Professional Services – Medical Social Services 29 17 I Allied Health Professional Services – Psychology Counselling Services 35 17 I Allied Health Professional Services – Psychology Counselling Services 30 17 J Allied Health Professional Services – Clinical Psychology Services 36 17 J Allied Health Professional Services – Clinical Psychology Services 4 th Edition Service Standards 26 27

No Std 4 th Edition No Std 5 th Edition MSQH Hospital Accreditation Standards Service Standards 31 18 Pharmacy Services 37 18 Pharmacy Services 32 19 Central Sterile Supply Services 38 19 Central Sterile Supply Services 33 20 Housekeeping Services 39 20 Housekeeping Services 34 21 Linen Services 40 21 Linen Services 35 22 Food and Dietary Services 41 22 Food Services 36 23 Forensic Medicine Services 42 23 Forensic Medicine Services 37 22 A Mortuary Services 43 23 A Mortuary Services 38 24 Standards for General Applications 44 24 Standards for General Application - Generic 45 24 A Standards for Clinical Research Centre

Outline of Standards 5 th Edition The MSQH Hospital Accreditation Standards 5 th Edition has both the standards and the assessment tool in the same document. This document is also termed the MSQH Hospital Accreditation Guide. The sections of the Guide includes the following: i) Title of the Service Standard ii) Preamble b

Outline of Standards 5 th Edition iii) Service Standards iv) Criteria for compliance - Core Criteria* * A number of criteria have been identified as core to the standards. They include core processes that impact patient/staff safety and compliance to regulatory requirements. v) Notes/Explanation vi) Evidence of Compliance

Outline of Standards 5 th Edition vii) Facility Comments viii) Self Rating ix) Surveyor Findings & Comments x) Surveyor Summary & Overall Rating

Outline of Standards 5 th Edition Ø 5 Areas of Focus/Topics (except for Standard No: 6) - Organisation and Management - Human Resource Development and Management - Policies and Procedures - Facilities and Equipment - Safety and Performance Improvement Activities & Special Requirements for specific standards The Standards are organised into

Outline of Standards – Topic: Special Requirements • • Std. 2: Std. 3: • Std. 7: Std. 9 A: • • • Std. 9 B: Std. 10: Std. 14: Std. 19: Std. 22: • Environmental and Safety Services Facility and Biomedical Equipment Management and Safety Health Information Management System (HIMS) Cardiology Services – invasive & non invasive cardiac laboratories Oncology Services Anaesthetic Services Radiology/Diagnostic Imaging Services CSSS Food Services

Outline of Standards - Topic Standard No. 6: Patient & Family Rights; the areas of focus are: 1. Patient and Family rights 2. Informed consent 3. Research 4. Organ donation 5. Patient Centred Care

Standards & Self Assessment Tool

Outline of Standards Every Service Standard is categorized by Title of Service & Preamble: SERVICE STANDARD 1 : GOVERNANCE, LEADERSHIP AND DIRECTION PREAMBLE : Each Facility shall have a body ultimately responsible for all aspects of the Facility’s operations. This is commonly called the Board of Directors/Facility Management or other similar name. For the purposes of these Standards, this group shall be called “The Governing Body”. The Governing Body may delegate its duties and functions to the Person In Charge (PIC) of the Facility who shall be responsible for the organisation, management and control of the Healthcare Facility and services. For private healthcare facilities, a license or registration is required which relates to the services.

Outline of Standards Every Service Standard is categorized by Topic: Topic 1. 1: ORGANISATION AND MANAGEMENT Standard 1. 1. 1 The Governing Body shall adopt a governing framework that constitutes the internal legislation that will meet the particular needs and complexities of the management of the Facility and the range of services. These may be called Facility Operational Policies and Medical Staff By-Laws, which include Rules and Regulations, Terms of Reference, Policies, Resolutions or other similar terms and they shall govern the actions of the Board and Management of the Facility. The governing framework is essential for the governance of the Facility.

Outline of Standards CRITERIA FOR COMPLIANCE: 1. 1 The Governing Body shall ensure that the Vision, Mission and values statements, goals and objectives are identified, clearly documented and measurable; these reflect the Facility’s roles and aspirations in the community that it serves. These statements are monitored, reviewed and revised as required accordingly and communicated to all staff.

Outline of Standards EVIDENCE OF COMPLIANCE 1. Vision, Mission and values statements, goals, and objectives of the Facility are available; endorsed and dated by the Governing Body. 2. Evidence of planned reviews of the above statements 3. These statements are communicated to all staff (orientation programme, minutes of meeting, etc). 4. Achievement of goals and objectives are monitored, reviewed and revised accordingly.

Outline of Standards- Core Criteria 1. 1. 1. 3 CORE The Governing Body shall adopt a governing framework in accordance with statutory and other legal requirements. Evidence of Compliance : 1. License to operate (Private Healthcare Facility)/Gazetement letters and supporting documents (Public Healthcare Facility) 2. Appointment of full time Person In Charge (PIC) in accordance with the Fourth Schedule in Private Healthcare Facilities and Services Act 1998 and Regulations 2006. 3. Facility Operational Policies 4. Medical Staff By-Laws

Outline of Standards 3. Notes/Explanation Additional information to clarify the requirements/guide what information to look for. e. g. Note: Staff personal record may be kept in Human Resource Department as per Facility policy.

C MSQH Copyright

MSQH Hospital Accreditation Standards (GENERIC) Interpretation of MSQH Hospital Accreditation Standards - 5 th Edition

Organization and Management 1. Standard The …………… Services shall be organised, directed and coordinated with other services in the Facility according to the goals and objectives of the Facility to meet the needs of the patient population being served. .

Organization and Management 1. 1 Criteria for Compliance Ø Ø Ø Vision, Mission and values statements of the Facility are accessible. Goals and objectives that suit the scope of the ………… Services are clearly documented and measurable that indicates safety, quality and patient centred care. These reflect the roles and aspirations of the service and the needs of the community. These statements are monitored, reviewed and revised as required accordingly and communicated to all staff. .

Organization and Management Evidence of Compliance 1. Vision, Mission and values statements of The Facility 2. Goals and objectives of the Services 3. Evidence of planned reviews of the above statements. 4. These statements are communicated to all staff 5. Achievement of goals and objectives are monitored & revised

Organization and Management 1. 2 Criteria for Compliance (Core) There is an organisation chart which: Ø provides a clear representation of the structure, functions and reporting relationships between the PIC, Head of the Services, Consultants, medical practitioners and staff of the Services Ø accessible to all staff and clients Ø is revised when there is a major change in the organisation, functions, reporting relationships & staffing patterns

Organization and Management Evidence of Compliance 1. Clearly delineated current organisation chart with line of functions and reporting relationships 2. Organisation chart is endorsed, dated and accessible 3. The organisation chart is revised when there is a major change

Organization and Management 1. 3 Criteria for Compliance Ø Regular staff meetings are held between Head of Service and staff to discuss issues and matters pertaining to the operations of the ………. Services Ø Minutes are kept; decisions and resolutions made during meetings made accessible & communicated to all staff and implemented

Organization and Management Evidence of Compliance 1. Minutes are accessible, disseminated & acknowledged by the staff. 2. Attendance list of members 3. Frequency of meetings as scheduled. 4. Discussion and resolutions are implemented.

Organization and Management 1. 4 Criteria for Compliance Ø The Head of the Services is involved in clinical governance and patient management. Evidence of Compliance 1. Departmental, unit or committee meetings are chaired by Head of Services. 2. Clinical procedures are endorsed by the Head of Services.

Organization and Management 1. 5 Criteria for Compliance Ø The Head of the Service is involved in the planning, justification and management of the budget and resource utilisation of the services. Evidence of Compliance 1. Minutes of Facility-wide management meetings. 2. Documented evidence on request for allocation of budget and resources (staffing, equipment, etc) 3. Approved budget and resources.

Organization and Management 1. 6 Criteria for Compliance Ø The Head of the Service is involved in the appointment and /OR assignment of the staff Evidence of Compliance 1. Records on staff interview (if applicable) 2. Appointment/assignment letter of Head of Service 3. Job description of Head of Service 4. Duty roster 5. Records on staff deployment

Organization and Management 1. 7 Criteria for Compliance Ø Appropriate statistics and records shall be maintained and used for managing the services and patient care purposes.

Organization and Management Evidence of Compliance Records are available but not limited to the following: a) workload/census; b) annual report; c) accident/incident reports; d) staffing number and staff profile; e) staff training records; f) data on performance improvement activities, including performance indicators

Organization and Management 1. 8 Criteria for Compliance Where the ………. Services provides clinical experience for students of medicine and paramedical sciences, a comprehensive documented agreement between the Facility and the educational institution shall exist detailing the responsibilities of all parties. Ø

Organization and Management Evidence of Compliance 1. Valid letter of intent (Mo. U) or request/posting and assigned supervisor 2. Ratio of Clinical Instructor (CI) and students commensurate with the number of students 3. Student allocation roster or programme

Organization and Management 1. 2 Standard Where the Facility does not have the facilities or medical ability to render optimum care to the patient, arrangements shall be made for transfer to another facility or appropriate treatment centre after performing basic resuscitation or stabilization

Organization and Management 1. 2. 1 Criteria for Compliance When arranging for patient to be transferred to a receiving facility, there is evidence that: communication between the facilities is established and the transfer is mutually agreed Ø Ø appropriately qualified staff accompanies the patient when clinically deemed necessary; Ø relevant clinical details need to be documented and communicated to the accompanying staff and the team receiving the patient; Ø clinical accountability and continuity of care is in place.

Organization and Management Evidence of Compliance 1. Copy of referral letter is available 2. Contents in the referral letter are appropriately written; including acceptance of the patient by the referred facility and name of receiving person. 3. Ambulance transfer and in-transit records

Organization and Management 1. 3 STANDARD Where external services are used to assist in the operations of the Facility, these contracted or referral services shall meet the MSQH Standards of Accreditation

Organization and Management 1. 3. 1 Criteria for Compliance There are written agreements on the appointment and provision of external services to the Facility, which include the following: Ø The services shall meet all patient and environmental safety standards contained in the MSQH Standards of Accreditation, regardless of where the activities occur, on-site and off-site. Ø There is detailed documentation on the external aspects of the services

Organization and Management Evidence of Compliance Ø Service contracts have appropriate terms and conditions Ø date and duration of contract; Ø system for quality control of outsourced services (visit to off-site services, recognised certification); Ø procedures for managing shortfall in service; Ø Involvement in performance measurement of the relevant services provided to the Healthcare Facility.

Human Resource Development & Management 2. Standard ………. Services shall be directed by and The staffed with suitably qualified and trained personnel to achieve the goals and objectives of the services.

Human Resource Development & Management 2. 1 Criteria for Compliance The Head and staff of the…. . Services shall be qualified by education, training, experience individuals and certification to commensurate with the requirements of the various positions.

Human Resource Development & Management Evidence of Compliance: 1. Records on credentials of Head of Service and staff required to fill up the posts within the service (to match the complexity of the Facility and services) 2. Appointment/assignment letters 3. Certification, Valid professional Annual Practising Certificate (APC), National Specialist Registration (NSR). 4. Training and competency records

Human Resource Development & Management 2. 2 Criteria for Compliance Ø The Authority, responsibilities of the Head of the ……………Services are clearly delineated and documented in a letter of appointment Evidence of Compliance 1. Appointment /assignment letter for Head of Service 2. Description of duties and responsibilities

Human Resource Development & Management 2. 3 Criteria for Compliance Ø Sufficient numbers of personnel and support staff with appropriate qualifications are employed to enable the services to meet the documented purposes

Human Resource Development & Management Evidence of Compliance 1. Compliance with current norms - Policy of the Ministry of Heath (where applicable), PHFS Act 1998, Regulations 2006 2. Number of staff and qualification commensurate with workload 3. Staffing pattern 4. Duty roster 5. Census and statistics

Human Resource Development & Management 2. 4 Criteria for Compliance Credentialing and Privileging Ø Clinical staff appointments, re-appointment, credentialing and privileging shall be documented. These shall meet the requirements of the relevant Acts and Regulations. Ø There is documented evidence of appropriate training and competency for the granting of clinical privileging. The criteria for determining privileges are specified and documented.

Human Resource Development & Management Evidence of Compliance Ø Documented policies and procedures are established to govern the credentialing and privileging processes Ø Compliance with policy and criteria for credentialing and privileging Ø Annual Practising Certificate (APC), National Specialist Register (NSR) certificates and privileging certificates. Ø Availability of the list of procedures requiring

Human Resource Development & Management 2. 5 Criteria for Compliance Ø Documented evidence of privileges conferred by the Governing Body is available and accessible to relevant staff at point of care Evidence of Compliance Ø Formal letter of assignment or certificate of privileging with stipulated timeline are issued and reviewed accordingly. Ø Updated list of staff with privileges conferred is made accessible at point of care.

Human Resource Development & Management 2. 6 Criteria for Compliance Ø Clinical staff performs within the privileges conferred Evidence of Compliance Ø Verification of procedures performed by individuals at point of care within the awarded privileging rights with evidence of: a) list of procedures privileged b) clinical notes

Human Resource Development & Management 2. 7 Criteria for Compliance Ø There are written and dated job description for all categories of staff that include: a) b) c) d) qualifications, training, experience and certification required for the position lines of authority, accountability, functions and responsibilities reviewed when required and when there is a major change in duties and responsibilities, qualifications, privileges granted, administrative and clinical functions

Human Resource Development & Management Evidence of Compliance 1. Updated specific job description is available for each staff 2. Job description includes specialisation skills 3. Relevant privileges granted where applicable 4. The nature and scope of work of each staff is specified 5. The job description is acknowledged by the staff and signed by the Head of Service and dated.

Human Resource Development & Management 2. 8 Criteria for Compliance Ø Personnel records on training, staff development, leave and others are maintained for every staff. Note: Staff personal record may be kept in Human Resource Department as per Facility policy.

Human Resource Development & Management Evidence of Compliance Staff personal records include: a) staff biodata; b) qualification and experience; c) evidence of current registration; d) training record; e) competency record and privileging; f) leave record; g) confidentiality agreement.

Human Resource Development & Management 2. 9 Criteria for Compliance Ø There is a structured orientation programme for all newly appointed staff to the Emergency Services including medical practitioners and for those new to specific areas.

Human Resource Development & Management Evidence of Compliance 1. Policy requiring all new staff to attend a structured orientation programme. 2. Records on structured orientation programme 3. Orientation module 4. List of attendance

Human Resource Development & Management 2. 10 Criteria for Compliance Ø There is evidence of training needs assessment and staff development plan which provides the knowledge and skills required for staff to maintain competency in their current positions and future advancement.

Human Resource Development & Management Evidence of Compliance i. Training needs assessment is carried out and gaps identified. ii. A staff development plan based on training needs assessment is available. iii. Training schedule/calendar is in place. iv. Training module

Human Resource Development & Management 2. 11 Criteria for Compliance Ø i. There are continuing education activities for staff including medical practitioners to pursue professional interests and to prepare for current and future changes in practice

Human Resource Development & Management Evidence of Compliance 1. Training calendar includes in-house/external courses/ workshop/conferences 2. Contents of training programme 3. Training records on continuing education activities are kept and maintained for each staff. 4. Certificate of attendance/degree/post basic training. i.

Human Resource Development & Management 2. 12 Criteria for Compliance Ø Staff including medical practitioners receive written evaluation of their performance at the completion of the probationary period annually thereafter, or as defined by the Facility. Evidence of Compliance 1. Performance appraisal for staff including medical practitioners is completed and acted upon appropriately upon probationary period and as an annual exercise.

Policies and Procedures 3. STANDARD There are written and dated policies and procedures for all activities of the……… Services. They shall reflect current standards of practice and serve as standard operating procedures and are consistent with the objectives of the services, relevant regulations and statutory requirements.

Policies and Procedures 3. 1 Criteria for Compliance Ø There are written policies and procedures for the …………. . Services which are consistent with the overall policies of the Facility, regulatory requirements and current standard practices. These policies and procedures are signed, authorised and dated. Ø There is a mechanism for and evidence of a periodic review at least once in every three years.

Policies and Procedures Evidence of Compliance 1. Documented policies and procedures for the service. 2. Policies and procedures are consistent with regulatory requirements and current standard practices. 3. Evidence of periodic review of policies and procedures. 4. The policies and procedures are endorsed and dated

Policies and Procedures Examples of Policies and Procedures: • Hospital operational policies & procedures • Departmental/Service specific operational policies & procedures • Cross departmental policies & procedures • Medical Staff By- Laws

Policies and Procedures 3. 2 Criteria for Compliance Ø Policies and procedures are developed in collaboration with staff, medical practitioners, Management and where required with other external service providers and with reference to relevant sources involved. Ø Cross departmental collaboration is practised in developing relevant policies and procedures where applicable.

Policies and Procedures Evidence of Compliance 1. Minutes of committee meetings on development and revision on policies and procedures. 2. Minutes of meeting with evidence of cross reference with other departments 3. Documented cross departmental policies

Policies and Procedures 3. 3 Criteria for Compliance Ø New and revised policies and procedures are communicated to all staff Evidence to Compliance 1. Training and briefing on the current policies and procedures 2. Minutes of meetings 3. Circulation list and acknowledgement

Policies and Procedures 3. 4 Criteria for Compliance Ø There is evidence of compliance with policies and procedures Evidence to Compliance 1. Results of audit on practices 2. Practices in line with established policies and procedures

Policies and Procedures 3. 5 Criteria for Compliance Ø Copies of policies and procedures, relevant Acts Regulations, By-Laws and statutory requirements are accessible to staff Evidence of Compliance 1. Copies of relevant Acts, Regulations, policies and procedures etc are accessible on site/ designated location for staff reference.

Facilities and Equipment -

Facilities and Equipment 4. STANDARD The Head of the ……. . Services shall ensure that adequate facilities and equipment that are safe and appropriate are available for the staff to function effectively and to meet the goals and objectives of the …………Services.

Facilities and Equipment 4. 1 Criteria for Compliance There adequate and appropriate facilities and equipment with proper utilisation of space to enable staff to carry out their professional, teaching and administrative functions.

Facilities and Equipment Evidence of Compliance 1. Adequate and proper utilisation of space 2. Appropriate type of equipment to match the complexity of services 3. Adequate facilities and equipment at each patient care area for safe care (defibrillator, emergency cart, hand washing facilities etc) 4. Easy access and clear exit routes 5. Absence of overcrowding

Facilities and Equipment 4. 2 Criteria for Compliance There is documented evidence that facilities and equipment comply with relevant national & international standards and current statutory requirements

Facilities and Equipment Evidence of Compliance Ø Testing, commissioning and records (certificates or stickers) Ø Certificates of calibration, e. g. Standards and Industrial Research Institute of Malaysia (SIRIM), etc. calibration

Facilities and Equipment 4. 3 Criteria for Compliance (Core) There is evidence that the facility has a comprehensive maintenance programme such as predictive maintenance, planned preventive maintenance and calibration activities, to ensure the facilities and equipment are in good working order.

Facilities and Equipment Evidence of Compliance Ø Planned Preventive Maintenance records such as schedule, sticker Ø Planned Replacement Programme where applicable Ø Complaint records Ø Asset inventory

Facilities and Equipment 4. 4 Criteria for Compliance Where specialised equipment is used, there is evidence that only staff who are trained and authorised operate such equipment.

Facilities and Equipment Evidence of Compliance Ø Ø User training records Competency assessment record Letter of authorisation List of staff trained and authorised to operate specialised equipment

Facilities and Equipment 4. 5 Criteria for Compliance Ø Evidence of general safety of the facility (building design, location) 4. 6 Criteria for Compliance Ø Evidence of attention given to safety pertaining to fire, electrical supply, water, air and medical gases

Facilities and Equipment 4. 7 Criteria for Compliance Ø Presence of uninterrupted supply of amenities (electricity, water, medical gases, steam, telephone etc) 4. 8 Criteria for Compliance Ø Presence of monitoring and alarm systems 4. 9 Criteria for Compliance Ø Error prevention & recovery mechanisms (Contingency Plans)

Safety and Performance Improvement Activities 5. STANDARD The Head of Emergency Services shall ensure the provision of high quality performance with staff involvement in the ongoing safety and performance improvement activities of the Emergency Services. 5. 1 Criteria for Compliance There are planned and systematic safety and performance improvement activities to monitor and evaluate the performance of the services.

Safety and Performance Improvement Activities Evidence of Compliance Planned performance improvement activities : v Records on performance improvement activities v Minutes of performance improvement meetings v Performance improvement studies v Mortality and morbidity audits with remedial actions v Records on innovation if available

Safety and Performance Improvement Activities 5. 2 Criteria for Compliance Ø The Head of the Service assigns the responsibilities for planning, monitoring and managing safety and performance improvement activities to appropriate individual/personnel within the respective services. Evidence of Compliance a) Minutes of meetings b) Letter of assignment of responsibilities c) Job description

Safety and Performance Improvement Activities 5. 3 Criteria for Compliance Ø The Head of the Service shall ensure that the staff completes incident reports which are promptly reported, investigated, discussed by the staff with learning objectives and forwarded to the PIC of the Facility. Ø Incidents reported have Root Cause Analysis done and action taken within the agreed time frame to prevent recurrence.

Safety and Performance Improvement Activities Evidence of Compliance 1. System for incident reporting is in place, which include: a) Training of staff b) Policy on incident reporting c) Methodology of incident reporting d) Register/records of incidents

Safety and Performance Improvement Activities 2. Completed incident reports 3. Root Cause Analysis 4. Corrective and preventive action plans 5. Remedial measure 6. Minutes of meetings 7. Acknowledgment by Head of Service and PIC/Hospital Director 8. Feedback given to staff regarding incident reporting

Safety and Performance Improvement Activities 5. 4 Criteria for Compliance Ø There is tracking and trending of specific performance indicators not limited to but at least two (2) for each service

Safety and Performance Improvement Activities Evidence of Compliance Ø Specific performance indicators monitored Ø Records on tracking and trending analysis Ø Remedial measures taken where appropriate

Safety and Performance Improvement Activities 5. 5 Criteria for Compliance Ø Feedback on results of the safety and performance improvement activities are regularly communicated to the staff. Evidence of Compliance Ø Ø Ø Results on safety and performance improvement activities are accessible to staff. Evidence of feedback via communication on results of performance improvement activities through continuing medical education/meetings Minutes of service meetings

Safety and Performance Improvement Activities 5. 5 Criteria for Compliance Ø Appropriate documentation of safety and performance improvement activities is kept and confidentiality of medical practitioners, staff and patients is preserved. Evidence of Compliance Ø Ø Documentation on performance improvement activities and performance indicators. Policy statement on anonymity on patients and providers involved in performance improvement activities.

Safety Concerns Addressed in MSQH Hospital Accreditation Standards IS IT SAFE TO BE TREATED IN THIS HOSPITAL? IS IT SAFE TO BE WORKING HERE? IS IT SAFE TO VISIT?

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